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Viral meningitis: Epidemiology, pathogenesis, and etiology in children

Cecilia Di Pentima, MD
Section Editors
Sheldon L Kaplan, MD
Douglas R Nordli, Jr, MD
Deputy Editor
Carrie Armsby, MD, MPH


Viral meningitis is defined as:

A febrile illness with clinical signs and symptoms of meningeal irritation

No associated neurologic dysfunction

No evidence of bacterial pathogens in the cerebrospinal fluid in a patient who has not received prior antibiotics

The epidemiology, pathogenesis, and etiology of viral meningitis will be reviewed here. Clinical manifestations, diagnosis, treatment, and prevention of viral meningitis and bacterial meningitis are discussed separately. (See "Viral meningitis: Clinical features and diagnosis in children" and "Viral meningitis: Management, prognosis, and prevention in children" and "Bacterial meningitis in children older than one month: Clinical features and diagnosis" and "Bacterial meningitis in children older than one month: Treatment and prognosis".)

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Literature review current through: Sep 2017. | This topic last updated: Jun 23, 2016.
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  1. Rotbart HA. Viral meningitis. Semin Neurol 2000; 20:277.
  2. Centers for Disease Control and Prevention (CDC). Outbreaks of aseptic meningitis associated with echoviruses 9 and 30 and preliminary surveillance reports on enterovirus activity--United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52:761.
  3. Cassady K, Gnann JW, Whitley RJ. Viral infections of the central nervous system. In: Therapy of Infectious Diseases, Baddour L, Gorbach S (Eds), WB Saunders, Philadelphia 2003. p.237.
  4. Khetsuriani N, Lamonte-Fowlkes A, Oberst S, et al. Enterovirus surveillance--United States, 1970-2005. MMWR Surveill Summ 2006; 55:1.
  5. Kaplan MH, Klein SW, McPhee J, Harper RG. Group B coxsackievirus infections in infants younger than three months of age: a serious childhood illness. Rev Infect Dis 1983; 5:1019.
  6. Khetsuriani N, Lamonte A, Oberste MS, Pallansch M. Neonatal enterovirus infections reported to the national enterovirus surveillance system in the United States, 1983-2003. Pediatr Infect Dis J 2006; 25:889.
  7. Wolthers KC, Benschop KS, Schinkel J, et al. Human parechoviruses as an important viral cause of sepsislike illness and meningitis in young children. Clin Infect Dis 2008; 47:358.
  8. Li CC, Yang MY, Chen RF, et al. Clinical manifestations and laboratory assessment in an enterovirus 71 outbreak in southern Taiwan. Scand J Infect Dis 2002; 34:104.
  9. Herrero LJ, Lee CS, Hurrelbrink RJ, et al. Molecular epidemiology of enterovirus 71 in peninsular Malaysia, 1997-2000. Arch Virol 2003; 148:1369.
  10. Kehle J, Roth B, Metzger C, et al. Molecular characterization of an Enterovirus 71 causing neurological disease in Germany. J Neurovirol 2003; 9:126.
  11. Alexander JP Jr, Baden L, Pallansch MA, Anderson LJ. Enterovirus 71 infections and neurologic disease--United States, 1977-1991. J Infect Dis 1994; 169:905.
  12. 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.
  13. Gutierrez K, Abzug MJ. Vaccine-associated poliovirus meningitis in children with ventriculoperitoneal shunts. J Pediatr 1990; 117:424.
  14. Centers for Disease Control and Prevention (CDC). Acute flaccid paralysis associated with circulating vaccine-derived poliovirus--Philippines, 2001. MMWR Morb Mortal Wkly Rep 2001; 50:874.
