Combinations of first- and second-line agents (consult an expert)
Human immunodeficiency virus
Antiretroviral therapy (see Acute Retroviral Syndrome)
IVIG used routinely for severe disease in Asia
Comment: Comprehensive review of evaluation and management of the patient with aseptic meningitis.
Comment: Review of 180 patient admitted to IM unit with aseptic meningitis, including 124 without encephalitis. Most with ID diagnosis due to enteroviruses (43%), HSV-2 (17%), and VZV (14%). Significant differences in CSF profiles between enteroviral meningitis and these herpes virus meningitides, including lower CSF protein and lymphocyte percentages.
Meta-analysis that mostly includes studies from 1970s and 1980s; it argues for use of CSF lactate to help distinguish aseptic from bacterial meningitis with 93% sensitivity, 96% specificity. Utility diminished (sensitivity 49%) if antibiotics administered before LP.
Epidemics of Enterovirus 71 infections have arisen in Asia over the past 10-15 years. Excellent review of the spectrum of clinical manifestations of EV 71 infections, including aseptic meningitis, acute flaccid paralysis, and brainstem encephalitis, as well as differential diagnostic considerations, recommended diagnostic tests, and treatment modalities (admittedly largely limited to supportive care and consideration of IVIg).
Comment: Another study that seeks to help distinguish between life-threatening bacterial meningitis versus likely viral causes. This study examined 198 patients presenting with acute meningitis n six European centers. The clinical decision rules used were two: the Bacterial Meningitis Score [BMS--start antibiotics in case of seizure, positive cerebrospinal fluid (CSF) Gram staining, blood neutrophil count ≥10 ×10(9)/l, CSF protein level ≥80 mg/dl or CSF neutrophil count ≥1000 ×10(6)/l); and the Meningitest (start antibiotics in case of seizure, purpura, toxic appearance, PCT level ≥0.5 ng/ml, positive CSF Gram staining or CSF protein level ≥50 mg/dl). When compared, both were 100% senstivie but the BMS yielded better specificity (52% vs 36%, p< 0.00000001). Authors conclude that BMS is better when used cautiously in an alogrithm and avoid unnecessary antibiotics.
Comment: Review article most useful for its differential diagnosis of chronic meningitis and the uveo-meningitis syndromes.
Comment: Case report and review of the literature for one of the more common causes of drug-induced meningitis. Many of the patients noted in the literature with this syndrome also had pre-existing autoimmune disorders such as SLE.
Comment: Report from Finland finds that adult aseptic meningitis is mostly due to enteroviral infection and HSV-2.
Comment: Besides an aseptic meningitis as a presentation of acute retroviral infection, authors detail a case wherein similar clinical scenarios developed after structured interruption of ART.
Comment: Prospective study suggesting that besides encephalitic presentations, WNV well capable of causing an aseptic meningitis picture as 5/16 (31%) West Nile seropositive patients only developed meningitis but not encephalitis as a consequence of infection.
Comment: A summary of the evidence behind the use of intravenous immunoglobulin in severe or chronic CNS enteroviral infections. It also reviews the early clinical studies with pleconaril, which has now been shown in a multi-center randomized trial to reduce the duration of headache and hasten the return to school or work in patients with acute meningitis.
Comment: Describes series of patient with HANDL (Headache with neurological deficits and CSF lymphocytosis. Pts with severe headache, temporary neurological deficit and CSF pleocytosis (cells 16-350 wbc, predominantly lymphocytes) and elevated CSF protein that is self limiting. Most have more than one episode and there is often a strong migraine history.
Comment: Case series including one patient with acute and three patients with recurrent meningitis associated with recurrent genital lesions. Obviously a small sample size, but no further episodes were reported over 1-3 years of follow-up while taking acyclovir continuously or at the first sign of recurrent genital lesions.
Comment: Use of enterovirus PCR (typically 97-100% sensitive, 100% specific) in aseptic meningitis studied here prospectively with 137/276 (~50%)peds pts with positive studies. Those pts. all had fewer tests, abxs and discharged faster suggesting marked economic benefits of the test.
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