Herpes simplex virus type 2 recurrent meningitis (Mollaret's meningitis): a consideration for the recurrent pathogenesis

Mollaret Meningitis Caused by Varicella-Zoster Virus: A Case Report

Mollaret meningitis is a recurrent aseptic meningitis mostly caused by herpes simplex virus type 2. Other causes of the disease rarely exist, and its pathology is not well understood. Herein, we present a 57-year-old man who had been admitted to our hospital eight times with recurrent aseptic meningitis. Although the deoxyribonucleic acid (DNA) of varicella-zoster virus (VZV) was not detected in the cerebrospinal fluid (CSF), his genetic analysis, measurement of anti-VZV immunoglobulin-G (IgG) in the CSF, the VZV IgG index, IgG in the serum, and interleukin-1 beta in the CSF revealed that the Mollaret meningitis had been caused by the VZV. This case demonstrates that Mollaret meningitis can be caused by the VZV when specific factors are associated with decreased immune response. This case is valuable in elucidating the pathophysiology of Mollaret meningitis.

Benign Recurrent Aseptic Meningitis (Mollaret's Meningitis) in an Elderly Male: A Case Report

Mollaret's meningitis is an aseptic recurrent benign lymphocytic meningitis lasting 2-5 days and occurs over years with spontaneous complete resolution of symptoms between episodes. An 88 years-old-male presented with acute onset headache, lethargy and altered sensorium after a recent ear infection. He had multiple similar episodes in the past, each preceded by ear or sinus infection with cerebrospinal fluid finding consistent with aseptic meningitis. However, no specific causative agent was ever identified. He was confused, disoriented and lethargic with normal vitals and systemic examination. Blood tests showed leukocytosis with neutrophilia. Cerebrospinal fluid analysis revealed increased cell count with lymphocyte predominance, elevated protein and negative polymerase chain reaction. Magnetic resonance imaging of brain showed chronic small vessel ischemic changes. He fulfilled the Bruyn's criteria for clinical diagnosis. He was empirically administered acyclovir during hospitalization and was discharged without prophylactic antiviral due to negative cerebrospinal fluid analysis, culture and multiplex polymerase chain reaction.

Herpes simplex virus type 2-associated recurrent aseptic meningitis (Mollaret's meningitis) with a recurrence after 11-year interval: a case report

A 55-year-old woman was diagnosed with aseptic meningitis at the age of 43 and 44. She developed sudden fever and headache, and she showed nuchal rigidity. Cerebrospinal fluid examination revealed pleocytosis (cell count 208/mm³) and was positive for herpes simplex virus type 2 (HSV-2) DNA by PCR. Acyclovir was started on the first day of admission, and she was complete recovery. Preserved cerebrospinal fluid specimen from aseptic meningitis at the age of 44 was also positive for HSV-2 DNA by PCR. She was diagnosed with HSV-2 associated recurrent aseptic meningitis (Mollaret's meningitis) with a recurrence after 11-year interval. She repeatedly relapsed genital herpes after 44 years old and she was treated with valacyclovir whenever genital herpes relapses. But she showed no genital herpes at the onset of meningitis. Because HSV-2 is one of the most significant causes of recurrent meningitis, we would like to stress that HSV-2 infection and antiviral therapy should always be kept in mind for a recurrent meningitis case.

Herpes simplex virus 2 infection: molecular association with HIV and novel microbicides to prevent disease

Infection with herpes simplex viruses is one of the most ancient diseases described to affect humans. Infection with these viruses produces vexing effects to the host, which frequently recur. Infection with herpes simplex viruses is lifelong, and currently there is no vaccine or drug to prevent or cure infection. Prevalence of herpes simplex virus 2 (HSV-2) infection varies significantly depending on the geographical region and nears 20 % worldwide. Importantly, HSV-2 is the first cause of genital ulcers in the planet. HSV-2 affects approximately 500 million people around the globe and significantly increases the likelihood of acquiring the human immunodeficiency virus (HIV), as well as its shedding. Thus, controlling HSV-2 infection and spread is of public health concern. Here, we review the diseases produced by herpes simplex viruses, the factors that modulate HSV-2 infection, the relationship between HSV-2 and HIV and novel therapeutic and prophylactic microbicides/antivirals under development to prevent infection and pathological outcomes produced by this virus. We also review mutations associated with HSV-2 resistance to common antivirals.