  15. Inaba H, Hori H, Ito M, et al. Polio vaccine virus-associated meningoencephalitis in an infant with transient hypogammaglobulinemia. Scand J Infect Dis 2001; 33:630.
  16. Chow KC, Lee CC, Lin TY, et al. Congenital enterovirus 71 infection: a case study with virology and immunohistochemistry. Clin Infect Dis 2000; 31:509.
  17. Cherry, JD, Krogstad, P. Enterovirus and parechovirus infections. In: Infectious Diseases of the Fetus and Newborn Infant, 7th ed, Remington, JS, Klein, JO, Wilson, CB, et al (Eds), Elsevier Saunders, Philadelphia 2011. p.756.
  18. Minor P. Characteristics of poliovirus strains from long-term excretors with primary immunodeficiencies. Dev Biol (Basel) 2001; 105:75.
  19. Rotbart HA. Viral meningitis and the aseptic meningitis syndrome. In: Infections of the Central Nervous System, 2nd ed, Scheld MW, Durack WR (Eds), Lippincott Raven, Philadelphia 1997. p.23.
  20. Wyatt HV. Provocation poliomyelitis and entry of poliovirus to the CNS. Med Hypotheses 1976; 2:269.
  21. Levorson RE, Jantausch BA. Human parechoviruses. Pediatr Infect Dis J 2009; 28:831.
  22. Calvert J, Chieochansin T, Benschop KS, et al. Recombination dynamics of human parechoviruses: investigation of type-specific differences in frequency and epidemiological correlates. J Gen Virol 2010; 91:1229.
  23. Centers for Disease Control and Prevention (CDC). Nonpolio enterovirus and human parechovirus surveillance --- United States, 2006-2008. MMWR Morb Mortal Wkly Rep 2010; 59:1577.
  24. Boivin G, Abed Y, Boucher FD. Human parechovirus 3 and neonatal infections. Emerg Infect Dis 2005; 11:103.
  25. Benschop KS, Schinkel J, Minnaar RP, et al. Human parechovirus infections in Dutch children and the association between serotype and disease severity. Clin Infect Dis 2006; 42:204.
  26. Figueroa JP, Ashley D, King D, Hull B. An outbreak of acute flaccid paralysis in Jamaica associated with echovirus type 22. J Med Virol 1989; 29:315.
  27. Gubler DJ. The global resurgence of arboviral diseases. Trans R Soc Trop Med Hyg 1996; 90:449.
  28. Verboon-Maciolek MA, Groenendaal F, Hahn CD, et al. Human parechovirus causes encephalitis with white matter injury in neonates. Ann Neurol 2008; 64:266.
  29. Levorson RE, Jantausch BA, Wiedermann BL, et al. Human parechovirus-3 infection: emerging pathogen in neonatal sepsis. Pediatr Infect Dis J 2009; 28:545.
  30. Selvarangan R, Nzabi M, Selvaraju SB, et al. Human parechovirus 3 causing sepsis-like illness in children from midwestern United States. Pediatr Infect Dis J 2011; 30:238.
  31. Sharp J, Harrison CJ, Puckett K, et al. Characteristics of young infants in whom human parechovirus, enterovirus or neither were detected in cerebrospinal fluid during sepsis evaluations. Pediatr Infect Dis J 2013; 32:213.
  32. Khatami A, McMullan BJ, Webber M, et al. Sepsis-like disease in infants due to human parechovirus type 3 during an outbreak in Australia. Clin Infect Dis 2015; 60:228.
  33. Ito M, Yamashita T, Tsuzuki H, et al. Isolation and identification of a novel human parechovirus. J Gen Virol 2004; 85:391.
  34. Watanabe K, Oie M, Higuchi M, et al. Isolation and characterization of novel human parechovirus from clinical samples. Emerg Infect Dis 2007; 13:889.
  35. Pham NT, Trinh QD, Khamrin P, et al. Diversity of human parechoviruses isolated from stool samples collected from Thai children with acute gastroenteritis. J Clin Microbiol 2010; 48:115.
  36. Harvala H, Robertson I, Chieochansin T, et al. Specific association of human parechovirus type 3 with sepsis and fever in young infants, as identified by direct typing of cerebrospinal fluid samples. J Infect Dis 2009; 199:1753.
