Etiologies and Management of Aseptic Meningitis in Patients Admitted to an Internal Medicine Department

The Clinical Manifestations, Risk Factors, Etiologies, and Outcomes of Adult Patients with Infectious Meningitis and Encephalitis: Single Center Experience

(1) Background: Central nervous system (CNS) infections, including meningitis and encephalitis, are serious conditions which are associated with high morbidity and mortality. This study aims to identify the clinical manifestations, etiologies, and outcomes of meningitis and encephalitis in adult patients in Saudi Arabia, addressing the current gap in understanding these conditions within this population. (2) Methods: This is a single-center retrospective study which included all adult patients diagnosed with meningitis and encephalitis from March 2016 to May 2022. (3) Results: This study found that most cases of meningitis and encephalitis occurred due to unknown pathogens. Pretreatment with antibiotics prior to lumbar puncture (LP) was found in 71.2% of patients with meningitis. Altered mental status and seizures were common presenting symptoms among patients with encephalitis while altered mental status and fever were common among patients with meningitis. (4) Conclusions: Adherence to guidelines in treating meningitis and encephalitis and performing LPs in a timely manner are important. Establishing national biobanks with biological samples from patients suspected of having meningitis or encephalitis will significantly enhance our understanding of these conditions in Saudi Arabia.

Impact of the COVID-19 Outbreak on Aseptic Meningitis in Children

Objectives

Viruses are the most common infectious causes of aseptic meningitis (AM). After the COVID-19 pandemic, AM following the COVID-19 disease and its different vaccines were reported. This study compares some characteristics of patients with AM before and after the COVID-19 pandemic.

Materials & Methods

This retrospective cross-sectional study analyzed patients' demographic and laboratory data (one month to 14 years old) with AM from March 2018 to March 2022. The first period involves two years before the COVID-19 outbreak (March 2018 to March 2020). The second period starts with the COVID-19 pandemic (from March 2020 until March 2022).

Results

A significant decrease was observed in the frequency of patients admitted with AM after the COVID-19 pandemic in the referral children's hospital in Qazvin. The incidence of AM in children older than five decreased significantly, and as a result, the average age of patients with this diagnosis decreased, too. A meaningful decline in the prevalence of AM in the summer and fall seasons has been observed.

Conclusion

After the COVID-19 outbreak, the incidence of AM in children significantly decreased. Implementing the hygienic recommendations for inhibiting COVID-19 virus transmission also protected children from the spread of other viruses.

Audit of adherence to international guidelines (IDSA) in the treatment of infectious meningitis in pediatric patients in Jordan

OBJECTIVE

This study aims to audit the adherence of Jordanian medical care staff to the guidelines provided by the Infectious Disease Society of America (IDSA) for managing pediatric patients admitted with suspected cases of meningitis.

METHODS

A retrospective observational study was conducted at Jordan University Hospital (JUH). All pediatric patients admitted to JUH with suspected meningitis between January 1, 2019, and September 30, 2022, who underwent Cerebrospinal Fluid (CSF) and blood culture tests were recruited in this study unless there was a reason for exclusion. The study collected data on the empiric antibiotics prescribed prior to diagnostic cultures and susceptibility results. Additionally, the length of hospital stay and all-cause mortality were observed. The appropriateness of antibiotics prescription before culture results was compared to IDSA guidelines, and an overall adherence rate was calculated.

RESULTS

A total of 332 pediatric patients were included in this study, of whom 12.3% (n = 41) were diagnosed with bacterial meningitis. Among the enrolled pediatric patients, only 27 patients (8.1%) received appropriate treatment adhering to the IDSA guidelines. The remaining 91.9% (n = 305) showed various forms of non-adherence to recommendations. The highest adherence rate was observed for performing CSF culture (n = 330, 99.4%), while the lowest adherence rate was found in selecting the appropriate dose and duration for empiric antibiotics (n = 107, 41.3% and n = 133, 51.0%, respectively).

CONCLUSION

This study revealed a low overall adherence in the management of pediatric patients with meningitis in Jordan. Establishing an antimicrobial stewardship program may improve the outcomes of meningitis infections found in Jordan, and prevent dangerous adverse effects and bacterial resistance.

The Worldwide Prevalence of Herpes Simplex Virus Encephalitis and Meningitis: A Systematic Review and Meta-Analysis

Given the relatively high frequency of central nervous system infections and considerable mor- tality and morbidity reported to be caused by herpes simplex viruses among the other viral agents, having a clear knowledge about their epidemiological profile seems necessary. This systematic review and meta-analysis aimed to determine the relative frequency and preva- lence of herpes simplex encephalitis and meningitis in patients tested for viral etiologies. A comprehensive systematic review was performed in PubMed, Scopus, and Web of Science databases, searching for studies on the prevalence and relative frequency of herpes sim- plex virus 1 and herpes simplex virus 2 encephalitis and meningitis. Seventy-one studies were included. Overall, the prevalence of herpes simplex virus encephalitis among patients tested was 8% (95% confidence interval, 6%-11%; I2 = 98%) and the prevalence of herpes simplex virus meningitis among aseptic patients tested was 4% (95% confidence interval, 3%-7%; I2 = 95%), and a significant difference was observed by region. The results of our subgroup analysis for herpes simplex virus encephalitis revealed a prevalence of 8% for pediatric patients and ado- lescents and 12% for adults. The results for herpes simplex virus meningitis showed a prevalence of 4% for pediatric patients and adolescents and 9% for adults. We observed significant differ- ences in the frequency of herpes simplex virus 1 and herpes simplex virus 2 detection rates by region. Having high rates of missed cases due to inadequate, highly sensitive paraclinical tests performed on patients with suspected viral central nervous system infection is one of the pos- sible factors. More studies are needed to detect the possible flaws in the process of diagnosis in different regions.

COVID-19-Associated Acute Necrotizing Encephalopathy: A Case Report

COVID-19 is a pandemic disease in which most patients have pulmonary symptoms. However, several cases of CNS involvement associated with COVID-19 have been reported. Acute necrotizing encephalopathy of childhood (ANEC) is a rare CNS complication of viral infections such as influenza, herpes virus, and COVID-19, leading to high mortality and morbidity rates. Several cases of COVID-19-associated acute necrotizing encephalopathy (ANE) have been reported since March 2020 in adults, with just a few cases in pediatrics. This article reports a 5-month-old child who presented with seizures, with the final diagnosis of ANE as a complication of COVID-19. MRI findings of ANEC, as reported in most COVID-19-associated ANEC case reports, involve bilateral, symmetric, multifocal lesions in the central thalami. Moreover, the brainstem, cerebral white matter, and cerebellum could be affected. The prognosis of COVID-19-associated ANE is poor, leading to neurologic dysfunction or mortality. COVID-19-associated ANE cases must be reported, especially in pediatrics, with detailed clinical history, laboratory data, and radiologic findings to introduce diagnostic criteria, prognosis, and a management protocol.

