Viral meningitis: Management, prognosis, and prevention in children
- Cecilia Di Pentima, MD
Cecilia Di Pentima, MD
- Director of Pediatric Infectious Diseases
- Goryeb Children's Hospital
- Section Editors
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
- Douglas R Nordli, Jr, MD
Douglas R Nordli, Jr, MD
- Section Editor — Pediatric Neurology
- Chief of Neurology
- Children’s Hospital Los Angeles
- Vice Chair of Neurology
- USC Keck School of Medicine
The management, prognosis, and prevention of viral meningitis in children will be discussed here. The epidemiology, pathogenesis, clinical manifestations, diagnosis, and differential diagnosis are discussed separately. (See "Viral meningitis: Epidemiology, pathogenesis, and etiology in children" and "Viral meningitis: Clinical features and diagnosis in children".)
OVERVIEW OF APPROACH
Viral meningitis may be suspected on the basis of epidemiologic data, clinical features, and initial cerebrospinal (CSF) studies, but clinical features cannot reliably differentiate viral from bacterial meningitis; the CSF profiles of bacterial and viral meningitis overlap considerably (table 1) [1,2]. The diagnosis of viral meningitis requires negative CSF culture for routine bacterial pathogens and positive identification of a viral pathogen in the CSF or other patient samples. (See "Viral meningitis: Clinical features and diagnosis in children", section on 'Diagnosis'.)
Pending results of CSF cultures and virologic studies, the results of the initial evaluation can be used to make a provisional diagnosis of bacterial meningitis, viral meningitis, or unclear etiology (table 1). The provisional diagnosis is one of several considerations in the initial management.
Indications for hospitalization may include [3,4]:
●Ill-appearance or signs of encephalitis (eg, altered mental status, behavior, or personality; motor or sensory deficits; speech or movement disorders; hemiparesis; flaccid paralysis; paresthesias; seizures) (see "Acute viral encephalitis in children: Clinical manifestations and diagnosis", section on 'Clinical features' and "Paraneoplastic and autoimmune encephalitis")
- Logan SA, MacMahon E. Viral meningitis. BMJ 2008; 336:36.
- Negrini B, Kelleher KJ, Wald ER. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics 2000; 105:316.
- Abzug MJ. Viral meningitis and encephalitis. In: Current Pediatric Therapy, 18th, Burg FD, Ingelfinger JR, Polin RA, Gershon AA (Eds), Saunders, Philadelphia 2006. p.810.
- Singer JI, Maur PR, Riley JP, Smith PB. Management of central nervous system infections during an epidemic of enteroviral aseptic meningitis. J Pediatr 1980; 96:559.
- Overall JC Jr. Is it bacterial or viral? Laboratory differentiation. Pediatr Rev 1993; 14:251.
- Jaffe M, Srugo I, Tirosh E, et al. The ameliorating effect of lumbar puncture in viral meningitis. Am J Dis Child 1989; 143:682.
- Feigin RD, Shackelford PG. Value of repeat lumbar puncture in the differential diagnosis of meningitis. N Engl J Med 1973; 289:571.
- Amir J, Harel L, Frydman M, et al. Shift of cerebrospinal polymorphonuclear cell percentage in the early stage of aseptic meningitis. J Pediatr 1991; 119:938.
- Wilfert CM, Lehrman SN, Katz SL. Enteroviruses and meningitis. Pediatr Infect Dis 1983; 2:333.
- Waagner DC, Kennedy WA, Hoyt MJ, McCracken GH Jr. Lack of adverse effects of dexamethasone therapy in aseptic meningitis. Pediatr Infect Dis J 1990; 9:922.
- 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.
- Long SS. In defense of empiric acyclovir therapy in certain neonates. J Pediatr 2008; 153:157.
- Kimberlin DW. When should you initiate acyclovir therapy in a neonate? J Pediatr 2008; 153:155.
- Long SS, Pool TE, Vodzak J, et al. Herpes simplex virus infection in young infants during 2 decades of empiric acyclovir therapy. Pediatr Infect Dis J 2011; 30:556.
- Shah SS, Volk J, Mohamad Z, et al. Herpes simplex virus testing and hospital length of stay in neonates and young infants. J Pediatr 2010; 156:738.
- Whitley RJ, Kimberlin DW, Roizman B. Herpes simplex viruses. Clin Infect Dis 1998; 26:541.
- Kimberlin DW. Acyclovir Dosing in the Neonatal Period and Beyond. J Pediatric Infect Dis Soc 2013; 2:179.
- American Academy of Pediatrics. Herpes simplex. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.432.
- Malcom BS, Eiden JJ, Hendley JO. ECHO virus type 9 meningitis simulating tuberculous meningitis. Pediatrics 1980; 65:725.
- Rorabaugh ML, Berlin LE, Heldrich F, et al. Aseptic meningitis in infants younger than 2 years of age: acute illness and neurologic complications. Pediatrics 1993; 92:206.
- Bronstein DE, Glaser CA. Aseptic meningitis and viral meningitis. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th, Cherry JD, Harrison GJ, Kaplan SL, et al. (Eds), Elsevier Saunders, Philadelphia 2014. p.484.
- Rotbart HA. Viral meningitis. Semin Neurol 2000; 20:277.
- 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.
- Modlin JF. Perinatal echovirus infection: insights from a literature review of 61 cases of serious infection and 16 outbreaks in nurseries. Rev Infect Dis 1986; 8:918.
- Sawyer MH. Enterovirus infections: diagnosis and treatment. Semin Pediatr Infect Dis 2002; 13:40.
- Wilfert CM, Thompson RJ Jr, Sunder TR, et al. Longitudinal assessment of children with enteroviral meningitis during the first three months of life. Pediatrics 1981; 67:811.
- Sells CJ, Carpenter RL, Ray CG. Sequelae of central-nervous-system enterovirus infections. N Engl J Med 1975; 293:1.
- Bergman I, Painter MJ, Wald ER, et al. Outcome in children with enteroviral meningitis during the first year of life. J Pediatr 1987; 110:705.
- Chang LY, Huang LM, Gau SS, et al. Neurodevelopment and cognition in children after enterovirus 71 infection. N Engl J Med 2007; 356:1226.
- McKinney RE Jr, Katz SL, Wilfert CM. Chronic enteroviral meningoencephalitis in agammaglobulinemic patients. Rev Infect Dis 1987; 9:334.
- Calisher CH. Medically important arboviruses of the United States and Canada. Clin Microbiol Rev 1994; 7:89.
- Bao X, Wong V. Brainstem auditory-evoked potential evaluation in children with meningitis. Pediatr Neurol 1998; 19:109.
- American Academy of Pediatrics. Enterovirus (nonpoliovirus). In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS. (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.333.
- OVERVIEW OF APPROACH
- Suspected bacterial meningitis
- Suspected viral meningitis
- Unclear etiology
- - Repeat LP
- SUPPORTIVE CARE
- EMPIRIC THERAPY
- Empiric antibiotics
- - Choice of agent
- - Duration of therapy
- Empiric antivirals
- - Duration
- SPECIFIC THERAPY
- PERSISTENT SYMPTOMS
- Personal protection
- Infection control
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS