What is the management and treatment of aseptic meningitis?

Management and Treatment of Aseptic Meningitis

Aseptic meningitis is generally a self-limited viral illness requiring primarily supportive care, with rapid clinical improvement expected once any causative medications are discontinued. 1, 2

Initial Assessment and Stabilization

All patients with suspected meningitis must be hospitalized for evaluation and lumbar puncture, regardless of presumed etiology. 3 The priority is to:

• Stabilize airway, breathing, and circulation immediately 3
• Obtain blood cultures within 1 hour of hospital arrival 3
• Perform lumbar puncture within 1 hour if no contraindications exist (focal neurological signs, papilledema, continuous seizures, or GCS ≤12) 3
• Document presence or absence of fever, headache, altered mental status, neck stiffness, rash, and seizures 3

Distinguishing Aseptic from Bacterial Meningitis

The critical challenge is differentiating viral aseptic meningitis from bacterial meningitis, which requires immediate antibiotic therapy. CSF analysis is essential for diagnosis:

Classic CSF Findings in Aseptic Meningitis 1, 2:

• Lymphocytic pleocytosis (elevated white cells, predominantly lymphocytes)
• Normal glucose levels
• Normal to slightly elevated protein
• Negative bacterial and fungal cultures

Important Diagnostic Adjuncts:

• CSF lactate and serum C-reactive protein may help differentiate aseptic from bacterial meningitis 1
• Molecular diagnostics should be emphasized for pathogen identification 3

Empiric Antibiotic Therapy Decision

If bacterial meningitis cannot be excluded clinically, start empiric antibiotics immediately after blood cultures and LP. 3 This is critical because:

• Delays in antibiotic administration increase mortality in bacterial meningitis 3, 4
• Even if antibiotics are started, LP should still be performed within 4 hours to preserve diagnostic yield 3

When to Start Empiric Antibiotics:

• Any patient with shock, severe sepsis, or rapidly evolving rash 3
• Inability to perform LP within 1 hour of arrival 3
• Clinical uncertainty about bacterial vs. viral etiology 2

Treatment of Confirmed Aseptic Meningitis

Once bacterial meningitis is excluded through CSF analysis and cultures:

Primary Management 1, 2:

• Discontinue empiric antibiotics and antivirals 5
• Provide supportive care (hydration, analgesia, antipyretics)
• Maintain euvolemia with crystalloids if IV fluids needed 3
• Viral meningitis is self-limited with good prognosis 2

Drug-Induced Aseptic Meningitis (DIAM):

If medication-induced etiology is suspected, immediately discontinue the offending agent. 5, 6 Common culprits include:

• NSAIDs, antimicrobials (including amoxicillin), intravenous immunoglobulins, monoclonal antibodies 6
• Rapid recovery after drug cessation confirms the diagnosis 5
• Rechallenge is not recommended unless medically supervised with informed consent 6

Monitoring and Follow-Up

Neurological Monitoring 4:

• Monitor Glasgow Coma Scale, pupillary responses, and motor function closely
• Assess for complications including seizures, which should be treated early 3

Assessment for Sequelae 3:

• Evaluate for physical and psychological sequelae before discharge
• Perform hearing tests if clinically indicated or if patient/family reports concerns (within 4 weeks)
• Screen for cognitive deficits, headaches, and emotional difficulties
• Consider early mental health referral, as psychological impacts can be profound 3

Infection Control

Respiratory isolation is NOT required for aseptic meningitis. 3 However:

• Maintain isolation until meningococcal disease is excluded 3
• Other causes of meningitis do not require isolation 3

Critical Pitfalls to Avoid

• Never delay antibiotics in uncertain cases—bacterial meningitis mortality increases with treatment delays 3, 4
• Do not rely on Kernig's or Brudzinski's signs for diagnosis, as they have poor sensitivity and specificity 3, 2
• Do not perform LP in patients with signs of increased intracranial pressure without prior CT imaging 3, 4
• Do not miss drug-induced causes—always obtain detailed medication history including recent antibiotic use 5, 6
• Do not assume benign course without proper CSF analysis—unusual bacterial organisms (TB, Leptospira, Borrelia, Brucella) can present as "aseptic" meningitis 1

Outpatient Considerations

Outpatient management may be considered only after:

• Bacterial meningitis is definitively excluded by CSF analysis 2
• Patient is clinically stable and improving 7
• Close follow-up is arranged for symptom monitoring 2