Cerebrospinal fluid proteomics in meningitis patients with reactivated varicella zoster virus

OBJECTIVE

This study investigated the proteomic characteristics of cerebrospinal fluid (CSF) in patients with varicella zoster virus (VZV) meningitis to understanding the pathogenesis of central nervous system (CNS) infection by reactivated VZV.

METHOD

We used data-independent acquisition model to analyze the CSF proteomic differences of 28 patients with VZV meningitis and 11 herpes zoster (HZ) patients. According to the clinical manifestations at discharge, 28 VZV meningitis patients were divided into favorable outcome group and unfavorable outcome (UO) group and their differences in CSF proteome were also analyzed.

RESULTS

Compared with the HZ group, the proteins (CXCL10, ELANE, IL-1RN, MPO, PRTN3, etc.) related to inflammation and immune cell activation were significantly upregulated in the VZV meningitis group (p < .01). The protein related to the nerve function and energy metabolism (CKMT1B, SLITRK3, Synaptotagmin-3, KIF5B, etc.) were significantly downregulated (p < .05). The levels of a pro-inflammatory factor, IL-18, in CSF were significantly higher in patients in the UO group as compared to patients with favorable prognosis (p < .05).

CONCLUSION

Inflammatory immune response is an important pathophysiological mechanism of CNS infection by VZV, and the CSF IL-18 levels might be a potential prognostic indicator of the outcomes of VZV meningitis.

Inborn Errors of Immunity Predisposing to Herpes Simplex Virus Infections of the Central Nervous System

Herpesvirus infections can lead to a number of severe clinical manifestations, particularly when involving the central nervous system (CNS), causing encephalitis and meningitis. However, understanding of the host factors conferring increased susceptibility to these diseases and their complications remains incomplete. Previous studies have uncovered defects in the innate Toll-like receptor 3 pathway and production of type I interferon (IFN-I) in children and adults that predispose them to herpes simplex encephalitis. More recently, there is accumulating evidence for an important role of IFN-independent cell-autonomous intrinsic mechanisms, including small nucleolar RNAs, RNA lariat metabolism, and autophagy, in restricting herpesvirus replication and conferring protection against CNS infection. The present review first describes clinical manifestations of HSV infection with a focus on neurological complications and then summarizes the host-pathogen interactions and innate immune pathways responsible for sensing herpesviruses and triggering antiviral responses and immunity. Next, we review the current landscape of inborn errors of immunity and the underlying genetic defects and disturbances of cellular immune pathways that confer increased susceptibility to HSV infection in CNS. Ultimately, we discuss some of the present outstanding unanswered questions relating to inborn errors of immunity and HSV CNS infection together with some perspectives and future directions for research in the pathogenesis of these severe diseases in humans.

The impact of cerebrospinal fluid viral polymerase chain reaction testing on the management of adults with viral meningitis: A multi-center retrospective study

The aim of this study was to evaluate the role of viral polymerase chain reaction (PCR) testing in patients with aseptic meningitis and identify opportunities for improvement in clinical management. All cerebrospinal fluid samples collected in 1 year from four teaching hospitals in Sydney, Australia, were reviewed. Patients with aseptic meningitis were selected, and clinical and diagnostic features, hospital length of stay (LOS), and treatment were analyzed. Identifying a cause by viral PCR did not reduce hospital LOS (median 3 days) or antibiotic use (median 2 days), but the turnaround time of the PCR test correlated with LOS (Rs = 0.3822, p = 0.0003). Forty-one percent of patients received intravenous acyclovir treatment, which was more frequent in patients admitted under neurologists than infectious diseases physicians (56% vs. 24%; p = 0.013). The majority of patients did not have investigations for alternative causes of aseptic meningitis such as human immunodeficiency virus and syphilis if the viral PCR panel was negative. The benefit of PCR testing in aseptic meningitis in adults in reducing LOS and antibiotic use is unclear. The reasons for unnecessary aciclovir use in meningitis syndromes require further assessment.

Optic ataxia in a patient with HaNDL syndrome

We present a woman in her 40s who arrived at the emergency room with hypertension and optic ataxia. Her medical history is only relevant for obesity. Her lumbar puncture revealed high intracranial pressure and lymphocytic pleocytosis, and her neuroimaging tests, including angiography and venography, were normal. The patient improved after a cerebrospinal fluid drainage with a lumbar puncture, and her clinical manifestations resolved in parallel to the lymphocytic pleocytosis.The patient was diagnosed with a syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis and fully recovered 21 days after her discharge.

Cerebral vasculitis due to Aspergillus spp. in immunocompromised patients: literature review

OBJECTIVES

Invasive aspergillosis is a threat for immunocompromised patients. We present a case series of aggressive cerebral vasculitis caused by Aspergillus spp. infection in immunocompromised patients.

METHODS

We present a retrospective case series of three autopsy-proven invasive cerebral aspergillosis with diffuse vasculitis affecting large caliber cerebral vessels.

RESULTS

Three patients were immunosuppressed: one on rituximab, one on corticosteroids, and one with a renal transplant. Two of these patients were diagnosed with cerebral aspergillosis on postmortem.

CONCLUSION

Aspergillus cerebral vasculitis is a rare form of invasive aspergillosis that should be considered in an immunocompromised individual with suggestive lesions on imaging. It should be suspected as a possible cause of aseptic neutrophil meningitis.

Herpes simplex virus 2 meningitis in adults: A prospective, nationwide, population-based cohort study

BACKGROUND

Data on the clinical presentation are scarce and prognostic factors of Herpes simplex virus type 2 (HSV-2) meningitis remain unknown.

METHODS

Prospective, nationwide, population-based database identifying all adults treated for HSV-2 meningitis at departments of infectious diseases in Denmark from 2015-2020. Unfavorable outcome was defined as Glasgow Outcome Scale (GOS) score of 1-4 and extended GOS score of 1-6. Modified Poisson regression was used to compute relative risks with 95% confidence intervals (RR, 95% CI) for unfavorable outcome.

RESULTS

HSV-2 meningitis was diagnosed in 205 cases (76% female, median age 35 [IQR 27-49]) yielding an incidence of 0.7/100,000/year. Common symptoms were headache 195/204 (95%), photo/phonophobia 143/188 (76%), and neck stiffness 106/196 (54%). Median time to lumbar puncture was 2.0 hours (IQR 1-4.8) and cerebrospinal fluid (CSF) leukocyte count was 360x10 6/L (IQR 166-670) with a mononuclear predominance of 97% (IQR 91-99). Lumbar puncture was preceded by brain imaging in 61/205 (30%). Acyclovir/valaciclovir was administered in 197/205 (96%) cases for a median of 10 days (IQR 7-14).Unfavorable outcome was observed in 64/205 (31%) at discharge and 19/181 (11%) after six months and was not associated with female sex (RR 1.08, 95% CI 0.65-1.79), age ≥35 years (1.28, 0.83-1.97), immuno-compromise (1.07, 0.57-2.03), or CSF leukocyte count >1,000x10 6/L (0.78, 0.33-1.84).

