What is the best management approach for Mollaret meningitis?

Management of Mollaret Meningitis

The best management approach for Mollaret meningitis is supportive care with analgesia and fluids as needed, as there is currently no proven effective antiviral therapy for this condition. 1

Understanding Mollaret Meningitis

Mollaret meningitis, also known as recurrent lymphocytic meningitis, is characterized by:

• Recurrent episodes of aseptic meningitis that occur over several years
• Complete recovery between episodes with symptom-free intervals
• Most commonly caused by Herpes Simplex Virus type 2 (HSV-2), though other viruses have been reported 1, 2
• Large granular plasma cells considered the hallmark, though rarely seen in clinical practice 1

Diagnostic Approach

1. CSF Analysis:

   • Prompt lumbar puncture during symptomatic episodes 3
   • Look for lymphocytic pleocytosis consistent with aseptic meningitis 3, 4
   • CSF PCR for HSV-1 and HSV-2 (gold standard for confirmation) 1
   • CSF cytology may help clinch diagnosis when PCR is negative 4

2. Rule out other causes:

   • Bacterial meningitis
   • Other viral etiologies
   • Inflammatory conditions
   • Drug-induced meningitis

Treatment Recommendations

Acute Episode Management:

• Supportive care is the mainstay of treatment:

  • Adequate analgesia for headache and pain
  • Maintain hydration with fluids as necessary 1
  • Avoid unnecessary antibiotics once viral diagnosis is confirmed 3

• Antiviral therapy:

  • Despite theoretical benefits, there is no evidence supporting aciclovir or valaciclovir for treatment of Mollaret meningitis 1
  • A placebo-controlled trial showed valaciclovir did not reduce recurrences of HSV-2 meningitis and patients who received it tended to have a greater rate of relapse once the trial stopped 1
  • Empiric antiviral therapy may be deferred in cases with established diagnosis of Mollaret meningitis 3

Prophylactic Treatment:

• No proven prophylactic measures are established for preventing recurrences 1
• Higher doses of antiviral agents have been postulated to potentially give better outcomes, but no study has evaluated this hypothesis 1

Prognosis

• Generally favorable with complete recovery between episodes 1, 3
• Episodes typically last 2-5 days followed by spontaneous recovery 4
• Rare cases may develop neurological sequelae 4
• Neuro-ophthalmic manifestations such as papilledema and sixth nerve palsy have been reported 5

Key Considerations

• Mollaret meningitis is likely underrecognized among clinicians 6
• Improved recognition may limit unnecessary antibiotic use and hospital admissions 6
• For patients with established diagnosis, empiric antiviral therapy for HSV encephalitis may be safely deferred 3
• If there are any signs of encephalitis (changes in personality, behavior, cognition, or altered consciousness), intravenous aciclovir should be given 1

Pitfalls to Avoid

• Misdiagnosing as bacterial meningitis leading to prolonged unnecessary antibiotic therapy
• Prolonged hospitalization for antiviral therapy that has not shown benefit
• Failure to recognize the benign and self-limiting nature of most cases
• Not considering Mollaret meningitis in patients with recurrent episodes of aseptic meningitis