Management of Viral Meningitis
Viral meningitis should be managed with supportive care only—analgesia and fluids—as there are no treatments of proven benefit for most viral causes, and antibiotics should be discontinued once the viral diagnosis is confirmed. 1
Immediate Diagnostic Priorities
The cornerstone of management is confirming the viral etiology through CSF analysis, which allows you to safely stop antibiotics and expedite discharge. 1
- Perform lumbar puncture within 1 hour of hospital arrival (provided it is safe to do so) to obtain CSF for analysis 2
- CSF PCR is the gold standard for diagnosis, testing specifically for enterovirus, HSV-1, HSV-2, and VZV 1
- Blood cultures should be obtained within 1 hour of arrival before any antibiotics are given 2
- Document Glasgow Coma Scale on arrival, as preserved consciousness distinguishes viral from bacterial meningitis 3
Critical pitfall: Early CSF in viral meningitis may show polymorphonuclear predominance and even low glucose, mimicking bacterial meningitis—this is especially common with enteroviral infections. 4 If viral infection is suspected but the initial CSF shows neutrophil predominance, repeat the lumbar puncture within 12 hours; a shift to mononuclear cells confirms viral etiology. 4
Treatment Algorithm
Supportive Care (All Patients)
- Provide analgesia for headache and other symptoms 1
- Ensure adequate hydration with intravenous or oral fluids as needed 1
- Discontinue antibiotics immediately once viral diagnosis is confirmed 1
- Expedite hospital discharge once diagnosis is established 1
Etiology-Specific Considerations
Enterovirus meningitis (most common cause, 50-80% of cases):
- Supportive care only—no specific antiviral therapy exists 1
- Throat swabs for enterovirus PCR can support the diagnosis 3
HSV meningitis (predominantly HSV-2):
- Despite theoretical benefits, there is no evidence supporting aciclovir or valaciclovir treatment for HSV meningitis 1
- However, if encephalitis cannot be excluded (any altered mental status), immediately administer intravenous aciclovir for presumed HSV encephalitis 1, 5
VZV meningitis:
- Similar to HSV, no evidence supports specific antiviral treatment 1
Recurrent HSV-2 meningitis:
- Episodes occur months to years apart with complete recovery between 1
- Prophylactic aciclovir/valaciclovir is NOT recommended, as placebo-controlled trials showed no reduction in recurrence 1
Critical Decision Point: Meningitis vs. Encephalitis
If there is any doubt about whether the patient has meningitis versus encephalitis, manage as suspected encephalitis. 2 Any alteration in mental status beyond the baseline suggests encephalitis or bacterial meningitis rather than uncomplicated viral meningitis. 3
Follow-Up and Long-Term Sequelae
All patients require assessment for potential complications before discharge:
- Common sequelae include headaches (occurring in up to one-third of patients), fatigue, sleep disorders, and emotional difficulties 2, 1
- Many patients feel well at discharge but cannot immediately return to normal activities 2
- Staged return to work or studies on a part-time basis is often necessary 2
- Post-discharge follow-up should be offered to all patients, as many issues only become apparent after leaving the hospital 2, 1
- Consider early referral to mental health services for emotional difficulties and psychological impacts 2
Hearing assessment should be performed if the clinician, patient, or family suspects hearing loss, ideally before discharge or within 4 weeks 2
Infection Control
Viral meningitis does not require isolation precautions, unlike bacterial meningitis. 2 Standard infection prevention measures are sufficient. 2
Prognosis
Viral meningitis is rarely fatal in immunocompetent adults, with most patients making a full recovery, though long-term sequelae can occur. 1 The key to good outcomes is distinguishing viral from bacterial meningitis to avoid unnecessary antibiotics and prolonged hospitalization while ensuring appropriate supportive care. 1