CONCLUSIONS

HSV-2 meningitis often presented as meningeal symptoms in younger females. Unfavorable outcome at discharge was common and was not associated with sex, age, immune-compromise, or CSF leukocyte count. Sequelae persisted beyond six months in one tenth of patients.

Molecular identification and clinical characteristics of mumps virus and human herpesviruses associated with aseptic meningitis in South of Iran

Viral infections are the major etiological agent of aseptic meningitis; though, limited data exist on the prevalence and molecular epidemiology of viral pathogens responsible for the occurrence of aseptic meningitis in Iran. Therefore, this study aimed to elucidate the prevalence and clinical features of mumps virus and human herpesviruses associated with aseptic meningitis in the South of Iran. A total of 73 patients with aseptic meningitis were enrolled in this study. Cerebral spinal fluid (CSF) samples were tested for detection of HSV, CMV, VZV and mumps virus using nested PCR assay. Mumps virus, HSV-1 and VZV were found in 4 (5.5%), 4 (5.5%) and 3 (4.1%) of the CSF samples, respectively. The highest rates of mumps virus and HSV infections were observed in infants less than one year, and VZV was more prevalent in patients under 5 years of age. The majority of mumps virus and VZV infections were found among male patients, while HSV was more prevalent among female patients. The highest incidence of aseptic meningitis associated with mumps virus was observed in summer, while HSV and VZV were more prevalent during spring. Headache was the most common symptom in mumps meningitis. About HSV and VZV, the most predominant clinical symptom was fever. The results of this study indicate the importance of molecular assay in the diagnosis of etiological agents of aseptic meningitis. Prompt detection of viral pathogens provides a better chance of managing viral meningitis in health care settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13337-021-00718-y.

High rate of human enteroviruses among clinically suspected meningitis cases at selected Hospitals in Addis Ababa, Ethiopia

BACKGROUND

Because of limited infrastructure and skilled human capital, the etiology of meningitis is rarely identified in developing countries like Ethiopia. This results in unnecessary antibiotics use, economic crisis, hospitalization, and related nosocomial infections. Thus, we aimed to assess the epidemiology of human enteroviruses (HEVs) among clinically suspected meningitis cases in Addis Ababa, Ethiopia.

METHOD

A cross-sectional study was conducted from January to August 2020 at selected Hospitals in Addis Ababa, Ethiopia. Reverse transcriptase-polymerase chain reaction (RT-PCR) was conducted on cerebrospinal fluid (CSF) collected from 146 clinically suspected meningitis and bacterial culture-negative patients. SPSS v 21.0 was used for data analysis and bivariate correlation was done for the association between variables of interest.

RESULTS

HEVs were detected in 39 (26.7%) of the 146 clinically suspected meningitis cases. Most of the HEVs cases 28 (71.9%) were detected in younger-aged infants less than 1 year. The most commonly observed clinical manifestations were vomiting (75.5%) followed by fever (56.8%) and impaired consciousness or irritability (50.7%). The mean length of hospital stay for patients with enteroviral meningitis was 9 days. Many patients with HEVs were recovered with sequelae (46.2%), and HEVs has contributed for one out of the nine meningeal deaths (11.1%).

CONCLUSIONS

HEVs were found to be the commonest cause of morbidity and mortality in all age groups. Many of the patients were mistreated with antibiotics and hospitalized. The detection of HEVs in 26.7% of clinically suspected meningitis cases indicated the need for molecular tests in investigating the etiology of meningitis. Therefore, we suggest the introduction of molecular tests as a routine practice in referral hospitals and the need to further characterize circulating HEVs strains.

Epidemiology Profile of Viral Meningitis Infections Among Patients in Qatar (2015-2018)

Background: Little is known about the etiology of meningitis in the MENA region, including Qatar. Viral agents are considered the major cause for meningitis worldwide. Here, we present primary data about the etiology and clinical and demographic characteristics of viral meningitis (VM) in Qatar between 2015 and 2018.

Methods: We retrospectively collected data from Hamad Medical Corporation (HMC), which provides about 80% of healthcare services in Qatar. Data were collected for the period between 2015 and 2018. During this time period, 6,705 specimens were collected from patients with suspected meningitis attending HMC and primary healthcare centers. These specimens were tested for a panel of viruses using the “FTD Viral meningitis” multiplex real-time PCR kit that detects Adenovirus (ADV), Human herpesvirus 1&2 (HSV1 and HSV2), Epstein–Barr virus (EBV), Enteroviruses (EV), Cytomegalovirus (CMV), Varicella zoster virus (VZV), and Parechovirus (PV).

Results: Only 10.9% (732/6,705) of all suspected meningitis cases were caused by viral agents. 60.9% of the reported cases were males, compared to 39.1% in females. Most of the infections (73.9%) were reported in children younger than 10 years of age. EV were identified as the main causative agent (68.7%), followed by EBV (7.5%) and ADV (6.8%). Other viral agents including VZV, PV, HSV-1, and HSV-2 were also detected with a lower frequency. Confirmed VM were more prevalent among Qatari subjects compared to other nationalities. We observed no specific seasonality of viral agents, but a slight rise was recorded during the spring seasons (March to June). Fever (59.4%, 435/732) and acute central nervous system (CNS) infection (15.6%, 114/732) were initial symptoms of most cases.

Conclusion: This is the first report about the molecular epidemiology of VM in Qatar. In line with the international records, our data showed that EV is responsible for 68.7% of Qatar's VM cases. Further studies are needed to genotype and serotype the identified viruses.

Molecular epidemiology of enteroviruses and predominance of echovirus 30 in an Iranian population with aseptic meningitis

Human enteroviruses are the most prevalent causes of aseptic meningitis worldwide. However, despite such predominancy, defining the enteroviral etiology of aseptic meningitis remains a diagnostic dilemma for the clinician in Iran. Therefore, this study was conducted to characterize the prevalence and clinical significance of enteroviral aseptic meningitis as well as the predominant enterovirus serotypes among patients with aseptic meningitis in the South of Iran.Cerebrospinal fluid (CSF) specimens were obtained from 73 patients with aseptic meningitis (52.1% males and 47.9% females), ages ranging from 1 month to 88 years. Following the extraction of nucleic acid, the detection of enteroviruses was performed by RT-PCR, targeting the 5' untranslated region of the genome, and sequencing. Enteroviruses were found in 46.6% of samples (34/73). The most predominant serotype was echovirus 30, followed by coxsackievirus B5 and poliovirus type 1 Sabin strain. The enterovirus infections were more prevalent among female patients (58.8%) and those below 5 years of age (52.9%). Although enterovirus infections were observed throughout the year, the infections were more prevalent during autumn with fever as the predominant clinical symptom. The outcomes revealed that enteroviruses are significant causes of aseptic meningitis in the South of Iran, while suspected cases of aseptic meningitis are usually monitored by bacterial culture and biochemical testing of CSF samples. Therefore, the etiology remains unknown in most cases. Molecular detection of viral pathogens should be included as a common approach in the screening of patients with aseptic meningitis to prevent unnecessary treatment and to improve clinical management.

