Viral meningitis
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39409.673657.AE (Published 03 January 2008) Cite this as: BMJ 2008;336:36All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
MENINGITIS TRUST,
Fern House,
Bath Road,
Stroud,
Glos
GL5 3TJ
Letter to the Editor
10th January 2007
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
Chief Executive
The Meningitis Trust
www.meningitis-trust.org
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:
• a 24-hour freephone helpline led by specially trained nurses offering
information
and support in over 100 languages -0800 028 18 28
• free professional counselling
• a home visiting service
• financial grants to fund special equipment; respite care; therapeutic
activities;
special training; travel and accommodation costs; and much more.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
viral meningitis: clinical review
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
Competing interests: No competing interests