What is the treatment for viral meningitis?

Treatment of Viral Meningitis

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

Diagnostic Considerations

• Viral meningitis accounts for 50-80% of all meningitis cases, with enteroviruses and herpes viruses (predominantly HSV-2 and VZV) being the most common causes 1
• CSF PCR is the gold standard for confirmation of viral meningitis, testing for enterovirus, HSV-1, HSV-2, and VZV 1
• Identifying the viral pathogen allows for appropriate diagnosis, discontinuation of unnecessary antibiotics, reduced investigations, and shorter hospital stays 1

Treatment Algorithm

General Management for All Viral Meningitis Cases

• Provide supportive care with analgesia for headache and other symptoms 1
• Ensure adequate hydration with intravenous or oral fluids as needed 1
• Discontinue antibiotics once viral diagnosis is confirmed 1
• Prioritize expediting discharge from hospital once diagnosis is confirmed 1

Special Considerations by Viral Etiology

1. Enterovirus meningitis

   • Supportive care only, as no specific antiviral therapy is available 1

2. Herpes simplex virus (HSV) meningitis

   • Despite theoretical benefits, there is no evidence supporting aciclovir or valaciclovir treatment for HSV meningitis 1
   • Risks of drug side effects and prolonged hospitalization should be weighed against lack of efficacy evidence 1

3. Varicella zoster virus (VZV) meningitis

   • Similar to HSV, no evidence supports specific antiviral treatment 1

4. If encephalitis is suspected (changes in personality, behavior, cognition, or altered consciousness)

   • Immediately administer intravenous aciclovir for suspected HSV encephalitis 1
   • Follow British Infection Association/Association of British Neurologists guidelines for encephalitis management 1

Recurrent Viral Meningitis (Mollaret's Meningitis)

• Most commonly caused by HSV-2 1
• Episodes can occur months to years apart with complete recovery between episodes 1
• Prophylactic aciclovir/valaciclovir is NOT recommended, as it did not reduce recurrent HSV-2 meningitis in a placebo-controlled trial 1
• Patients on valaciclovir actually showed a greater rate of relapse once the trial stopped 1

Follow-up Care

• All patients should be assessed for potential long-term sequelae before discharge 1
• Common sequelae include headaches (in up to one-third of patients), fatigue, sleep disorders, and emotional difficulties 1, 2
• Patients may need staged return to work or studies initially 1
• Follow-up care should be offered as many issues only become apparent after discharge 1, 2

Common Pitfalls to Avoid

• Failing to distinguish viral meningitis from bacterial meningitis or encephalitis 1
• Unnecessarily prolonging antibiotic treatment after viral diagnosis is confirmed 1
• Underestimating the psychological impact and need for support during recovery 1, 2
• Inadequate follow-up care 1
• Premature return to full activities before complete recovery 1, 2

Prognosis

• Viral meningitis is rarely fatal in immunocompetent adults 2
• Most patients make a full recovery, though some may experience long-term sequelae 1, 2
• Headaches are the most common long-term sequela 1, 2