Viral Etiologies of Meningitis in Patients with Presumed Pyogenic Meningitis at University Hospitals in Ethiopia

Introduction

Viral meningitis is common in most resource-limited settings, posing a challenge for the management and prognosis of suspected patients. No study has been done on the detection of either viral or viral-bacterial co-infection among presumed pyogenic meningitis cases in Ethiopia. We, therefore, aimed to determine the distribution of cytomegalovirus (CMV) and human enteroviruses (HEVs) among patients with presumptive pyogenic meningitis at University hospitals in Ethiopia.

Methods

Viral nucleic acid was extracted from 86 repository CSF samples, which were collected from patients presumptively diagnosed with pyogenic meningitis between 2012 and 2013. PCR was done consecutively to investigate the possible viral etiologic agents of meningitis.

Results

HEVs were detected in 11 (12.8%) of the analyzed samples while none of the 86 samples were tested positive for CMV. Viral-bacterial co-infections were found among 4/11 (36.4%) confirmed cases. The majority of the patients (10/11) with HEVs were younger aged ≤ 19 years old.

Conclusions

In this study, the magnitude of HEVs was shown to have a significant role in presumed pyogenic meningitis cases. Therefore, we recommend presumed pyogenic meningitis cases to be inspected for viral etiologies and improve meningeal symptoms interpretations.

Clinical Signs, Prevention and Treatment of Viral Infections in Infants

Certain infectious diseases are common in infants than any other age groups and are associated with morbidities in childhood and adulthood, and even mortality in severe cases. Environment, epidemic and maternal immunity are the main causes of these infections. Early diagnosis using molecular methods and treatment is therefore important to prevent future complications. Vaccines are recommended during infancy and childhood to prevent these infections. This review highlights some of the most commonly reported viral infections in children, their clinical signs, prevention and treatment.

Viruses Causing Aseptic Meningitis: A Tertiary Medical Center Experience With a Multiplex PCR Assay

Background: Central nervous system (CNS) infection is associated with high rates of morbidity and mortality, and despite advancements in molecular testing, aseptic meningitis remains challenging to diagnose. Aseptic meningitis cases are often underreported worldwide, which impacts the quality of patient care. Therefore, we aimed to assess the results of BioFire® FilmArray® meningitis/encephalitis (ME) PCR panel, clinical characteristics, and etiologies of aseptic meningitis patients.

Methods: From January 2018 to January 2020, all pediatric and adult patients in a large tertiary medical center who underwent lumbar puncture and cerebrospinal fluid (CSF) testing by a ME multiplex PCR panel and who fit the aseptic meningitis definition were retrospectively reviewed.

Results: Data were reviewed from 1,607 patients; 240 met the inclusion criteria (54.6% males; 68.8% <4 years of age). The rate of detected viral causes of aseptic meningitis was 40.4%; therefore, 59.6% of the patients remained with unidentified etiology. Among the identified viral meningitis, enterovirus and human herpesvirus 6 (HHV-6) were the most common (25 and 7.9%, respectively). The median length of hospital stay was 6 days, and it was longer in patients with unidentifiable aseptic meningitis (p < 0.0001).

Conclusion: Aseptic meningitis is common among suspected meningitis patients, but most cases remained of unknown etiology. The most common identified viruses were enterovirus followed by HHV-6, and there is predominance in males and the pediatric age group. These results highlight that further research is needed to identify other etiologies and possible additional viral pathogens for aseptic meningitis in the current diagnostic methods.

Viral Meningitis: A Pediatric Case Study

Meningitis is a significant viral, bacterial, or fungal infection of the meninges that cover and protect the brain and the spinal cord. Symptoms of meningitis may present rapidly or develop gradually over a period of days, manifesting with common prodromal flu-like symptoms of headache, photophobia, fever, nuchal rigidity, myalgias, and fatigue. Character and significance of symptoms vary by patient age. Symptoms of infection may improve spontaneously or worsen, becoming potentially lethal. Early recognition and treatment of meningitis are crucial to prevent morbidity and mortality. The case reviewed in this article focuses on viral meningitis in a pediatric patient that may be unrecognized or underreported because of indistinct symptoms. Epidemiology, pathophysiology, presentation, assessment techniques, diagnostics, clinical management, and health promotion relevant to viral meningitis are presented.

Etiology, Clinical Presentation and Incidence of Infectious Meningitis and Encephalitis in Polish Children

Little is known about the causes and the frequency of meningitis and encephalitis in Poland. We did a retrospective single-center cohort study of children under 18 years old hospitalized with infectious meningitis or encephalitis. Incidence rates were calculated using collected data from patients from the North-East Poland only. A total of 374 children hospitalized between 1 January 2015 and 31 December 2019 were included in the study. A total of 332 (89%) children had meningitis, and 42 (11%) had encephalitis. The etiology of the infection was established in 331 (89%) cases. Enteroviruses accounted for 224 (60%) of all patients. A total of 68 (18%) cases were tick-borne infections. Bacterial pathogens were detected in 26 (7%) children. The median length of hospital stay for children with enteroviral meningitis was 7 days (IQR 7–9), increasing to 11 days (8–13) in those treated with antibiotics. The incidence of meningitis was estimated to be 32.22 (95% CI, 25.33–40.98) per 100,000 and that of encephalitis to be 4.08 (95% CI, 2.07–8.02) per 100,000. By the broad use of molecular diagnostic methods, we managed to identify etiology of the infection in the majority of children. Our data suggest that thorough diagnostics of central nervous system infections are needed to rationalize treatment.

Varicella-Zoster as a Cause of Aseptic Meningitis in an Immunocompetent Young Patient With Skin Rash

We present a case of aseptic meningitis due to Varicella-Zoster infection in an immunocompetent patient. Varicella-Zoster virus (VZV) causes chickenpox disease in children, teens, and young adults. Typically, it runs its course and stays dormant in nerve tissue, which can get reactivated in elderly, immunocompromised patients. Frequently, reactivation results in the painful dermatomal rash of herpes zoster, but in sporadic cases, it can cause meningitis or encephalitis in the immunocompromised population. Our case demonstrates a healthy immunocompetent adult male who presented with headache, fever, mild neck stiffness, and painless right-sided abdominal skin rash and was later diagnosed with VZV meningitis via polymerase chain reaction (PCR) of the cerebrospinal fluid (CSF). We are reporting this case due to its rarity, and the challenging nature of its diagnosis and treatment. In the hospital, he was treated with IV acyclovir for three days and discharged home on 14 days of oral valacyclovir. Our case demonstrates the importance of having a high degree of suspicion, even if the presentation is unexpected and atypical.

