Aseptic meningitis in adults
- Allan R Tunkel, MD, PhD, MACP
Allan R Tunkel, MD, PhD, MACP
- Professor of Medicine
- Warren Alpert Medical School of Brown University
The term aseptic meningitis refers to patients who have clinical and laboratory evidence for meningeal inflammation with negative routine bacterial cultures. The most common causes are the enteroviruses . Additional etiologies include other infections (mycobacteria, fungi, spirochetes), parameningeal infections, medications, and malignancies (table 1) .
Aseptic meningitis often has a similar presentation to that of bacterial meningitis (ie, fever, headache, altered mental status, stiff neck, photophobia), which can be a life-threatening illness. However, in contrast to bacterial meningitis, many patients with aseptic meningitis (particularly those who have disease caused by viruses or medications) have a self-limited course that will resolve without specific therapy.
The assessment of patients with probable aseptic meningitis is complicated by the large number of potential etiologic agents and the relatively limited diagnostic tools for identifying specific pathogens. (See "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Herpes simplex virus type 1 encephalitis".)
The symptoms, signs, and cerebrospinal fluid (CSF) findings for various etiologies of aseptic meningitis will be reviewed here. Each diagnostic entity is discussed in detail separately on the appropriate topic reviews.
MENINGITIS VERSUS ENCEPHALITIS
The presence or absence of normal brain function is the important distinguishing feature between encephalitis and meningitis. Patients with meningitis may be lethargic or distracted by headache, but their cerebral function remains normal. In contrast, patients with encephalitis commonly present with abnormalities in brain function such as altered mental status, motor or sensory deficits, altered behavior and personality changes, and speech or movement disorders. Seizures and postictal states can be seen with meningitis alone and should not be construed as definitive evidence of encephalitis. Other neurologic manifestations include hemiparesis, flaccid paralysis, and paresthesias.
- Parasuraman TV, Frenia K, Romero J. Enteroviral meningitis. Cost of illness and considerations for the economic evaluation of potential therapies. Pharmacoeconomics 2001; 19:3.
- Connolly KJ, Hammer SM. The acute aseptic meningitis syndrome. Infect Dis Clin North Am 1990; 4:599.
- Kupila L, Vuorinen T, Vainionpää R, et al. Etiology of aseptic meningitis and encephalitis in an adult population. Neurology 2006; 66:75.
- MEYER HM Jr, JOHNSON RT, CRAWFORD IP, et al. Central nervous system syndromes of "vital" etiology. A study of 713 cases. Am J Med 1960; 29:334.
- Rotbart H. Viral meningitis and the aseptic meningitis syndrome. In: Infections of the Central Nervous System, Scheld W, Whitley RJ, Durack DT (Eds), Raven, New York 1991. p.19.
- Pérez-Vélez CM, Anderson MS, Robinson CC, et al. Outbreak of neurologic enterovirus type 71 disease: a diagnostic challenge. Clin Infect Dis 2007; 45:950.
- O'Sullivan CE, Aksamit AJ, Harrington JR, et al. Clinical spectrum and laboratory characteristics associated with detection of herpes simplex virus DNA in cerebrospinal fluid. Mayo Clin Proc 2003; 78:1347.
- Landry ML, Greenwold J, Vikram HR. Herpes simplex type-2 meningitis: presentation and lack of standardized therapy. Am J Med 2009; 122:688.
- Noska A, Kyrillos R, Hansen G, et al. The role of antiviral therapy in immunocompromised patients with herpes simplex virus meningitis. Clin Infect Dis 2015; 60:237.
- Shalabi M, Whitley RJ. Recurrent benign lymphocytic meningitis. Clin Infect Dis 2006; 43:1194.
- Schlesinger Y, Tebas P, Gaudreault-Keener M, et al. Herpes simplex virus type 2 meningitis in the absence of genital lesions: improved recognition with use of the polymerase chain reaction. Clin Infect Dis 1995; 20:842.
- Tedder DG, Ashley R, Tyler KL, Levin MJ. Herpes simplex virus infection as a cause of benign recurrent lymphocytic meningitis. Ann Intern Med 1994; 121:334.
- Aurelius E, Forsgren M, Gille E, Sköldenberg B. Neurologic morbidity after herpes simplex virus type 2 meningitis: a retrospective study of 40 patients. Scand J Infect Dis 2002; 34:278.
- Aurelius E, Franzen-Röhl E, Glimåker M, et al. Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis: a double-blind, randomized controlled trial. Clin Infect Dis 2012; 54:1304.
- Achard JM, Lallement PY, Veyssier P. Recurrent aseptic meningitis secondary to intracranial epidermoid cyst and Mollaret's meningitis: two distinct entities or a single disease? A case report and a nosologic discussion. Am J Med 1990; 89:807.
