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Similarities between viral meningitis and tuberculous meningitis also deserve mention
- Oscar M Jolobe (5 January 2008)
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Other important diagnoses to be excluded or established
- Harold P Lambert, SW14 7AN (6 January 2008)
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Increasing cases of Viral Meningitis in the UK
- Kirsty A Barnby (10 January 2008)
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Paediatric points
- denis g gill (18 January 2008)
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Is HSV-2 the commonest cause of viral meningitis?
- Mark Melzer (18 January 2008)
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viral meningitis: clinical review
- Martin J Sheppard (15 February 2008)
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Oscar M Jolobe, retired geriatrician Manchester Medical Society, c/o John Rylands University Library, Oxford Road, Manchester
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Appropriately, the authors drew attention to similarities between viral meningitis and bacterial meningitis, both in their clinical presentation and in their cerebrospinal fluid(CSF) stigmata(1). Important similarities also exist between viral meningitis and tuberculous meningitis(TBM). Clinical features may be similar, and the CSF parameter which typically distinguishes classical TBM from viral meningitis, namely, a CSF glucose of < 2.2 mmol/l or a CSF glucose < 40% of concurrent serum glucose may not be a feature in up to 28% of adults with TBM(2). TBM also simulates herpes virus-2(HSV-2) meningitis in sometimes having sacral radiculomyelitis as a complicating feature(3)(4). The onset of this complication may either be simultaneous with TBM or may occur subsequently(3)(4). The co-existence of paraparesis and sphincter disturbance was the defining feature of radiculomyelitis in all five cases in one report, and in all five cases the reduction in CSF glucose levels ensured that there could be no confusion with viral meningitis(4). Nevertheless clinicians, especially in countries with high prevalemce of TBM, should remain vigilant to the possibility that the occasional patient with the association of TBM and radiculomyelitis could present with a CSF characterised by normal levels of CSF glucose. References (1) Logan SAE., MacMahon E Viral meningitis British Medical Journal 2008:336:36-40 (2) Garcia-Monco JC Central nervous system tuberculosis Neurologic Clinics 1999:17:737-59 (3) Hernandez-Albujar S., Arribas JR., Royo A et al Tuberculous radiculomyelitis complicating tuberculous meningitis: case report and review Clinical Infectious Diseases 2000:30:915-21 (4) Moghtaderi A., Nain RA Tuberculous radiculomyelitis: review and presentation of five patients International Journal of Tuberculosis and Lung Disease 2003:7:1186-90 Competing interests: None declared |
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Harold P Lambert, Retired Professor of Infectious Diseases 69 Christchurch Road, SW14 7AN
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The crucial aspect is to consider non-viral causes of aseptic meningitis, not mentioned in the review. Of these, tuberculous meningitis and partly treated bacterial meningitis are most relevant. There are many others, for example leptospirosis, drug-related meningitis and parameningeal brain abscess presenting as aseptic meningitis before focal signs have developed. The CSF findings in all these conditions can be similar, even identical, to those found in viral meningitis. The authors mention various advantages in making a positive viral identification. Its real importance is in helping to exclude these non-viral illnesses. Many of them carry a serious prognosis and require immediate treatment. Competing interests: None declared |
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Kirsty A Barnby, Communications Officer GL5 3TJ
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MENINGITIS TRUST, Fern House, Bath Road, Stroud, Glos GL5 3TJ Letter to the Editor
Dear Sir / Madam, Increasing cases of Viral Meningitis in the UK The Meningitis Trust is urging people to remain vigilant of the signs and symptoms of meningitis after research recently published in the British Medical Journal warns ‘that cases of viral meningitis are set to rise’. The research shows that enteroviruses (a group of viruses that live in the intestines) are now the leading cause of viral meningitis, followed by the Herpes simplex virus. People should be aware of the signs and symptoms which can include fever, severe headache, nausea and vomiting, dislike of light and a stiff neck and the Trust recommends that all suspected cases should seek urgent medical attention. The Meningitis Trust, the UK’s longest established meningitis charity, is dedicated to providing lifelong practical, emotional and financial support wherever it is needed to those whose lives have been shattered by meningitis. The Trust’s own research is now focused on the after-effects and aftercare issues to help us understand how we can provide timely and quality care for all those affected by meningitis. The Trust aims to keep the disease high on the agenda of health professionals and at the forefront of public awareness, to ensure prompt life-saving action is taken and proper care is available to all affected. For further information and support call the Meningitis Trust’s freephone 24-hour nurse-led helpline on 0800 028 18 28. Yours faithfully, Sue Sue Davie
For further information please contact the Meningitis Trust Press Office: Kirsty Barnby, Communications Officer on 01453 769030 or email kirstyb@meningitis-trust.org About the Meningitis Trust This year The Meningitis Trust marks a major milestone as we celebrate our 21st birthday. The Trust was founded in 1986 by parents of sufferers in Stroud. It has built upon 21 years of knowledge, expertise and understanding to become firmly established in its national and international position, as the major meningitis charity for helping people rebuild their lives after the disease. For the many thousands of people who have been, and continue to be, affected by meningitis, and for those who sadly will be affected in the future, the Meningitis Trust is a lifeline. The only charity of its kind, focusing on fighting meningitis through awareness and providing the best possible support to those affected. Specifically, the Meningitis Trust provides support through the
