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Viral Meningitis

By John E. Greenlee, MD

Last full review/revision November 2015 by John E. Greenlee, MD

Viral meningitis tends to be less severe than acute bacterial meningitis. Findings include
headache, fever, and nuchal rigidity. Diagnosis is by CSF analysis. Treatment is with
supportive measures, acyclovir for suspected herpes simplex, and antiretroviral drugs for
suspected HIV infection.

Viral meningitis is sometimes used synonymously with aseptic meningitis. However, aseptic
meningitis usually refers to acute meningitis caused by anything other than the bacteria that
typically cause acute bacterial meningitis. Thus, aseptic meningitis can be caused by viruses,
noninfectious conditions (eg, drugs, disorders), fungi, or, occasionally, other organisms (eg,
in Lyme disease, in syphilis).


Viral meningitis usually results from hematogenous spread, but meningitis due to herpes
simplex virus type 2 (HSV-2) can also result from reactivation of latent infection.

The most common cause of viral meningitis is

 Enteroviruses

For many viruses that cause meningitis (unlike the bacteria that cause acute bacterial
meningitis), incidence is seasonal (see Table: Common Causes of Viral Meningitis).

Common Causes of Viral Meningitis

Virus Mechanism of Transmission Seasonal Incidence

Virus Mechanism of Transmission Seasonal Incidence
Summer to early
Enteroviruses (eg, Fecal-oral spread (eg, via autumn
coxsackieviruses, contaminated food, in swimming
echoviruses pools) Sometimes sporadic
cases throughout year

*Herpes simplex, usually Close contact with a person None
virus type 2 actively shedding the virus

Varicella-zoster virus Inhalation of respiratory droplets None
from or by contact with an
infected person

‡ Lymphocytic choriomeningitis virus is associated with exposure to infected wild mice (the natural host for this virus) and is most common during autumn or winter when mice tend to move indoors. However. followed by symptoms and signs of meningitis (headache. fever. but no cases have been reported in the US in recent years. nuchal rigidity may be less pronounced). myalgias. nuchal rigidity). a throat swab. glucose)  PCR of CSF and sometimes IgM  Sometimes PCR and/or culture of blood. † Western equine and Venezuelan equine viruses have been associated with meningitis. protein. Louis virus autumn California encephalitis virus Mosquito Summer to early La Crosse virus autumn Colorado tick fever virus Ticks Late spring to early (unusual) summer Lymphocytic Airborne‡ Autumn to winter choriomeningitis virus HIV-1 Contact with body fluids of an None§ HIV-2 infected person *Herpes simplex type 2 meningitis may occur as an isolated instance or may recur (see below). Symptoms and Signs Viral meningitis. GI or respiratory symptoms). fever. findings are sometimes severe enough to suggest acute bacterial meningitis. Western equine virus† Mosquito Summer to early Venezuelan equine virus † autumn West Nile virus Mosquito Summer to early St. like acute bacterial meningitis. Infection may also occur year-round when the cause is exposure to infected pet hamsters. Diagnosis  CSF analysis (cell count. nasopharyngeal secretions. § Meningitis due to HIV usually begins early in the course of systemic infection—when seroconversion occurs. usually begins with symptoms that suggest viral infection (eg. or stool . Manifestations tend to resemble those of bacterial meningitis but are usually less severe (eg.

and glucose can rule out bacterial meningitis. Nonetheless. then stop the drug. most clinicians begin empiric treatment with acyclovir and. Measurement of IgM in CSF is more sensitive than PCR in diagnosing suspected West Nile virus or other arboviruses. Viral serologic tests. PCR. Treatment  Supportive measures  Acyclovir (for suspected herpes simplex or herpes zoster) and antiretroviral drugs (for HIV infection) If patients appear seriously ill and if acute bacterial seems possible (even if viral meningitis is suspected). Pearls & Pitfalls  If patients appear seriously ill. occasionally (eg. protein. months. the protein level can be very high in West Nile virus meningitis. however.Diagnosis of viral meningitis is based on analysis of CSF obtained by lumbar puncture (preceded by neuroimaging if increased intracranial pressure or a mass is suspected). Typically. West Nile viruses). Treatment is mainly supportive. If either of these viruses is suspected or if herpes simplex encephalitis is at all suspected. if PCR is negative for these viruses. in West Nile virus meningitis or lymphocytic choriomeningitis). Viral meningitis usually resolves spontaneously over weeks or. Patients with HIV meningitis are treated with antiretroviral drugs. CSF viral culture is insensitive and not routinely done. or culture of samples taken from other areas (eg. even if the cause is suspected to be viral. < 150 mg/dL). no combination of findings in CSF cells. a throat swab. . Glucose is usually normal or only slightly lower than normal. stool) may help identify the causative virus. Acyclovir is efficacious in treating herpes simplex meningitis and can be used to treat herpes zoster meningitis. Other findings include pleocytosis with a lymphocytic predominance. CSF is shown to be sterile). appropriate antibiotics and corticosteroids are started immediately (without waiting for test results) and continued until bacterial meningitis is ruled out (ie. blood. Pleconaril is only modestly efficacious for meningitis due to enteroviruses and is not available for routine clinical use. protein is slightly increased but less than that in acute bacterial meningitis (eg. PCR can be used to detect some viruses in CSF (enteroviruses and herpes simplex. nasopharyngeal secretions. treat them for acute bacterial meningitis until it is ruled out. herpes zoster.

 Treat patients for acute bacterial meningitis until that diagnosis is ruled out. but is rarely as severe as acute bacterial meningitis.Key Points  Viral meningitis begins with symptoms typical of a viral illness. and slightly increased protein) cannot exclude acute bacterial meningitis. patients with herpes simplex or herpes zoster meningitis may be treated with acyclovir .  Enteroviruses are the most common cause. fever. near normal glucose.  CSF findings (usually lymphocytic pleocytosis. followed by headache. usually during summer or early autumn.  Treatment is mainly supportive. and nuchal rigidity.