What is the treatment for granular meningitis?

Treatment of Granular Meningitis

The treatment for granular meningitis (also known as Mollaret's meningitis or recurrent lymphocytic meningitis) is primarily supportive care with analgesia and fluids, as there are currently no treatments of proven benefit for most causes of this condition. 1

Understanding Granular Meningitis

Granular meningitis, also known as Mollaret's meningitis, is characterized by:

• Recurrent episodes of lymphocytic meningitis with large granular plasma cells (although these are rarely seen in practice) 1
• Most commonly caused by HSV-2, although other viruses have been reported 1
• Episodes typically occur months to years apart with complete recovery between episodes 1

Treatment Approach

First-line Management

• Supportive care is the mainstay of treatment:
  • Adequate analgesia for pain management 1
  • Appropriate fluid management 1
  • If antibiotics were started empirically, they should be discontinued once viral diagnosis is confirmed 1

Antiviral Therapy Considerations

• Despite theoretical benefits, there is no evidence supporting the use of aciclovir or valaciclovir for HSV or VZV-associated granular meningitis 1
• A placebo-controlled trial showed that valaciclovir did not reduce recurrent HSV-2 meningitis episodes and may even increase relapse rates after treatment cessation 1
• The lack of efficacy was hypothesized to be due to inadequate CSF penetration of the drug 1

Special Considerations

• If there are any signs of encephalitis (personality changes, behavioral changes, cognitive changes, or altered consciousness), intravenous aciclovir should be administered immediately 1
• In such cases, follow the British Infection Association/Association of British Neurologists guidelines for encephalitis management 1

Diagnostic Approach

• CSF PCR is the gold standard for confirmation of viral meningitis 1
• Most laboratories test for enterovirus, HSV-1, HSV-2, and VZV 1
• Identifying the viral pathogen allows for:
  • Providing a definitive diagnosis 1
  • Discontinuing unnecessary antibiotics 1
  • Reducing unnecessary investigations 1
  • Shortening hospital stays 1

Common Pitfalls to Avoid

• Prolonging hospitalization unnecessarily after viral diagnosis is confirmed 1
• Continuing antibiotics after viral etiology is established 1
• Using antivirals without clear evidence of benefit, exposing patients to potential drug side effects 1
• Failing to recognize signs of encephalitis, which would require immediate intravenous aciclovir 1

Follow-up Considerations

• Patients should be assessed by an infection or neurological specialist 1
• Patient education about the recurrent nature of the condition is important 1
• Higher doses of antivirals might theoretically provide better outcomes, but no studies have evaluated this approach 1