Mollaret's meningitis and herpes simplex virus type 2 infections

Benign recurrent aseptic meningitis is a rare disorder described by Mollaret in 1944. When initially described, this form of aseptic meningitis had no identifiable infecting agent. New sophisticated diagnostic tools have now identified herpes simplex type 2 virus as the most commonly isolated agent. Antiviral treatment has been used successfully for prophylaxis and treatment.

A case of recurrent benign lymphocytic (Mollaret's) meningitis and review of the literature

Mollaret's meningitis is a rare form of benign recurrent aseptic meningitis first described in 1944. We report a case of Mollaret's meningitis due to Herpes Simplex Virus type 2 (HSV2), diagnosed with Polymerase Chain Reaction (PCR) implementation in the Cerebrospinal fluid (CSF) of the patient and treated successfully with acyclovir. To our knowledge, this is the first case of Mollaret's meningitis reported in Greece. We reviewed the literature since PCR has become widely available. Herpes Simplex Virus type 2 has been the most commonly identified causative agent of Mollaret's meningitis.

Recurrent meningitis attributable to herpes simplex virus-2 in a child

A boy manifested episodes of recurrent meningitis that were attributed to herpes simplex virus-2 infection. He presented no concurrent or previous history of involvement of the genitourinary system. He exhibited headaches, dizziness, photophobia, loss of balance, and vomiting. He underwent three episodes of aseptic meningitis. The herpes simplex virus-2 etiology was confirmed by polymerase chain reaction of the cerebrospinal fluid in the last two episodes. After the third occurrence, he was treated with acyclovir. Five years have elapsed since then, without the recurrence of aseptic meningitis.

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.

Mollaret meningitis associated with an intraspinal epidermoid cyst

Mollaret meningitis, a benign recurrent aseptic disease, is known to be associated with intracranial epidermoid cysts. In this report, we describe a case of Mollaret meningitis caused by an intraspinal epidermoid cyst located at thoracic level 12. The patient's clinical manifestations and cerebrospinal fluid features were similar to those with bacterial meningitis characterized by predominant polymorphonuclear leukocytes. However, Mollaret cells, not bacteria, were identified in the patient's cerebrospinal fluid. The illness ceased after surgical resection of the cyst, and the cyst tissue was pathologically diagnosed as epidermoid. Therefore, an intraspinal epidermoid cyst can be etiologically associated with Mollaret meningitis and should be included in the differential diagnosis of recurrent aseptic meningitis.

Adult meningism and viral meningitis, 1997-2004: clinical data and cerebrospinal fluid cytokines

OBJECTIVE

Although meningism manifesting acute headache has been observed to be associated with common viral and bacterial infections, its definition and pathogenesis have not been clarified. Clinical findings and cerebrospinal fluid (CSF) cytokines in adult patients with meningism were investigated and compared with those in viral meningitis.

PATIENTS AND METHODS

Among the adult inpatients in our hospital from 1997 to 2004, 5 with meningism and 17 with viral meningitis were identified according to the criteria described in this study, and their clinical data were analyzed. In the CSF samples of the 5 patients with meningism and the 17 with viral meningitis, the concentrations of interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), interleukin-2 (IL-2), IL-4, IL-6, and IL-10 were determined using a cytometric bead array.

RESULTS

The five patients with meningism all showed fever and meningeal signs such as severe headache and nuchal stiffness without CSF pleocytosis (<5 cells/mm3). Four patients were associated with herpetic Kaposi's eczema, herpes simplex, or herpes zoster, and all five patients had favorable outcomes. The levels of all CSF cytokines in patients with meningism were below normal values, whereas IFN-gamma and IL-6 in patients with viral meningitis were moderately elevated.

CONCLUSION

The normal cytokine levels in meningism may possibly reflect the lack of direct viral infection and may be helpful in differentiating both meningism and viral meningitis at an early stage.