Mollaret meningitis: report of a case with recovery after colchicine

A Hypothesis Regarding Neurosecretory Inhibition of Stress Mediators by Colchicine in Preventing Stress-Induced Familial Mediterranean Fever Attacks

Familial Mediterranean fever (FMF) is a monogenic autoinflammatory disease characterized by recurrent episodes of fever and serositis. Colchicine (Col) has a crucial role in the prevention of amyloidosis and FMF attacks. The effect of Col on innate immune cells is based on the inhibition of the microtubule system. The microtubule system is also very important for neurosecretory functions. The inhibitory effect of Col on neurosecretory functions is an overlooked issue. Considering that the neuroimmune cross-talk process plays a role in the development of inflammatory diseases, the effect of Col on the neuronal system becomes important. FMF attacks are related to emotional stress. Therefore, the effect of Col on stress mediators is taken into consideration. In this hypothetical review, we discuss the possible effects of Col on the central nervous systems (CNS) and peripheral nervous systems (PNS) in light of mostly experimental study findings using animal models. Studies to be carried out on this subject will shed light on the pathogenesis of FMF attacks and the other possible mechanisms of action of Col apart from the anti-inflammatory features.

La Méningite de Mollaret

Clinical and biological aspects of a case of Mollaret meningitis are reported. Some of the typical characteristics observed in the CSF of this rare entity will be discussed.

Herpes simplex virus type 2-associated recurrent aseptic (Mollaret's) meningitis in genitourinary medicine clinic: a case report

INTRODUCTION

Cases of idiopathic recurrent benign aseptic meningitis were first described by Mollaret. Today, herpes simplex virus (HSV) is considered the cause of most cases of Mollaret's meningitis.

CASE REPORT

A 40-year-old male was referred to our genitourinary medicine clinic with recurrent genital herpetic lesions. He had HSV-2-positive genital ulcers 8 years earlier. One year after the first infection, he developed severe recurrent attacks of headache associated with meningitis symptoms. The results of all radiological and biochemical tests were normal, but the patient reported a correlation between his attacks and genital herpes flare-ups. We diagnosed the patient with Mollaret's meningitis and started him on continuous suppressive acyclovir therapy, which resulted in marked clinical improvement.

DISCUSSION

Mollaret's meningitis is a rare form of idiopathic recurrent aseptic meningitis that has a sudden onset, short duration, and spontaneous remission with unpredictable recurrence. We believe that the presence of concurrent or recurrent mucocutaneous herpetic lesions can aid its diagnosis, prior to which, affected patients usually have many unnecessary investigations and treatments. Therefore, detailed sexual history should be sought in all patients with aseptic meningitis, and clinicians should also ask about history of recurrent headaches in all patients with recurrent herpetic anogenital lesions. Continuous suppressive acyclovir therapy may reduce the frequency and severity of attacks and can dramatically improve lifestyle.

[A case of colchicine-responsive Mollaret's meningitis with MEFV gene mutation]

A 66-year-old woman was admitted to our hospital with recurrent meningitis. She presented with 10 episodes of meningitis in 10 months. Examination of cerebrospinal fluid demonstrated pleocytosis, with neutrophils dominant at the early stage, and lymphocytes dominant at the late stage. Mollaret cells were found and the level of IL-6 was increased in cerebrospinal fluid. Several antibiotics and antiviral agents failed to prevent relapse. However, colchicine therapy successfully prevented the recurrence of meningitis. Genetic testing for familial Mediterranean fever (FMF) showed a mutation in the MEFV gene. It is difficult to diagnose the cause of Mollaret's meningitis in some patients. FMF, neuro-Behçet's disease, and neuro-Sweet disease should be included in the differential diagnosis of recurrent meningitis. In addition, colchicine therapy can prevent the relapse of meningitis in such cases.

Mollaret meningitis may be caused by reactivation of latent cerebral toxoplasmosis

Mollaret meningitis (MM) occurs mainly in females and is characterized by recurrent episodes of headache, transient neurological abnormalities, and the cerebrospinal fluid containing mononuclear cells. HSV-2 was usually identified as the causative agent. Recently, we found that recurrent headaches in non-HIV-infected subjects were due to acquired cerebral toxoplasmosis (CT). The aim of the study was therefore to focus on molecular pathomechanisms that may lead to reactivation of latent CT and manifest as MM. Literature data cited in this work were selected to illustrate that various factors may affect latent CNS Toxoplasma gondii infection/inflammation intensity and/or host defense mechanisms, i.e., the production of NO, cytokines, tryptophan degradation by indoleamine 2,3-dioxygenase, mechanisms mediated by an IFN-gamma responsive gene family, limiting the availability of intracellular iron to T. gondii, and production of reactive oxygen/nitrogen species, finally inducing choroid plexitis and/or vasculitis. Examples of triggers revealing MM and accompanying disturbances of IFN-gamma-mediated immune responses that control HSV-2 and T. gondii include: female predominance (female mice are more susceptible to T. gondii infection than males); HSV-2 infection (increased IFN-gamma, IL-12); metaraminol (increased plasma catecholamine levels, changes in cytokine expression favoring T(H)2 cells responses); probably cholesterol contained in debris from ruptured epidermoid cysts (decreased NO; increased TNF-alpha, IL-6, IL-8). These irregularities induced by the triggers may be responsible for reactivation of latent CT and development of MM. Thus, subjects with MM should have test(s) for T. gondii infection performed obligatorily.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