  37. Piñeiro L, Vicente D, Montes M, et al. Human parechoviruses in infants with systemic infection. J Med Virol 2010; 82:1790.
  38. van der Sanden S, de Bruin E, Vennema H, et al. Prevalence of human parechovirus in the Netherlands in 2000 to 2007. J Clin Microbiol 2008; 46:2884.
  39. Abed Y, Boivin G. Human parechovirus types 1, 2 and 3 infections in Canada. Emerg Infect Dis 2006; 12:969.
  40. Felsenstein S, Yang S, Eubanks N, et al. Human parechovirus central nervous system infections in southern California children. Pediatr Infect Dis J 2014; 33:e87.
  41. Drexler JF, Grywna K, Stöcker A, et al. Novel human parechovirus from Brazil. Emerg Infect Dis 2009; 15:310.
  42. Caviness AC, Demmler GJ, Almendarez Y, Selwyn BJ. The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in hospitalized neonates. J Pediatr 2008; 153:164.
  43. Davis LE, Johnson RT. An explanation for the localization of herpes simplex encephalitis? Ann Neurol 1979; 5:2.
  44. Johnson RT, Mims CA. Pathogenesis of viral infections of the nervous system. N Engl J Med 1968; 278:23.
  45. Bergström T, Vahlne A, Alestig K, et al. Primary and recurrent herpes simplex virus type 2-induced meningitis. J Infect Dis 1990; 162:322.
  46. Whitley RJ, Kimberlin DW, Roizman B. Herpes simplex viruses. Clin Infect Dis 1998; 26:541.
  47. Simko JP, Caliendo AM, Hogle K, Versalovic J. Differences in laboratory findings for cerebrospinal fluid specimens obtained from patients with meningitis or encephalitis due to herpes simplex virus (HSV) documented by detection of HSV DNA. Clin Infect Dis 2002; 35:414.
  48. Dupuis C, Despert V, Vigneron P. [Herpetic meningitis in the child]. Arch Pediatr 2002; 9:1153.
  49. Do AN, Green PA, Demmler GJ. Herpes simplex virus type 2 meningitis and associated genital lesions in a three-year-old child. Pediatr Infect Dis J 1994; 13:1014.
  50. Brown ZA, Benedetti J, Ashley R, et al. Neonatal herpes simplex virus infection in relation to asymptomatic maternal infection at the time of labor. N Engl J Med 1991; 324:1247.
  51. 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.
  52. Opitz JC, Kettrick MA, Sullivan BJ. Recurrent neonatal herpes presenting initially with hoarseness. Am J Perinatol 1989; 6:307.
  53. Cohen BA, Rowley AH, Long CM. Herpes simplex type 2 in a patient with Mollaret's meningitis: demonstration by polymerase chain reaction. Ann Neurol 1994; 35:112.
  54. Conway JH, Weinberg A, Ashley RL, et al. Viral meningitis in a preadolescent child caused by reactivation of latent herpes simplex (type 1). Pediatr Infect Dis J 1997; 16:627.
  55. 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.
  56. Jensenius M, Myrvang B, Størvold G, et al. Herpes simplex virus type 2 DNA detected in cerebrospinal fluid of 9 patients with Mollaret's meningitis. Acta Neurol Scand 1998; 98:209.
  57. Steel JG, Dix RD, Baringer JR. Isolation of herpes simplex virus type I in recurrent (Mollaret) meningitis. Ann Neurol 1982; 11:17.
  58. Graman PS. Mollaret's meningitis associated with acute Epstein-Barr virus mononucleosis. Arch Neurol 1987; 44:1204.
  59. Gutierrez KM, Whitley RJ, Arvin AM. Herpes simplex virus infections. In: Infectious Diseases of the Fetus and Newborn Infant, 7th ed, Remington JS, Klein JO, Wilson CB, et al (Eds), Elsevier Saunders, Philadelphia 2011. p.813.
  60. Centers for Disease Control and Prevention (CDC). Decline in annual incidence of varicella--selected states, 1990-2001. MMWR Morb Mortal Wkly Rep 2003; 52:884.