Methods for rapid diagnosis of meningitis etiology in adults

Infectious meningitis can be caused by viral, bacterial or fungal pathogens. Despite widely available treatments, many types of infectious meningitis are still associated with significant morbidity and mortality. Delay in diagnosis contributes to poor outcomes. Cerebrospinal fluid cultures have been used traditionally but are time intensive and sensitivity is decreased by empiric treatment prior to culture. More rapid techniques such as the cryptococcal lateral flow assay (IMMY), GeneXpert MTB/Rif Ultra (Cepheid) and FilmArray multiplex-PCR (Biofire) are three examples that have drastically changed meningitis diagnostics. This review will discuss a holistic approach to diagnosing bacterial, mycobacterial, viral and fungal meningitis.

Drug-induced meningitis: A review of the literature and comparison with an historical cohort of viral meningitis cases

BACKGROUND

Drug-induced aseptic meningitis (DIAM) is potentially insufficiently considered by clinician, being of rare etiology, with there being no previously published exhaustive study describing its clinical and biological features.

METHODS

Two independent academic clinicians searched all the case reports of DIAM from 1995 until 15^th April, 2017. The search was limited to studies performed in humans, published in English or French. Clinical and biological data of subjects were compared with those of patients with documented viral meningitis.

RESULTS

One hundred and fifty-one case reports fulfilled our inclusion criteria. Non-steroidal anti-inflammatory drugs were the commonest drug cause of AM n=49, followed by antibiotics n=46, biotherapy n=19 and finally immunomodulators n=15. The clinical and biological presentation of DIAM varies according to the causative etiological drug, especially with respect to the interval between exposure and presentation and cerebrospinal fluid (CSF) pleiocytosis. Clinical symptoms associated with meningitis were more prevalent in viral meningitis than in DIAM, except for fever and signs of encephalitis. Cerebrospinal fluid examination in DIAM reveals an increased CSF white cell count and an increased proportion of neutrophils and protein, compared with viral meningitis.

DISCUSSION

We present an extensive review of the DIAM case reports, and highlight their clinical and biological characteristics according to the drugs involved. While comparing for the first time their characteristics with those of viral meningitis, this review hopes in facilitate earlier diagnosis and management of DIAM in clinical practice.

Recurrent Herpes Simplex Virus 2 Lymphocytic Meningitis in Patient with IgG Subclass 2 Deficiency

We report a case of a patient with a lifetime history of 8 episodes of recurrent lymphocytic meningitis. Our findings suggest that susceptibility to recurrent lymphocytic meningitis might be caused by low serum IgG subclass 2 immunodeficiency.

Meningitis due to non-steroidal anti-inflammatory drugs: an often-overlooked complication of a widely used medication

A 40-year-old man developed aseptic meningitis after ibuprofen consumption for tension-type headaches. After a thorough diagnostic workup and lack of improvement on empirical therapy for common aetiologies of meningitis (bacterial and viral infections), we suspected non-steroidal anti-inflammatory drug (NSAID) induced meningitis due to the temporal relationship between drug administration and symptom onset. Two days after NSAID suppression, the evolution was progressively favourable with complete resolution of fever and symptoms. On follow-up, symptoms did not recur and there was no neurological sequela. This article summarises the clinical picture and the complementary exams that led to the difficult-to-make diagnosis of NSAID-induced acute meningitis, in parallel with a brief review of the literature.

Varicella zoster virus infection of the central nervous system in a tertiary care center in Lebanon

OBJECTIVE

To describe the clinical manifestations and treatment outcomes of patients with VZV meningitis and encephalitis consulting at two medical centers in Lebanon.

METHODS

Retrospective study of patients with VZV meningitis and/or encephalitis confirmed by positive cerebrospinal fluid (CSF) VZV PCR.

RESULTS

Twenty patients were identified (13 males). The average age was 49.7±22.2 years. The most common complaint was headache (n=17/20). Common comorbidities included hypertension (n=7/20) and diabetes mellitus (n=5/20). Immunosuppression was reported in two patients. Vesicles were only observed in eight patients. Altered mental status, focal neurological deficits, and fever were documented in six, two, and four patients respectively. All patients had CSF leukocytosis with lymphocytic predominance, normal CSF/serum glucose ratio, and high CSF protein. Eighteen patients had brain CT scans showing no relevant findings. Two of 12 patients with brain MRI had focal abnormalities. Unilateral temporal slow waves were observed in three of four patients who underwent electroencephalograms. Four patients had encephalitis and 16 had meningitis. Eighteen patients received an antiviral therapy. Treatment either included intravenous acyclovir or oral valacyclovir. The encephalitis and meningitis groups had comparable mean duration of treatment (13.5±6.6 vs. 12.2±5.4, respectively). All admitted patients showed clinical cure with no reported neurological sequelae.

CONCLUSION

VZV infection should be suspected in any patient with signs and symptoms of viral meningitis or encephalitis, irrespective of age, immune status, presence or absence of vesicles, fever, or neck stiffness.

Impact of Enterovirus Molecular Assay Turnaround Time on Hospitalization Length During an Echovirus 30 Meningitis Outbreak, France, Fall 2014

Background:

The impact of Enterovirus Real Time-Polymerase Chain Reaction assay (EV RT-PCR) on hospitalization lengths of patients with aseptic meningitis has been investigated but the impact of early EV RT-PCR results released on time before patient discharge remains unclear during Echovirus meningitis outbreaks.

Objective:

To assess a potential correlation between EV RT-PCR turn-around time and hospitalization lengths during an Echovirus meningitis outbreak.

Method:

Eighteen patients demonstrating a positive EV RT-PCR assay performed on Cerebrospinal Fluid (CSF) samples collected between October 1st 2014 and December 31st 2014 were retrospectively included. Viral protein 1 (VP1) gene region was amplified and sequenced using a classical Sanger sequencing reaction. Clinical data were retrospectively collected from patient’s records. Quantitative variables expressed as median values and ranges were compared using Mann Whitney U test. Correlations were performed using simple regression analysis.

Results:

Phylogenetic VP1 sequence analyses identified that the outbreak was related to an Echovirus 30 strain in 7 out of the 10 cases with available sequencing data. The three remaining sequences analyses evidenced Echovirus 14, 9 and 7 strains. Hospitalization length was statistically shorter in children without comorbidity (n=5) than in adult patients (n=10) or neonates and children with comorbidity (n=3) (p=0.003 and 0.01 respectively), whereas EV RT-PCR turnaround time was not statistically different between these groups. Correlation between hospitalization length and EV RT-PCR turnaround time was poor (R2=0.06), especially in adults (R2=0.01)

Conclusion:

Our data indicated that EV RT-PCR turnaround time was not correlated to hospitalization length during a short Echovirus meningitis outbreak.