Recurring aseptic meningitis after travel to the tropics: a case of Mollaret's meningitis? Case report with review of the literature

Recurrent aseptic meningitis in a 35-year-old caucasian woman is described. She had many attacks over a period of 9 years. The first attack occurred after travel in the tropics. In spite of extensive examinations no cause could be found for the recurrent attacks. Both the clinical presentation and characteristics of the cerebrospinal fluid are compatible with the diagnosis of Mollaret's meningitis. There is no known cure for this condition, although colchicine and indomethacin have been mentioned to relieve symptoms. In our patient, a treatment with indomethacin during the last attack resulted in a clear and rapid improvement of symptoms. Since this episode only mild relapses have occurred, all of which responded well to the same treatment. This case highlights the long time span in which attacks of Mollaret's meningitis can occur, and the spectacular benefit of indomethacin.

Cytology of Mollaret meningitis

The diagnosis of Mollaret meningitis was established by cytologic examination of the cerebrospinal fluid (CSF) in a patient with recurrent aseptic meningitis. The characteristic features of the "Mollaret cell," an activated monocyte, are presented; theories of etiology are reviewed.

Neurologic manifestations in familial Mediterranean fever

Neurologic involvement in children with familial Mediterranean fever is relatively uncommon and rarely described in the pediatric literature. Although headaches occur frequently, meningitis and convulsions are rare. Thirteen of 101 children with familial Mediterranean fever developed neurologic manifestations. Of these 13 patients, 10 had headaches during acute episodes of the fever. Two patients had convulsions with fever before the age of 5 years; the convulsions and acute episodes recurred at ages 9 and 10 years. Another patient had two episodes of aseptic meningitis followed by convulsive disorder before the diagnosis of familial Mediterranean fever was made; his convulsions were resistant to antiepileptic drugs alone and subsided only when colchicine was added. The possibility of neurologic involvement should be considered in patients with familial Mediterranean fever.

Mollaret's meningitis in association with delivery in a Bedouin woman; a case report

A young Bedouin woman suffered two clusters of recurrent benign aseptic (Mollaret's) meningitis in association with two of her deliveries. This is the first case of Mollaret's syndrome related to delivery, and also the first presentation in a Bedouin.

Cranial and spinal tumors with meningitic onset

We review the literature on cases of cranial or spinal tumor presenting with meningitic symptoms. Embryonal tumors-dermoid cysts, epidermoid cysts, craniopharyngiomas, teratomas-and malignant gliomas were the cause of most of the episodes of chemical meningitis, single or multiple in patients with no neurological symptoms. Differential diagnosis from aseptic meningitis, especially from Mollaret aseptic meningitis, is essential.

Mollaret's meningitis: CSF-immunocytological examinations

Mollaret's meningitis is a rare clinical entity consisting of recurrent attacks of meningeal irritation, which, after a sudden onset, last for a few days. The prognosis appears to be excellent, although the aetiology has not been established. In the CSF so-called endothelial cells are a typical finding, but their classification is not yet clear. In the present case immunocytological examination of CSF cells revealed that the so-called Mollaret cells are monocytes. The time course of changes in helper/suppressor ratio is similar to that in other infectious diseases of the central nervous system.

Mollaret's meningitis responding to phenylbutazonum. A case report

A patient with Mollaret's meningitis is presented, with some unusual features. Criteria for the diagnosis are discussed. Many therapies for this recurrent aseptic meningitis have been suggested. In our patient there was a good response to phenylbutazonum, which to our knowledge has not been reported before.

Recurrent aseptic meningitis secondary to intracranial epidermoids

Two patients with recurrent aseptic meningitis are reported. Intracranial epidermoid tumors were eventually found in both patients. CSF changes in our first case with an epidermoid tumor were similar to those reported in Mollaret's meningitis, with an initial polymorphonuclear pleocytosis early in each attack, followed by a lymphocytic predominance several days later. Large cells which proved to be macrophages were also seen in the CSF of this patient. Both patients had meningitis attacks for several years before the underlying epidermoid tumor was found. Mollaret's meningitis remains a diagnosis of exclusion. These patients should remain tumor suspects for many years and deserve careful and repeated investigation.

Mollaret's meningitis: an unusual disease with a characteristic presentation

Mollaret's meningitis (benign recurrent aseptic meningitis) is a rare syndrome with characteristic features. Patients present with recurrent attacks of meningismus which are sudden in onset and last from one to seven days. During the attacks the spinal fluid shows pleocytosis with lymphocyte predominance. Large endothelial cells with indistinct cytoplasm (Mollaret's cells) are typically present in the CSF. The attacks resolve spontaneously and without sequellae. Symptom-free intervals can be as brief as a few days or as long as several years. Though specific treatment is not available, Colchicine has been reported to decrease the severity and frequency of attacks. While acute episodes may cause significant symptoms, the long-term prognosis is excellent.

Contribution to the background of Mollaret's meningitis

An epidermoid cyst of the 3rd ventricle was verified by necropsy in a man of 60 with three episodes of Mollaret's aseptic leukocytic-endothelial meningitis. The authors accept the interpretation as macrophages of the "endothelial" cells. They bring forward evidence for the blastomatous nature of partly cornified epithelial cells present in their case. They suggest that cholesterin containing debris entering the subarachnoid space from the tumour cysts provoke an aseptic "chemical" meningitis of short course.