  61. Romero JR, Newland JG. Viral meningitis and encephalitis: traditional and emerging viral agents. Semin Pediatr Infect Dis 2003; 14:72.
  62. Gnann JW Jr. Varicella-zoster virus: atypical presentations and unusual complications. J Infect Dis 2002; 186 Suppl 1:S91.
  63. Kleinschmidt-DeMasters BK, Gilden DH. The expanding spectrum of herpesvirus infections of the nervous system. Brain Pathol 2001; 11:440.
  64. Ross JP, Choen JI. Epstein-Barr virus. In: Infections of the Central Nervous System, 2nd ed, Scheld MW, Durack WR (Eds), Lippincott Raven, Philadelphia 1997. p.117.
  65. Griffiths PD, McLaughlin JE. Cytomegalovirus. In: Infections of the Central Nervous System, 2nd ed, Scheld MW, Durack WR (Eds), Lippincott Raven, Philadelphia 1997. p.107.
  66. Caserta MT, Hall CB. Human Herpes-6. In: Infections of the Central Nervous System, 2nd ed, Scheld MW, Durack WR (Eds), Lippincott Raven, Philadelphia 1997. p.129.
  67. Yoshikawa T, Ihira M, Suzuki K, et al. Invasion by human herpesvirus 6 and human herpesvirus 7 of the central nervous system in patients with neurological signs and symptoms. Arch Dis Child 2000; 83:170.
  68. Pohl-Koppe A, Blay M, Jäger G, Weiss M. Human herpes virus type 7 DNA in the cerebrospinal fluid of children with central nervous system diseases. Eur J Pediatr 2001; 160:351.
  69. Calisher CH. Medically important arboviruses of the United States and Canada. Clin Microbiol Rev 1994; 7:89.
  70. Hammer SM, Connolly KJ. Viral aseptic meningitis in the United States: clinical features, viral etiologies, and differential diagnosis. Curr Clin Top Infect Dis 1992; 12:1.
  71. Sawyer MH. Enterovirus infections: diagnosis and treatment. Pediatr Infect Dis J 1999; 18:1033.
  72. Gubler DJ. Arboviruses as imported disease agents: the need for increased awareness. Arch Virol Suppl 1996; 11:21.
  73. Petersen LR, Brault AC, Nasci RS. West Nile virus: review of the literature. JAMA 2013; 310:308.
  74. Lindsey NP, Hayes EB, Staples JE, Fischer M. West Nile virus disease in children, United States, 1999-2007. Pediatrics 2009; 123:e1084.
  75. Lindsey NP, Lehman JA, Staples JE, et al. West nile virus and other arboviral diseases - United States, 2013. MMWR Morb Mortal Wkly Rep 2014; 63:521.
  76. Horga MA, Fine A. West Nile virus. Pediatr Infect Dis J 2001; 20:801.
  77. Barton LL, Mets MB. Congenital lymphocytic choriomeningitis virus infection: decade of rediscovery. Clin Infect Dis 2001; 33:370.
  78. Whitley, RJ. Rabies. In: Infections of the Central Nervous System, 2nd ed, Scheld, MW, Durack, WR (Eds), Lippincott Williams & Wilking, Raven, Philadelphia 1997. p.181.
  79. Wang YH, Huang YC, Chang LY, et al. Clinical characteristics of children with influenza A virus infection requiring hospitalization. J Microbiol Immunol Infect 2003; 36:111.
  80. Newland JG, Romero JR, Varman M, et al. Encephalitis associated with influenza B virus infection in 2 children and a review of the literature. Clin Infect Dis 2003; 36:e87.
  81. Newland JG, Shah SS, Zaoutis TE. The child with aseptic meningitis. Pediatr Case Rev 2003; 3:218.
  82. Centers for Disease Control and Prevention (CDC). Update: influenza activity--United States, January 18-24, 2004. MMWR Morb Mortal Wkly Rep 2004; 53:63.
  83. Schildgen O, Glatzel T, Geikowski T, et al. Human metapneumovirus RNA in encephalitis patient. Emerg Infect Dis 2005; 11:467.
  84. Arnold JC, Singh KK, Milder E, et al. Human metapneumovirus associated with central nervous system infection in children. Pediatr Infect Dis J 2009; 28:1057.