From the Guidelines
Aseptic meningitis is diagnosed through a combination of clinical evaluation, cerebrospinal fluid (CSF) analysis, and laboratory testing, and treatment is primarily supportive, focusing on hydration, rest, and pain management with acetaminophen or NSAIDs, with specific antiviral treatment rarely needed except in cases of herpes simplex virus meningitis, as recommended by the most recent guidelines 1.
Diagnosis of Aseptic Meningitis
The diagnosis of aseptic meningitis involves a lumbar puncture to collect CSF, which typically shows increased white blood cells (predominantly lymphocytes), normal or slightly elevated protein, normal glucose, and negative bacterial cultures.
- Clinical evaluation is crucial, including symptoms of headache, neck stiffness, and photophobia, often associated with meningitis, as defined in the UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1.
- Laboratory testing, including CSF analysis, is essential to distinguish aseptic meningitis from bacterial meningitis, which requires immediate antibiotic treatment, as delayed treatment can lead to serious complications or death.
Treatment of Aseptic Meningitis
Treatment for aseptic meningitis is primarily supportive, focusing on:
- Adequate hydration
- Rest
- Pain management with acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) for headache and fever
- In severe cases, hospitalization may be necessary for IV fluids and pain control
- Specific antiviral treatment is rarely needed, except in cases of herpes simplex virus meningitis, where acyclovir (10mg/kg IV every 8 hours for 14-21 days) may be administered, as suggested by the management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: ASCO guideline update 1.
- If the patient has significant symptoms like persistent vomiting, IV antiemetics such as ondansetron (4-8mg IV every 8 hours) can be given.
Importance of Distinguishing Aseptic Meningitis from Bacterial Meningitis
It is crucial to distinguish aseptic meningitis from bacterial meningitis, as bacterial meningitis requires immediate antibiotic treatment, and delayed treatment can lead to serious complications or death, as highlighted in the UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1.
- The guidelines emphasize the importance of early recognition and prompt treatment of bacterial meningitis and meningococcal sepsis, which are rare conditions with high case fatality rates.
- The management of aseptic meningitis, on the other hand, is primarily supportive, and specific antiviral treatment is rarely needed, except in cases of herpes simplex virus meningitis.
From the FDA Drug Label
Aseptic Meningitis Aseptic meningitis with fever and coma has been observed on rare occasions in patients on ibuprofen therapy. Although it is probably more likely to occur in patients with systemic lupus erythematosus and related connective tissue diseases, it has been reported in patients who do not have an underlying chronic disease If signs or symptoms of meningitis develop in a patient on ibuprofen tablets, the possibility of its being related to ibuprofen tablets should be considered.
onal liability, somnolence, aseptic meningitis with fever and coma [see PRECAUTIONS]
Diagnosis and Treatment of Aseptic Meningitis:
- The FDA drug label mentions that aseptic meningitis has been observed in patients on ibuprofen therapy, but it does not provide direct information on diagnosis and treatment.
- If signs or symptoms of meningitis develop in a patient on ibuprofen tablets, the possibility of its being related to ibuprofen tablets should be considered 2.
- The label does not provide specific guidance on the diagnosis and treatment of aseptic meningitis, and it is recommended to consult other medical resources for this information.
From the Research
Diagnosis of Aseptic Meningitis
- Aseptic meningitis is defined as meningeal inflammation not related to an infectious process, characterized by cerebrospinal fluid (CSF) pleocytosis ≥5 cells/mm3 3.
- Diagnosis can be challenging due to the difficulty in distinguishing clinical presentation from bacterial or viral meningitis 4.
- Diagnostic workup includes blood and CSF examination, serology for infectious meningitis, and polymerase chain reaction (PCR) for detection of microbial DNA in CSF 5.
- Imaging studies, such as head CT scans and MRI scans, may be normal or show meningeal enhancement 6.
Etiologies of Aseptic Meningitis
- Etiologies can be classified into three main groups: systemic diseases with meningeal involvement, drug-induced aseptic meningitis, and neoplastic meningitis 3.
- Systemic diseases include sarcoidosis, Behçet's disease, Sjögren's syndrome, systemic lupus erythematosus, and granulomatosis with polyangiitis 3.
- Drug-induced aseptic meningitis is mostly reported with non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics (sulfamides, penicillins), intravenous immunoglobulin, and monoclonal antibodies 3.
- Neoplastic meningitis can be related to solid cancer metastasis or malignant hemopathy (lymphoma, leukemia) 3.
Treatment of Aseptic Meningitis
- Treatment is mainly supportive, except for non-viral infectious etiology 5.
- Antiviral therapy may be administered in some cases, particularly in adults 6.
- Antibiotic therapy may be given to children, although the majority of cases have unknown etiologies 6.
- Discontinuation of the offending drug can lead to resolution of symptoms, as seen in cases of drug-induced aseptic meningitis 4.