- Crossley GH, Dismukes WE. Central nervous system epidermoid cyst: a probable etiology of Mollaret's meningitis. Am J Med 1990; 89:805.
- Rousseau MC, Saron MF, Brouqui P, Bourgeade A. Lymphocytic choriomeningitis virus in southern France: four case reports and a review of the literature. Eur J Epidemiol 1997; 13:817.
- Centers for Disease Control and Prevention (CDC). Interim guidance for minimizing risk for human lymphocytic choriomeningitis virus infection associated with rodents. MMWR Morb Mortal Wkly Rep 2005; 54:747.
- Centers for Disease Control and Prevention (CDC). Notes from the field: lymphocytic choriomeningitis virus infections in employees of a rodent breeding facility--Indiana, May-June 2012. MMWR Morb Mortal Wkly Rep 2012; 61:622.
- ADAIR CV, GAULD RL, SMADEL JE. Aseptic meningitis, a disease of diverse etiology: clinical and etiologic studies on 854 cases. Ann Intern Med 1953; 39:675.
- Ihekwaba UK, Kudesia G, McKendrick MW. Clinical features of viral meningitis in adults: significant differences in cerebrospinal fluid findings among herpes simplex virus, varicella zoster virus, and enterovirus infections. Clin Infect Dis 2008; 47:783.
- Tsai HC, Lee SS, Huang CK, et al. Outbreak of eosinophilic meningitis associated with drinking raw vegetable juice in southern Taiwan. Am J Trop Med Hyg 2004; 71:222.
- Podwall D, Gupta R, Furuya EY, et al. Angiostrongylus cantonensis meningitis presenting with facial nerve palsy. J Neurol 2004; 251:1280.
- Jolles S, Sewell WA, Leighton C. Drug-induced aseptic meningitis: diagnosis and management. Drug Saf 2000; 22:215.
- Moris G, Garcia-Monco JC. The challenge of drug-induced aseptic meningitis. Arch Intern Med 1999; 159:1185.
- Marinac JS. Drug- and chemical-induced aseptic meningitis: a review of the literature. Ann Pharmacother 1992; 26:813.
- Hoppmann RA, Peden JG, Ober SK. Central nervous system side effects of nonsteroidal anti-inflammatory drugs. Aseptic meningitis, psychosis, and cognitive dysfunction. Arch Intern Med 1991; 151:1309.
- Rodríguez SC, Olguín AM, Miralles CP, Viladrich PF. Characteristics of meningitis caused by Ibuprofen: report of 2 cases with recurrent episodes and review of the literature. Medicine (Baltimore) 2006; 85:214.
- Escalante A, Stimmler MM. Trimethoprim-sulfamethoxasole induced meningitis in systemic lupus erythematosus. J Rheumatol 1992; 19:800.
- Lafferty TE, DeHoratius RJ, Smith JB. Aseptic meningitis as a side effect of intravenous immune gammaglobulin. J Rheumatol 1997; 24:2491.
- Feinstein TM, Gibson MK, Argiris A. Cetuximab-induced aseptic meningitis. Ann Oncol 2009; 20:1609.
- Maniyar F, Rooney C, Lily O, Bazaz R. Anticonvulsant hypersensitivity syndrome presenting as aseptic meningitis. J Neurol 2009; 256:1190.
- Simms KM, Kortepeter C, Avigan M. Lamotrigine and aseptic meningitis. Neurology 2012; 78:921.
- Codding C, Targoff IN, McCarty GA. Aseptic meningitis in association with diclofenac treatment in a patient with systemic lupus erythematosus. Arthritis Rheum 1991; 34:1340.
- Horn AC, Jarrett SW. Ibuprofen-induced aseptic meningitis in rheumatoid arthritis. Ann Pharmacother 1997; 31:1009.
- Spanos A, Harrell FE Jr, Durack DT. Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations. JAMA 1989; 262:2700.
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
- http://www.idsociety.org/Content.aspx?id=9088 (Accessed on December 12, 2011).
- MENINGITIS VERSUS ENCEPHALITIS
- VIRAL MENINGITIS
- HIV infection
- Herpes simplex meningitis
- Recurrent (Mollaret's) meningitis
- Lymphocytic choriomeningitis virus
- Miscellaneous viruses
- OTHER INFECTIONS
- - Syphilis
- - Lyme disease
- Fungal infections
- - Cryptococcal infection
- - Coccidioidal infection
- Tuberculous meningitis
- Bacterial infections
- Angiostrongylus infection
- NEOPLASMS OF THE LEPTOMENINGES
- DRUG-INDUCED MENINGITIS
- APPROACH TO THE PATIENT
- Historical clues
- Clues on physical examination
- SUMMARY AND RECOMMENDATIONS
- - Suspected bacterial meningitis
- - Suspected viral meningitis
- - Unclear etiology