What is the typical course and prognosis of aseptic meningitis?

Aseptic Meningitis: Course and Prognosis

Aseptic meningitis is generally a self-limiting illness with a favorable prognosis in most immunocompetent adults, though it can cause significant morbidity and have profound psychological impacts. 1

Clinical Course

• Aseptic meningitis typically presents with meningism (neck stiffness, headache and photophobia), though fever is not always present 1
• Symptoms usually develop acutely and include:
  • Headache (predominant symptom)
  • Neck stiffness
  • Photophobia
  • Malaise 1
• The course is typically self-limited with spontaneous resolution of symptoms 2
• Duration of acute illness is usually 5-7 days, though this can vary depending on the specific etiology 3
• Symptoms may be more severe in the first 2-3 days before gradually improving 2

Etiology

• Viral causes account for 50-80% of aseptic meningitis cases 1
• The most common viral etiologies in adults include:
  • Enteroviruses (most common)
  • Herpes simplex virus type 2 (HSV-2)
  • Varicella zoster virus (VZV) 1
• Less common viral causes include cytomegalovirus, Epstein-Barr virus, and mumps virus 1
• Non-viral causes include:
  • Drug-induced aseptic meningitis (DIAM) 4
  • Partially treated bacterial meningitis 3
  • Autoimmune conditions 4

Prognosis

• Mortality is rare in immunocompetent adults with viral meningitis 1
• Complete recovery is the norm for most patients with viral meningitis 2
• Short-term complications during the acute phase may include:
  • Severe headaches 1
  • Sleep disturbances 1
  • Fatigue 1

Long-term Sequelae

• Headaches are frequently reported as a long-term sequela, occurring in up to one-third of patients 1
• Other potential long-term issues include:
  • Fatigue and sleep disorders 1
  • Emotional difficulties and psychological impacts 1
  • Cognitive deficits (less common than in bacterial meningitis) 1
  • Arthritis, limb pain, muscle pain, and neuropathic pain (in some cases) 1

Post-Recovery Period

• Many patients feel well at discharge but may not be able to return immediately to all normal activities 1
• A staged return to work or studies is often recommended, starting on a part-time basis 1
• Fatigue, sleep disorders, and emotional difficulties are frequently reported in the weeks and months after discharge 1

Special Considerations

• Recurrent episodes of lymphocytic meningitis (Mollaret's meningitis) can occur, most often caused by HSV-2 1

  • Episodes can be months to years apart with complete recovery between episodes 1
  • Prophylactic antiviral therapy with valaciclovir has not been shown to reduce recurrences 1

• Drug-induced aseptic meningitis typically resolves quickly after discontinuation of the offending medication 4

  • Symptoms typically develop within a week of starting the medication 4
  • Resolution occurs rapidly after stopping the suspected drug 4

Follow-up Recommendations

• All patients should be assessed for potential long-term sequelae, both physical and psychological, before discharge from hospital 1
• Follow-up care is important, as many issues may only become apparent after discharge 1
• Hearing tests should be performed if there is any suspicion of hearing impairment 1
• Support from hospital clinicians and primary care providers can help patients manage the post-recovery period 1

Common Pitfalls

• Misdiagnosis as bacterial meningitis, leading to unnecessary prolonged antibiotic treatment 2
• Failure to recognize drug-induced aseptic meningitis, resulting in repeated exposures to the causative agent 5
• Underestimating the psychological impact and need for support during recovery 1
• Inadequate follow-up care - studies show that follow-up is not routinely offered where needed 1
• Premature return to full activities before complete recovery 1