following services:
The Meningitis Trust is a registered charity which relies on donations for 99% of its income. About meningitis Meningitis is a life-threatening infection which affects the membranes that surround and protect the brain and spinal cord. Meningitis and its associated disease, septicaemia (blood poisoning), can kill within hours and can affect anyone at any time. Those most at risk are children under the age of five, teenagers and young adults, and people over 55. Approximately 4,000 cases are reported every year in the UK, but meningitis experts estimate that this is half of the true picture. There is still no vaccine available to protect against the meningococcal group B bacteria, the most common cause of the disease in the UK. It is vital that people know how to recognise the signs and symptoms as medical help should be sought immediately. Common signs and symptoms include fever (cold hands and feet), vomiting, headache, stiff neck, dislike of bright lights, joint or muscle pain, drowsiness, confusion, and also, in babies, dislike of being handled, pale blotchy skin, unusual cry, and a blank staring expression. Both adults and children may have a rash (septicaemia) that doesn’t fade under pressure. Symptoms can appear in any order and some may not appear at all. Competing interests: None declared |
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denis g gill, retired prof paediatrics RCSI Dublin 2
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Two short paediatric points to complement your excellent review on viral meningitis (jan 5,2008 ). The first is an anecdotal,non-evidence based comment.Many children with viral meningitis have told me of feeling better after lumbar puncture ;children with bacterial meningitis remain ill and feel awful.It is worth asking how is your headache when giving initial L.P results to verbal children. Secondly,viral PCR studies are particularly helpful in the first 4-6 weeks of life when standard LP results can be difficult to interpret Competing interests: None declared |
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Mark Melzer, Consultant Microbiologist Queen's Hospital, BHR Trust, Rom Valley Way, Romford, Essex RM7 0AG
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I read with interest Logan et al’s excellent review(1). In their article, enteroviral infections are quoted as ‘by far the commonest cause’ of viral meningitis. In East London, however, we found that HSV-2 infections occur more commonly. From June 2003 – December 2006, at King George Hospital, Barking Havering and Redbridge Trust, all patients with abnormal CSF findings were reviewed by two clinical microbiologists and managed in conjunction with their medical or paediatric teams. 80 patients had abnormal CSF findings, 73 infections were community-acquired and 16 bacterial and 13 viral infections were laboratory confirmed. In 9 cases, HSV DNA was detected in the CSF. Of the 9 HSV CNS cases, 3 had an ‘encephalitic’ presentation (headache, confusion, altered behaviour and seizures) and 6 had ‘meningitic’ symptoms (headache, photophobia, and meningism). The ‘meningitic’ cases occurred in young immunocompetent females aged 17-32 years. All were caused by HSV-2 and none had active genital lesions at the time of presentation. Two ‘encephalitic’ infections were caused by HSV-1, the serotype of the remaining case is unknown. The ‘encephalitic’ cases were treated with intravenous aciclovir for at least 14 days, but only 2 out of 6 ‘meningitic’ patients received 10 days of intravenous aciclovir. As aciclovir is administered intravenously for CNS infections, the average length of stay was considerably longer in those 2 patients who received 10 days of intravenous aciclovir (10 days vs 2.25 days). Despite different aciclovir regimens, all six patients with ‘meningitic’ symptoms recovered uneventfully. We agree HSV meningitis and HSV encephalitis should be considered as separate clinical entities. Our data suggests that HSV meningitis occurs predominantly in young females and is mainly caused by HSV-2, often in the absence of active genital lesions. In contrast, HSV encephalitis occurs in all ages, is caused predominantly by HSV-1 and, in the absence of intravenous aciclovir, poor clinical outcomes occur. Our experience is that in cases of HSV meningitis, treatment with intravenous aciclovir increases length of inpatient stay but has no effect on survival although a study to elucidate its effect on symptom duration and cognitive function would be welcomed. We agree with the authors that because of under notification, the overall prevalence and aetiology of viral meningitis in the UK is uncertain. In East London, however, HSV-2 is a commoner cause of viral meningitis than enteroviruses. Competing interests: None declared References: 1. Logan SAE, MacMahon E. Viral meningitis. BMJ 2008; 336:36-40. Competing interests: None declared |
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Martin J Sheppard, consultant microbiologist Withybush Hospital, Pembrokeshire, SA62 3HG
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This review states [correctly] that herpes encephalitis requires empirical treatment, whereas herpes meningitis is a self-limiting condition. This raises two questions. The review used two illustrative cases of herpes meningitis, in each of which treatment was given: contradicting the "self-limiting" statement. Current problems with bacterial resistance reflect gross over-use of antibiotics in the past, we should not encourage the same behaviour with anti-viral drugs. Secondly, if you treat encephalitis and do not treat meningitis, what is the purpose of testing the CSF for HSV? The result does not distinguish between these two conditions, and hence does not help in management of the patient. This should be the main reason for undertaking any investigation, especially those which are expensive and slow. By contrast Gram-stain and culture are quick, cheap, and may alter management. Competing interests: None declared |
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