Viral Meningitis

By John E. Greenlee, MD

Last full review/revision November 2015 by John E. Greenlee, MD

Viral meningitis tends to be less severe than acute bacterial meningitis. Findings include
headache, fever, and nuchal rigidity. Diagnosis is by CSF analysis. Treatment is with
supportive measures, acyclovir for suspected herpes simplex, and antiretroviral drugs for
suspected HIV infection.

Viral meningitis is sometimes used synonymously with aseptic meningitis. However, aseptic
meningitis usually refers to acute meningitis caused by anything other than the bacteria that
typically cause acute bacterial meningitis. Thus, aseptic meningitis can be caused by viruses,
noninfectious conditions (eg, drugs, disorders), fungi, or, occasionally, other organisms (eg,
in Lyme disease, in syphilis).

Causes

Viral meningitis usually results from hematogenous spread, but meningitis due to herpes
simplex virus type 2 (HSV-2) can also result from reactivation of latent infection.

The most common cause of viral meningitis is

Enteroviruses

For many viruses that cause meningitis (unlike the bacteria that cause acute bacterial
meningitis), incidence is seasonal (see Table: Common Causes of Viral Meningitis).

Common Causes of Viral Meningitis

Virus Mechanism of Transmission Seasonal Incidence

Virus Mechanism of Transmission Seasonal Incidence

Enteroviruses (eg,
coxsackieviruses,
echoviruses
Summer to early
Fecal-oral spread (eg, via autumn
contaminated food, in swimming
pools) Sometimes sporadic
cases throughout year

*Herpes simplex, usually Close contact with a person None

virus type 2 actively shedding the virus

Varicella-zoster virus Inhalation of respiratory droplets None

from or by contact with an
infected person
 Western equine virus
Mosquito Summer to early
Venezuelan equine virus autumn
West Nile virus
Mosquito Summer to early
St. Louis virus autumn
California encephalitis virus
Mosquito Summer to early
La Crosse virus autumn

Colorado tick fever virus Ticks Late spring to early

(unusual) summer

Lymphocytic Airborne Autumn to winter

choriomeningitis virus
HIV-1
Contact with body fluids of an None
HIV-2 infected person

*Herpes simplex type 2 meningitis may occur as an isolated instance or may recur (see
below).

Western equine and Venezuelan equine viruses have been associated with meningitis, but
no cases have been reported in the US in recent years.

Lymphocytic choriomeningitis virus is associated with exposure to infected wild mice (the
natural host for this virus) and is most common during autumn or winter when mice tend to
move indoors. Infection may also occur year-round when the cause is exposure to infected
pet hamsters.

Meningitis due to HIV usually begins early in the course of systemic infectionwhen
seroconversion occurs.

Symptoms and Signs

Viral meningitis, like acute bacterial meningitis, usually begins with symptoms that suggest
viral infection (eg, fever, myalgias, GI or respiratory symptoms), followed by symptoms and
signs of meningitis (headache, fever, nuchal rigidity). Manifestations tend to resemble those
of bacterial meningitis but are usually less severe (eg, nuchal rigidity may be less
pronounced). However, findings are sometimes severe enough to suggest acute bacterial
meningitis.

Diagnosis

CSF analysis (cell count, protein, glucose)

PCR of CSF and sometimes IgM

Sometimes PCR and/or culture of blood, a throat swab, nasopharyngeal secretions, or

stool
Diagnosis of viral meningitis is based on analysis of CSF obtained by lumbar puncture
(preceded by neuroimaging if increased intracranial pressure or a mass is suspected).
Typically, protein is slightly increased but less than that in acute bacterial meningitis (eg, <
150 mg/dL); however, the protein level can be very high in West Nile virus meningitis.
Glucose is usually normal or only slightly lower than normal. Other findings include
pleocytosis with a lymphocytic predominance. Nonetheless, no combination of findings in
CSF cells, protein, and glucose can rule out bacterial meningitis.

CSF viral culture is insensitive and not routinely done. PCR can be used to detect some
viruses in CSF (enteroviruses and herpes simplex, herpes zoster, West Nile viruses).
Measurement of IgM in CSF is more sensitive than PCR in diagnosing suspected West Nile
virus or other arboviruses.

Viral serologic tests, PCR, or culture of samples taken from other areas (eg, blood, a throat
swab, nasopharyngeal secretions, stool) may help identify the causative virus.

Pearls & Pitfalls

If patients appear seriously ill, treat them for acute bacterial meningitis until it is ruled
out, even if the cause is suspected to be viral.
Treatment

Supportive measures

Acyclovir (for suspected herpes simplex or herpes zoster) and antiretroviral drugs (for
HIV infection)

If patients appear seriously ill and if acute bacterial seems possible (even if viral meningitis is
suspected), appropriate antibiotics and corticosteroids are started immediately (without
waiting for test results) and continued until bacterial meningitis is ruled out (ie, CSF is shown
to be sterile).

Viral meningitis usually resolves spontaneously over weeks or, occasionally (eg, in West Nile
virus meningitis or lymphocytic choriomeningitis), months. Treatment is mainly supportive.

Acyclovir is efficacious in treating herpes simplex meningitis and can be used to treat herpes
zoster meningitis. If either of these viruses is suspected or if herpes simplex encephalitis is at
all suspected, most clinicians begin empiric treatment with acyclovir and, if PCR is negative
for these viruses, then stop the drug.

Pleconaril is only modestly efficacious for meningitis due to enteroviruses and is not
available for routine clinical use.

Patients with HIV meningitis are treated with antiretroviral drugs.

Key Points

Viral meningitis begins with symptoms typical of a viral illness, followed by

headache, fever, and nuchal rigidity, but is rarely as severe as acute bacterial
meningitis.
Enteroviruses are the most common cause, usually during summer or early autumn.

CSF findings (usually lymphocytic pleocytosis, near normal glucose, and slightly
increased protein) cannot exclude acute bacterial meningitis.

Treat patients for acute bacterial meningitis until that diagnosis is ruled out.

Treatment is mainly supportive; patients with herpes simplex or herpes zoster

meningitis may be treated with acyclovir