From the Guidelines
Aseptic meningitis is typically caused by viruses, with enteroviruses being the most common culprits, and treatment is primarily supportive care, including rest, adequate hydration, and pain management with acetaminophen or NSAIDs like ibuprofen at standard dosing. The condition is generally less severe than bacterial meningitis but can still cause significant discomfort with symptoms including headache, fever, neck stiffness, photophobia, and nausea 1.
Diagnosis and Treatment
Diagnosis typically involves lumbar puncture showing increased white blood cells (predominantly lymphocytes), normal or slightly elevated protein, normal glucose levels, and negative bacterial cultures 1. Patients should be monitored for complications such as increased intracranial pressure, seizures, or altered mental status. Hospitalization may be necessary for severe symptoms, particularly in very young children, elderly patients, or those with compromised immune systems.
Management of Immune-Related Adverse Events
In patients treated with immune checkpoint inhibitor therapy, management of aseptic meningitis may involve holding ICPi, concurrent IV acyclovir until PCR results obtained and negative, and a trial of methylprednisolone 1-2 mg/kg/d 1. If severe or progressing symptoms or oligoclonal bands present, consider pulse corticosteroids (methylprednisolone 1 g IV daily for 3-5 days) plus IVIG 2 g/kg over 5 days (0.4 g/kg/d) or plasmapheresis 1.
Key Considerations
The likelihood of any specific aetiology depends on a range of factors, and in many cases (34%-74%), no pathogen is identified 1. Aseptic meningitis is a syndrome of multiple etiologies, but many cases are caused by a viral agent 1. The condition can still cause significant discomfort, and patients should be closely monitored for complications. Treatment should prioritize supportive care and monitoring for complications, with consideration of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy.
From the Research
Definition and Causes of Aseptic Meningitis
- Aseptic meningitis is the most common form of meningitis, with an annual incidence of 7.6 per 100,000 adults 2.
- Most cases of aseptic meningitis are viral and require supportive care 2, 3.
- The aseptic meningitis syndrome is usually viral in origin, and enteroviruses account for most cases 4.
- Drug-induced aseptic meningitis is a rare entity, and diagnosis can be challenging due to the difficulty in distinguishing clinical presentation from bacterial or viral meningitis 5, 6.
Clinical Presentation and Diagnosis
- The classic presentation of aseptic meningitis consists of the acute onset of meningismus, headache, fever, malaise with pleocytosis and normal glucose and slightly elevated protein in the cerebrospinal fluid 4.
- Examination maneuvers such as Kernig sign or Brudzinski sign may not be useful to differentiate bacterial from aseptic meningitis because of variable sensitivity and specificity 2.
- The diagnosis relies on the examination of cerebrospinal fluid obtained from lumbar puncture 2.
- Cerebrospinal fluid lactate and serum C-reactive protein measurements may be helpful in differentiating aseptic meningitis from treatable bacterial meningitis 4.
Treatment and Prevention
- Viral meningitis is generally self-limited with a good prognosis, and treatment is usually supportive care 2, 3.
- Aseptic meningitis of viral origin usually responds to expectant care 4.
- Other causes of aseptic meningitis must be searched for and treated if present 4.
- Vaccination against the most common pathogens that cause bacterial meningitis is recommended 2.
- Chemoprophylaxis of close contacts is helpful in preventing additional infections 2.