What is the treatment for viral meningitis?

Treatment of Viral Meningitis

The treatment for viral meningitis is primarily supportive care with analgesia and fluids as needed, as there are currently no treatments of proven benefit for most causes of viral meningitis. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the viral etiology:

• CSF PCR testing is the gold standard for confirmation of viral meningitis 1
• Most laboratories test for:
  • Enteroviruses (most common cause)
  • HSV-1 and HSV-2
  • Varicella zoster virus (VZV)
• Additional testing should be guided by clinical features:
  • Stool and/or throat swabs should be tested for enterovirus by PCR 1
  • Travel history or immune compromise may warrant testing for other viruses

Treatment Algorithm

1. Supportive Care (First-line treatment)

• Adequate pain control with analgesics for headache and meningism
• Maintenance of hydration with IV or oral fluids as needed
• Rest and symptomatic relief

2. Management Based on Viral Etiology

• Enterovirus meningitis: Supportive care only 2
• HSV or VZV meningitis:
  • Despite theoretical benefits, there is no evidence supporting routine use of aciclovir or valaciclovir 1, 2
  • Potential risks from drug side effects and prolonged hospitalization outweigh unproven benefits

3. Important Management Steps

• If antibiotics were started empirically, discontinue once viral diagnosis is confirmed 1
• Prioritize expediting discharge from hospital once diagnosis is confirmed 1
• Consider a staged return to work or studies for patients who cannot immediately return to normal activities 2

Critical Distinctions and Pitfalls

When to Use Antivirals

• Important: If there are any signs of encephalitis (changes in personality, behavior, cognition, or altered consciousness), immediately start IV aciclovir for suspected HSV encephalitis and follow encephalitis management guidelines 1, 2

Recurrent Viral Meningitis

• Some patients suffer from recurrent episodes of lymphocytic meningitis (Mollaret's meningitis), most commonly caused by HSV-2 1
• Despite reducing genital HSV-2 recurrences, prophylactic valaciclovir has not been shown to reduce recurrent HSV-2 meningitis and should not be given as prophylaxis 1

Common Pitfalls

• Misdiagnosing viral vs. bacterial meningitis: Viral meningitis typically presents with meningism, while altered consciousness suggests alternative diagnosis 1
• Failing to recognize encephalitis: Any signs of altered mental status should prompt immediate IV aciclovir treatment 2
• Overlooking post-discharge symptoms: Patients may experience significant morbidity including headaches, fatigue, sleep disorders, and emotional difficulties 2

Expected Outcomes

• Most patients with enterovirus meningitis recover completely without specific treatment 2, 3
• For other viral causes or in immunocompromised patients, outcomes may be less favorable with potential neurological complications 3
• Follow-up assessment for sequelae before discharge is recommended 2

Remember that viral meningitis is not always benign, particularly for non-enterovirus pathogens and in immunocompromised patients or infants, where it can be associated with substantial neurological complications and mortality 3.