Viral (aseptic) meningitis: A review

Viral meningitis is an inflammation of the meninges associated with acute onset of meningeal symptoms and fever, pleocytosis of the cerebrospinal fluid, and no growth on routine bacterial culture. It is sometimes associated with viral encephalitis and meningoencephalitis. Viruses reach the central nervous system (CNS) hematogenously or in a retrograde manner from nerve endings. The viral etiology varies according to age and country. Molecular diagnostics technology has helped improve the rate of pathogen detection reducing unnecessary antibiotic use and length of hospitalization. Most of the viral infections detailed in this article have no specific treatment other than supportive care. Many of the viruses discussed are preventable by vaccination and proper skin protection against transmitting vectors.

Emerging role of prodromal headache in patients with anti-N-methyl-D-aspartate receptor encephalitis

Background

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis patients often present with psychiatric symptoms, cognitive dysfunction, epilepsy and memory deficits. A previous study has suggested that headache can occurr during the early stages of anti-NMDAR encephalitis. However, the exact association between headache and anti-NMDAR encephalitis has hardly been investigated, apart from a few case studies. This is probably due to the severity of encephalitis symptoms, and the mechanism underlying headache-associated anti-NMDAR encephalitis remains largely unclear.

Objective

This study aimed to investigate the role of prodromal headache in 28 patients diagnosed with anti-NMDAR encephalitis.

Methods

Clinical data related to the prodromal headache characteristics of anti-NMDAR encephalitis patients were prospectively collected from January first 2017 to June first 2018. Autoimmune antibodies in the cerebrospinal fluid (CSF) of anti-NMDAR encephalitis patients were detected by an indirect immunofluorescence staining kit. The differences between age, sex, clinical symptoms (fever, epilepsy, psychiatric symptoms, cognitive impairment, disturbance of consciousness), CSF, brain MRI abnormalities, and modified Rankin Scale (mRS) score were compared between patients with and without headache. In addition, the association of headache severity with brain MRI abnormalities, antibody titers, and mRS score was examined.

Results

Twenty-eight patients with anti-NMDAR encephalitis (median, 29 years; range, 15–62 years) reported headache. Among them, 18 (64%) were female, 24 (86%) had fever, 21 (75%) were positive for serum virus antibody, 19 (68%) had severe pain intensity (scored 4–7 out of 10 on the visual analog scale), 18 (64%) presented with pulsating character, and 5 (18%) patients accompanied by vomiting. Moreover, headache was detected in the frontal lobe of 14 (50%) patients and temporal lobe of 12 (43%) patients. Encephalitic symptoms (psychiatric symptoms, cognitive dysfunction, epilepsy, and memory deficits) appeared in 23 patients at average 5.5 days (range, 1–21 days) followed by headache attack. In five patients, the headache was lasted for 21 days.

Conclusion

Prodromal headache is commonly found in the temporal lobe and frontal lobe of young patients, and hardly accompanied by vomiting. Headache is rapidly substituted by encephalitis symptoms in the majority of patients, while gradually relieved in a few patients after the recovering from encephalitis symptoms. The results strongly suggest that the NR1 subunit of NMDAR is involved in prodromal headache. In sum, the symptom of prodromal headache is crucial for the diagnosis of anti-NMDAR encephalitis.

Combined testing for herpes simplex virus and Mycobacterium tuberculosis DNA in cerebrospinal fluid of patients with aseptic meningitis in Burkina Faso, West Africa

BACKGROUND

Little is known about the involvement of herpes simplex virus (HSV) or Mycobacterium tuberculosis (MTB) as potentially curable causes of central nervous system (CNS) infections in sub-Saharan Africa.

OBJECTIVE

In this study, we developed a PCR assay dedicated to simultaneous testing of HSV1/HSV2 and MTB in Burkina Faso, a country where HSV is neglected as a cause of CNS infection and where TB prevalence is high.

METHODS

A consensus HSV1/HSV2 set of primers and probe were designed and combined to primers and probe targeting the IS6110 repetitive insertion sequence of MTB. Analytical performances of the assay were evaluated on reference materials. Cerebrospinal fluid (CSF) collected from subjects with aseptic meningitis was tested for HSV1/HSV2 and MTB DNA.

RESULTS

The UL29 gene was chosen as a highly conserved region targeted by the HSV1/HSV2 nucleic acid test. The lower limits of detection were estimated to be 2.45 copies/µL for HSV1, 1.72 copies/µL for HSV2, and 2.54 IS6110 copies per µL for MTB. The PCR was used in 202 CSF collected from subjects suspected of aseptic meningitis. Five samples (2.46%) tested positive, including two children positive for HSV1 (0.99%) and three adults tested positive for MTB (1.47%).

CONCLUSION

Using an in-house real-time PCR assay, we showed that both HSV and MTB are etiologic pathogens contributing to aseptic meningitis in Burkina Faso. This molecular test may have clinical utility for early diagnosis for those treatable CNS infections.

Viral antigens detectable in CSF exosomes from patients with retrovirus associated neurologic disease: functional role of exosomes

BACKGROUND

HTLV-1 infects over 20 million people worldwide and causes a progressive neuroinflammatory disorder in a subset of infected individuals called HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP). The detection of HTLV-1 specific T cells in the cerebrospinal fluid (CSF) suggests this disease is immunopathologically mediated and that it may be driven by viral antigens. Exosomes are microvesicles originating from the endosomal compartment that are shed into the extracellular space by various cell types. It is now understood that several viruses take advantage of this mode of intercellular communication for packaging of viral components as well. We sought to understand if this is the case in HTLV-1 infection, and specifically if HTLV-1 proteins can be found in the CSF of HAM/TSP patients where we know free virus is absent, and furthermore, if exosomes containing HTLV-1 Tax have functional consequences.

RESULTS

Exosomes that were positive for HTLV-1 Tax by Western blot were isolated from HAM/TSP patient PBMCs (25/36) in ex vivo cultures by trapping exosomes from culture supernatants. HTLV-1 seronegative PBMCs did not have exosomes with Tax (0/12), (Fisher exact test, p = 0.0001). We were able to observe HAM/TSP patient CSF (12/20) containing Tax⁺ exosomes but not in HTLV-1 seronegative MS donors (0/5), despite the absence of viral detection in the CSF supernatant (Fisher exact test p = 0.0391). Furthermore, exosomes cultivated from HAM/TSP PBMCs were capable of sensitizing target cells for HTLV-1 specific CTL lysis.

CONCLUSION

Cumulatively, these results show that there are HTLV-1 proteins present in exosomes found in virus-free CSF. HAM/TSP PBMCs, particularly CD4⁺CD25⁺ T cells, can excrete these exosomes containing HTLV-1 Tax and may be a source of the exosomes found in patient CSF. Importantly, these exosomes are capable of sensitizing an HTLV-1 specific immune response, suggesting that they may play a role in the immunopathology observed in HAM/TSP. Given the infiltration of HTLV-1 Tax-specific CTLs into the CNS of HAM/TSP patients, it is likely that exosomes may also contribute to the continuous activation and inflammation observed in HAM/TSP, and may suggest future targeted therapies in this disorder.

