What is the management of viral meningitis?

Management of Viral Meningitis

The management of viral meningitis is primarily supportive, focusing on adequate analgesia, hydration, and rest, with no evidence supporting routine use of specific antiviral treatments except in certain cases involving herpes viruses with signs of encephalitis. 1

Diagnosis

Clinical Presentation

• Meningism symptoms: neck stiffness, headache, and photophobia
• Fever (not always present)
• Other non-specific symptoms: diarrhea, vomiting, muscle pain, sore throat
• Usually no reduced consciousness level (altered consciousness suggests alternative diagnoses) 2

Diagnostic Testing

1. Lumbar puncture is essential for diagnosis
2. CSF analysis should include:
   • PCR testing for enteroviruses, HSV-1, HSV-2, and VZV 2, 1
   • Additional PCR testing guided by clinical features (immune status, travel history)
3. Additional samples:
   • Stool and/or throat swabs for enterovirus PCR 2

Treatment Algorithm

1. Supportive Care (All Cases)

• Adequate analgesia: Paracetamol is recommended for persistent headache 1
• Hydration: Ensure adequate fluid intake
• Rest: Essential for recovery

2. Specific Antiviral Treatment

• Enterovirus meningitis (most common, 85-95% of cases): No specific antiviral treatment available 1
• HSV or VZV meningitis:
  • Routine use of acyclovir/valacyclovir is NOT recommended for uncomplicated viral meningitis 2, 1
  • Acyclovir IV IS recommended if signs of encephalitis are present 1, 3
  • For recurrent HSV meningitis: Early administration of acyclovir, valacyclovir, or famciclovir can shorten episode duration 4
  • Prophylactic acyclovir/valacyclovir is NOT recommended for recurrent herpes meningitis 2

3. Management of Complications

• Elevated intracranial pressure: Mainly supportive management
• Seizures: Anticonvulsant treatment when seizures occur 1
• Antibiotics: If started empirically, discontinue once viral diagnosis is confirmed 1

Follow-up Care

Short-term Follow-up

• Assess for complete resolution of symptoms
• Monitor for potential complications

Long-term Considerations

• Many patients experience fatigue, sleep disorders, and emotional difficulties weeks to months after discharge 2, 1
• Recommend gradual return to work or studies (part-time initially) 2
• One-third of HSV-2 meningitis patients may experience recurrent episodes 1

Important Caveats and Pitfalls

1. Distinguishing viral from bacterial meningitis:

   • Clinical findings alone are unreliable
   • CSF examination is crucial for differentiation
   • Early in viral meningitis, CSF may show polymorphonuclear predominance, potentially causing confusion with bacterial meningitis 5

2. Altered consciousness:

   • Suggests alternative diagnoses such as bacterial meningitis, encephalitis, or other intracranial pathology 2
   • Requires prompt investigation and potentially different management

3. Diagnostic challenges:

   • No cause is found in 30-50% of presumed viral meningitis cases 2
   • Consider consultation with infectious disease or neurology specialists

4. Post-discharge support:

   • Patients often feel well at discharge but may not be able to return to normal activities immediately 2
   • Support organizations can provide crucial help with recovery 2

5. Recurrence risk:

   • Particularly with HSV-2 meningitis, recurrence is common and may require consideration of prophylactic treatment in selected cases 4