Dakshnamoorthy Vythinathan

Viral Meningitis

INTRODUCTION

Meningitis is inflammation of the meninges, manifest by

cerebrospinal fluid (CSF) pleocytosis
Encephalitis is inflammation of the brain parenchyma that
produces neurologic dysfunction
Myelitis Myelitis is inflammation of the spinal cord,
manifest by flaccid paralysis and reduced or absent
reflexes

OVERVIEW

EPIDEMIOLOGY
PATHOGENESIS
ETIOLOGY
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
PREVENTION
TAKE HOME POINTS

EPIDEMIOLOGY

Viral meningitis accounts for approximately 26,000 to

42,000 hospitalizations each year in the United States,
Affecting mainly infants younger than one year and
children 5 to 10 years of age
Enterovirus being the most common cause with seasonal
pattern

PATHOGENESIS
PRIMARY VIRAL INFECTION

GI mucosa

Respiratory
mucosa

Primary Viremia

Onset of illness

Organ seeding

Secondary viremia

Reach CNS

Multiplication

CONT
Transendothelial passage of the virus occurs in vessels of the
choroid plexus, meninges, or cerebrum: Bridging the endothelium within migrating leukocytes
Pinocytosis or colloidal transport
Breaking through damaged endothelium
Direct infection of endothelial cells

ETIOLOGY
Enterovirus

( most common)
Human parechoviruses
Herpesviruses,
Arboviruses
lymphocytic choriomeningitis virus
Rabies
Influenza

CLINICAL FEATURES
Presence

or absence of normal brain

function distinguishes meningitis
from encephalitis
Certain viruses usually cause
isolated meningitis or isolated
encephalitis
Less discrete manifestations CNS
infection meningoencephalitis or
encephalomyelitis
Important to try to distinguish

CONT
Vary

with age, immune status, and

etiologic agent
Often are less severe than bacterial
meningtis
Neonates = non-specific symptoms
Older children = acute onset of
fever, headache, nausea, vomiting,
stiff neck, and photophobia

CONT

DIAGNOSING
History: The presence of classic symptoms
Symptoms of encephalitis
Symptoms associated with specific viruses
Preceding illness
Immunization history
Outbreaks of human or animal disease

CONT
Examination
Signs of meningeal inflammation
(nuchal rigidity, Kernig and
Brudzinski signs)
Assessment of mental status
(Glasgow coma scale) and presence
of focal neurologic signs
Findings associated with EV infection
Findings associated with other
potential causes of viral meningitis

CONT
Imaging

Computed

tomography (CT) of the

head is necessary before lumbar
puncture in patients with signs or
symptoms of ICP
Indications = Altered mental status ,
immune deficiency, papilledema,
CNS trauma, focal neurologic deficit.
Neuroimaging: Meningitis or
Encephalitis?

CONT
Laboratory Test
Blood test
-Blood culture, PT, PTT, CBC, Electrolyte, BUN,
urea , creatinine
CSF studies
-CSF WBC of <500 cells/microL with a
mononuclear predominance
-Normal CSF glucose
-CSF protein <100 mg/dL
-Negative CSF Gram stain
-Enterovirus disease in the Improvement in
symptoms following lumbar puncture

DIFFERENTIAL
DIAGNOSIS
Bacterial meningitis
-The Bacterial Meningitis Score (BMS) sensitivity
and specificity 99.3 percent (95% CI 98.7-99.7
percent) and 62.1 percent (60.5 to 63.7 percent),
respectively
Positive CSF Gram stain
CSF absolute neutrophil count 1000 cells/microL
CSF protein 80 mg/dL
Peripheral blood ANC 10,000 cells/microL
History of seizure before or at the time of
presentation

TREATMENT
Hospitalization
The

diagnosis of viral meningitis requires

negative CSF culture for routine
bacterial pathogens and positive
identification of a viral pathogen in the
CSF or other patient samples.
SUPPORTIVE CARE
EMPIRIC THERAPY
SPECIFIC THERAPY
PERSISTENT SYMPTOMS

PROGNOSIS

Most children with viral meningitis recover completely.

Some may complain of several weeks of fatigue, irritability,
decreased concentration, muscle weakness and spasm,
and incoordination after the acute illness

PREVENTION
Hygiene
Vaccine
Personal protection
Infection Control

TAKE HOME POINTS

In children, viral meningitis mainly affects infants younger

than one year and children 5 to 10 years of age
Enteroviruses are the most common cause of viral
meningitis
The manifestations of viral meningitis are generally similar
to those of bacterial meningitis but are usually less severe

CONT

Children who are suspected of having meningitis should be

treated as if they have bacterial meningitis until bacterial
meningitis has been excluded
Provisional diagnosis is one of several considerations in the
initial management
Empiric therapy (viral or bacterial) Specific therapy
Follow-up (Sequalae)

MATUR NUWUN

REFERENCE
Cecilia

Di Pentima, MD; Viral

meningitis: Epidemiology,
pathogenesis, and etiology in
children; Uptodate.com., 2014
Cecilia Di Pentima, MD; Viral
meningitis: Clinical features and
diagnosis in children; Uptodate.com.,
2014
Cecilia Di Pentima, MD; Viral
meningitis: Management, prognosis,