Rheumatoid meningitis: A rare cause of aseptic meningitis with frequently stroke-like episodes

Background

Rheumatoid meningitis (RM) is a rare manifestation of rheumatoid arthritis (RA) and may present with stroke-like episodes. We describe diagnostic findings and the outcome in patients with RM.

Methods

We identified 6 patients with RM in different stages of RA mostly admitted with stroke-like episodes or common features of meningitis. We used MRI, CSF, and histology for in-depth characterization.

Results

We observed RM in 2 patients without history of RA, 1 patient with early seropositive RA, and 3 patients with late-stage RA. Recurrent stroke-like episodes occurred in 5 of 6 patients; headache and partial status epilepticus was in the foreground in 1 patient. Symptoms were accompanied by constitutional symptoms in all patients. MRI showed leptomeningeal or pachymeningeal fluid-attenuated inversion recovery hyperintensities with contrast enhancement. CSF mostly showed mild pleocytosis but can initially be normal. Anticitrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) were positive in all patients. Histopathology revealed granulomatous inflammation in 2 patients. Response to steroids was prompt and further immunosuppressive treatment prevented recurrence.

Conclusions

RM is a rare manifestation of RA and often presents with stroke-like episodes. It is currently not implemented in the workup of aseptic meningitis in national guidelines. Crucial clues for diagnosis included recurrent stroke-like episodes refractory to antiepileptic treatment, headache and constitutional symptoms, meningeal enhancement on MRI, CSF pleocytosis, and positive serology findings for ACPA and RF. Prognosis is favorable with early immunosuppressive treatment.

Prodromal headache in anti-NMDAR encephalitis: An epiphenomenon of NMDAR autoimmunity

OBJECTIVE

To investigate the nature of prodromal headache in anti-NMDA receptor (NMDAR) encephalitis.

METHODS

Retrospective review of the clinical information of 39 patients with anti-NMDAR encephalitis admitted between January 1999 and September 2017. Five patients with an atypical presentation were excluded. Thus, in 34 patients (median 27 years [range, 12-47 years]; 28 [82%] female), the clinical features were compared between patients who initially reported headache and those who did not report.

RESULTS

Twenty-two patients (65%) reported headache either transiently (n = 5) or continuously (n = 17). Encephalitic symptoms (psychobehavioral memory alterations, seizure, dyskinesias, or altered level of consciousness) developed in 20 patients with median 5.5 days (range, 1-29 days) after headache onset. In one patient, NMDAR antibodies were detected in CSF 3 days after headache onset. Patients with headache had more frequently fever (14/22 [64%] vs. 2/12 [17%] p = 0.013) and higher CSF pleocytosis (median white blood cells 79/μl [range, 6-311/μl] vs. 30/μl [range, 2-69/μl], p = 0.035) than those without headache, but there was no difference in gender, age at onset, seizure, migraine, CSF oligoclonal band detection, elevated IgG index, tumor association, or brain MRI abnormalities between them.

CONCLUSIONS

Headache often developed with fever and pleocytosis, but it was rapidly replaced by psychiatric symptoms. Based on current knowledge on the antibody-mediated mechanisms that cause a decrease of synaptic NMDAR through crosslinking and internalization leading to a state mimicking "dissociative anesthesia," we speculated that prodromal headache is not likely caused by direct effect of the autoantibodies but rather meningeal inflammation (noninfectious aseptic meningitis) that occurs in parallel to intrathecal antibody synthesis as an epiphenomenon of NMDAR autoimmunity. Psychobehavioral alterations following headache is an important clue to the diagnosis.

Epidemiology and clinical outcomes of viral central nervous system infections

BACKGROUND

Central nervous system (CNS) viral infections are an important cause of morbidity and mortality. No data are available regarding their epidemiology in Qatar.

DESIGN

We retrospectively evaluated all cerebrospinal fluid findings from January 2011-March 2015 at Hamad Medical Corporation. Those with abnormal CSF finding were included in our study. We excluded those with missing medical records, no clinical evidence of viral CNS infection, or proven bacterial, fungal or tuberculosis CNS infection. CNS clinical findings were classified as meningitis, encephalitis or myelitis.

RESULTS

Among 7690 patients with available CSF results, 550 cases met the inclusion criteria (meningitis 74.7%; encephalitis 25%; myelitis 0.4%). Two-thirds (65%) were male and 50% were between 16-60 years old. Viral etiology was confirmed in 38% (enterovirus, 44.3%; Epstein-Barr virus, 31%; varicella zoster virus, 12.4%). The estimated incidence was 6.4 per 100,000 population. Two persons died and the rest were discharged to home. Among those with confirmed viral etiology, 83.8% received ceftriaxone (mean duration 7.3±5.2 days), 38% received vancomycin (mean duration 2.7±5.4 days) and 38% received at least one other antibiotic. Intravenous acyclovir was continued for more than 48h in patients with confirmed negative viral etiology (mean duration 5±5.6 days).

CONCLUSION

Viral etiology is not uncommon among those evaluated for CNS infection in Qatar. Clinical outcomes are excellent in this group of patients. Antibiotics and acyclovir are overly used even when a viral etiology is confirmed. There is a need for clinician education regarding etiology and treatment of viral CNS infections.

Clinical and biological features of enteroviral meningitis among adults and children and factors associated with severity and length of stay

BACKGROUND

Enterovirus (EV) meningitis is the most common form of meningitis. Clinical and biological manifestations may be non-specific, leading to prolonged and costly investigations.

OBJECTIVES

To determine the different aspects of EV meningitis and the variables associated with length of stay (LOS) in hospital independently of patients' age.

STUDY DESIGN

Single center retrospective study of all EV PCR positive CSF samples during 3.5 years in Bordeaux University Hospital, France.

RESULTS

172 patients were included. 65 were under 3 years old and 49 over 18 years old. 10% of patients had severe forms of the disease. 47 patients (27.3%) had normal CSF count and in 63 patients (36.6%) polynuclear cells predominated in CSF. Procalcitonin, Hoens' score or PCR in stool samples appeared as good markers for enteroviral diagnosis. Time elapsed before PCR results was associated with LOS (p = .002) and should help in limiting investigations in case of aseptic meningitis.

CONCLUSION

Rapid availability of EV PCR reduces LOS for patients and contributes to diminish unnecessary procedures and further tests.

Role of Exosomes in Human Retroviral Mediated Disorders

Retroviruses comprise an ancient and varied group of viruses with the unique ability to integrate DNA from an RNA transcript into the genome, a subset of which are able to integrate in humans. The timing of these integrations during human history has dictated whether these viruses have remained exogenous and given rise to various human diseases or have become inseparable from the host genome (endogenous retroviruses). Given the ability of retroviruses to integrate into the host and subsequently co-opt host cellular process for viral propagation, retroviruses have been shown to be closely associated with several cellular processes including exosome formation. Exosomes are 30-150 nm unilamellar extracellular vesicles that originate from intraluminal vesicles (ILVs) that form in the endosomal compartment. Exosomes have been shown to be important in intercellular communication and immune cell function. Almost every cell type studied has been shown to produce these types of vesicles, with the cell type dictating the contents, which include proteins, mRNA, and miRNAs. Importantly, recent evidence has shown that infection by viruses, including retroviruses, alter the contents and subsequent function of produced exosomes. In this review, we will discuss the important retroviruses associated with human health and disease. Furthermore, we will delve into the impact of exosome formation and manipulation by integrated retroviruses on human health, survival, and human retroviral disease pathogenesis.

