What is the treatment for viral meningitis?

Treatment of Viral Meningitis

The treatment of viral meningitis is primarily supportive care, including adequate analgesia, hydration, and rest, with no evidence supporting routine use of antiviral medications for most cases. 1

Etiology and Management Approach

Viral meningitis is most commonly caused by:

• Enteroviruses (85-95% of cases)
• Herpes simplex virus type 2 (HSV-2)
• Varicella-zoster virus (VZV)
• Less frequently: cytomegalovirus, Epstein-Barr virus, and mumps virus 1

General Management Principles

1. Supportive Care

   • Adequate analgesia (paracetamol is recommended for persistent headache)
   • Proper hydration
   • Rest 1

2. Medication Management

   • If antibiotics were started empirically, they should be discontinued once viral diagnosis is confirmed 2, 1
   • Priority should be given to expediting discharge from hospital once viral etiology is established 2

3. Special Considerations for Herpes Virus Meningitis

   • Despite theoretical benefits, there is currently no evidence supporting routine use of aciclovir or valaciclovir for HSV or VZV meningitis 2, 1
   • The potential risks from drug side effects and unnecessarily prolonged hospitalization should be weighed against lack of efficacy evidence 2

Important Clinical Distinctions

Viral Meningitis vs. Encephalitis

• If there are any signs of encephalitis (changes in personality, behavior, cognition, or altered consciousness), intravenous aciclovir should be administered for suspected HSV encephalitis 2, 1
• Follow appropriate encephalitis management guidelines in such cases 2

Recurrent Viral Meningitis

• Recurrent lymphocytic meningitis (Mollaret's meningitis) is most often caused by HSV-2 2
• Episodes can occur months to years apart with complete recovery between episodes 2
• Despite reducing genital HSV-2 transmission and recurrences, valaciclovir did not reduce recurrent HSV-2 meningitis in a placebo-controlled trial 2

Diagnostic Approach

Diagnosis is critical for appropriate management:

• CSF PCR is the gold standard for confirmation of viral meningitis 2, 1
• Most laboratories test for enterovirus, HSV-1, HSV-2, and VZV 2
• No causative agent is found in 30-50% of presumed viral meningitis cases 2

Follow-up and Prognosis

• Many patients experience fatigue, sleep disorders, and emotional difficulties weeks to months after discharge 1
• Gradual return to normal activities is recommended 1
• Follow-up care is important to evaluate potential sequelae 1
• Approximately one-third of patients with HSV-2 meningitis may experience recurrent episodes 1

Common Pitfalls to Avoid

1. Unnecessary Antiviral Treatment

   • Avoid routine use of antivirals for viral meningitis without evidence of encephalitis 2, 1

2. Prolonged Antibiotic Use

   • Discontinue antibiotics once viral diagnosis is confirmed 2, 1

3. Missing Signs of Encephalitis

   • Always assess for changes in personality, behavior, cognition, or altered consciousness that would indicate encephalitis requiring antiviral treatment 2

4. Inadequate Follow-up

   • Schedule appropriate follow-up to monitor for sequelae and complete symptom resolution 1