Varicella-zoster virus meningitis with hypoglycorrhachia in a young immunocompetent adult without rash: A case report and literature review

Overt aseptic meningitis rarely complicates varicella-zoster virus (VZV) reactivation in young and immunocompetent adults. Many of the cases of VZV meningitis are associated with an exanthem. We describe an otherwise healthy 36-year-old adult who had aseptic meningitis without skin rash, caused by reactivation of varicella-zoster virus. Cerebrospinal fluid (CSF) analysis revealed lymphocytosis, increased total protein, and low glucose. Diagnosis was made by polymerase chain reaction in CSF. The present case highlights the fact that VZV should be considered as a cause of aseptic meningitis with hypoglycorrhachia in healthy and young individuals, even in the absence of an exanthem.

Systemic inflammatory disorders in patients admitted for aseptic meningitis

Acute meningitis can be the first manifestation of an underlying systemic inflammatory disorder (SID). In the current study, we aimed to identify clinical indicators for SIDs in patients admitted for acute aseptic meningitis. All patients hospitalised for acute aseptic meningitis over a 4-year period in a department of internal medicine were included retrospectively. Patients with neoplastic meningitis were excluded. Extraneurological signs were recorded using a systematic panel. Systemic inflammatory disorder diagnosis was made according to current international criteria. Forty-three (average age 46 years [range 19-82 years], 60% females) consecutive patients were analysed retrospectively. Of these, 23 patients had an SID (mostly sarcoidosis and Behçet's disease). -Multiple logistic regression analysis showed that the probability of an SID was 93.7% in patients with both neurological and extraneurological signs, but 14.9% in patients with neither neurological nor extraneurological signs. In conclusion, clinical sorting according to both neurological and extraneurological signs could help to identify patients with acute aseptic meningitis caused by an SID.

[Clinical, epidemiological, and etiological studies of adult aseptic meningitis: a report of 12 cases of herpes simplex meningitis, and a comparison with cases of herpes simplex encephalitis]

We treated 437 cases of adult aseptic meningitis and 12 cases (including 2 recurrent patients; age, 31.8 ± 8.9 years; 7 females) of herpes simplex meningitis from 2004 to 2016. The incidence rate of adult herpes simplex meningitis in the cases with aseptic meningitis was 2.7%. One patient was admitted during treatment of genital herpes, but no association was observed between genital herpes and herpes simplex meningitis in the other cases. The diagnoses were confirmed in all cases as the cerebrospinal fluid (CSF) was positive for herpes simplex virus (HSV)-DNA. For diagnosis confirmation, the DNA test was useful after 2-7 days following initial disease onset. Among other types of aseptic meningitis, the patients with herpes simplex meningitis showed relatively high white blood cell counts and relatively high CSF protein and high CSF cell counts. CSF cells showed mononuclear cell dominance from the initial stage of the disease. During same period, we also experienced 12 cases of herpes simplex encephalitis and 21 cases of non-hepatic acute limbic encephalitis. Notably, the patients with herpes simplex meningitis were younger and their CSF protein and cells counts were higher than those of the patients with herpes simplex encephalitis.

A concordance study of the Altona RealStar Varicella-Zoster virus real-time quantitative PCR and in-house conventional qualitative PCR

This study compared the Altona RealStar™ VZV Kit 1.0 real time quantitative VZV PCR with in-house qualitative conventional VZV PCR on cerebrospinal fluid, mucocutaneous, and other uncommon clinical specimens. Overall, positive and negative agreement percentages were respectively 97.9% (95%CI: 93.8-99.6), 100.0% (95%CI: 93.1-100.0), and 96.3% (95%CI: 89.4-99.2) while Cohen's kappa statistic value was 0.96 (95%CI: 0.91-1.00). RealStar™ VZV quantitative PCR assay reported average quantitative viral loads of 4.4 × 10⁵ and 1.1 × 10⁷  copies/mL in cerebrospinal fluid and cutaneous specimens, respectively (P < 0.01). RealStar™ VZV PCR assay showed excellent agreement with in house conventional assay for various clinical specimens.

Cerebrospinal fluid cytology in nonmalignant aseptic meningeal disorders

Cerebrospinal fluid cytology examination is a common and reliable primary and/or complementary procedure for the diagnosis of central nervous system (CNS) disorders. This review provides an update of aseptic meningeal disorders that may be encountered in cytopathology practice. The article covers the cytological findings and helpful ancillary studies needed of nonmalignant aseptic CNS disorders such as viral, bacterial, fungal and parasitic infections, and other noninfectious diseases, such as Mollaret's meningitis (recurrent benign lymphocytic meningitis), Guillain-Barré syndrome, multiple Sclerosis, subarachnoid haemorrhage, and drug-induced disorders.

Aseptic meningitis in adults and children: Diagnostic and management challenges

BACKGROUND

Aseptic meningitis represents a common diagnostic and management dilemma to clinicians.

OBJECTIVES

To compare the clinical epidemiology, diagnostic evaluations, management, and outcomes between adults and children with aseptic meningitis.

STUDY DESIGN

We conducted a retrospective study from January 2005 through September 2010 at 9 Memorial Hermann Hospitals in Houston, TX. Patients age≥2months who presented with community-acquired aseptic meningitis with a CSF white blood cell count >5cells/mm³ and a negative Gram stain and cultures were enrolled. Patients with a positive cryptococcal antigen, positive blood cultures, intracranial masses, brain abscesses, or encephalitis were excluded.

RESULTS

A total of 509 patients were included; 404 were adults and 105 were children. Adults were most likely to be female, Caucasian, immunosuppressed, have meningeal symptoms (headache, nausea, stiff neck, photophobia) and have a higher CSF protein (P <0.05). In contrast, children were more likely to have respiratory symptoms, fever, and leukocytosis (P <0.05). In 410 (81%) patients, the etiologies remained unknown. Adults were more likely to be tested for and to have Herpes simplex virus and West Nile virus while children were more likely to be tested for and to have Enterovirus (P <0.001). The majority of patients were admitted (96.5%) with children receiving antibiotic therapy more frequently (P <0.001) and adults receiving more antiviral therapy (P=0.001). A total of 384 patients (75%) underwent head CT scans and 125 (25%) MRI scans; all were normal except for meningeal enhancement. All patients had a good clinical outcome at discharge.

DISCUSSION

Aseptic meningitis in adults and children represent a management challenge as etiologies remained unknown for the majority of patients due to underutilization of currently available diagnostic techniques.