II. Epidemiology

  1. Age: under 30 years (90%)
  2. Peaks in late summer

III. Etiology: Common

  1. Coxsackie virus
  2. Echovirus

IV. Causes

  1. Most common in children
    1. Enterovirus or Arbovirus (summer, fall)
    2. Herpes Simplex Virus (HSV)
  2. Most common in adults
    1. Enterovirus
    2. Herpes Simplex Virus (HSV, typically HSV 2)
    3. Varicella-Zoster Virus (VZV)
  3. Common Viral Infections causing Aseptic Meningitis
    1. Enterovirus (85% of Viral Meningitis)
      1. Echovirus (esp. children)
      2. Coxsackievirus (type A which causes hand, foot and mouth, and Type B)
      3. Polio Virus
    2. Arbovirus (Arthopod-borne viruses such as St. Louis Encephalitis virus, West Nile Virus)
    3. Herpes Viruses
      1. HSV1 (typically causes HSV Encephalitis instead of Meningitis)
      2. HSV2 Meningitis (Mollaret Meningitis) - most common of herpes virus Meningitis
        1. Causes primary and secondary recurrent lymphocytic Meningitis
      3. Epstein Barr Virus (Mononucleosis)
      4. Cytomegalovirus
      5. Varicella Zoster Virus
    4. Acute Retroviral Syndrome (HIV Infection)
    5. Lymphocytic choriomeningitis virus (rodent-borne arena virus)
    6. Mumps
    7. Less common causes include Adenovirus, Measles, Rubella

V. Symptoms

  1. Flu-like Prodrome
  2. Intense Onset of symptoms
    1. Headache
    2. Malaise
    3. Nausea
    4. Vomiting
    5. Photophobia
    6. Stupor (rarely)
    7. Neck stiffness

VI. Signs

  1. Fever (maximum 38-40 degrees Celsius)
  2. Meningeal Irritation
    1. Nuchal Rigidity
    2. Spinal Rigidity
    3. Kernig's Sign
    4. Brudzinski's Sign
  3. Rash (Coxsackie or Echovirus)
  4. Herpangina (Coxsackie Virus)
    1. Painful Vesicles at posterior third of oropharynx

VII. Differential Diagnosis

  1. Aseptic Meningitis
    1. Includes Viral Meningitis, fungal Meningitis, malignancy, Autoimmune Conditions, medications
  2. Bacterial Meningitis
    1. Often indistinguishable without Lumbar Puncture and CSF Culture
    2. Additional findings (e.g. Parotitis in mumps) may suggest cause
  3. Encephalitis (e.g. HSV Encephalitis, West Nile Virus, St. Louis Encephalitis)
    1. Abnormal brain function distinguishes Encephalitis from Meningitis
    2. Altered behavior, personality, Level of Consciousness, speech, movement or weakness
    3. Seizures may occur with either Meningitis or Encephalitis

VIII. Labs: Cerebrospinal Fluid (CSF)

  1. CSF White Blood Cells: 10-100 (75% Lymphs)
  2. CSF Protein Normal
  3. CSF Glucose Normal
    1. May be reduced in Mumps and HSV
  4. CSF Culture Negative

IX. Course

  1. Fever typically resolves in 3-5 days
  2. CSF Leukocytes increased for weeks

X. Management

  1. Symptomatic Therapy
  2. See Meningitis
  3. See Bacterial Meningitis Management
    1. Empiric antibiotics for Meningitis if diagnosis unclear

XI. References

  1. Johnson in Hirsch (2012) Aseptic Meningitis, UpToDate, Wolters-Kluwer, accessed 4/9/2016
  2. Wan in Roos (2015) Viral Meningitis, EMedicine, Medscape, accessed 4/9/2016
  3. Bamberger (2010) Am Fam Physician 82(12): 1491-8 [PubMed]
  4. Mount (2017) Am Fam Physician 96(5): 314-22 [PubMed]

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Related Studies

Ontology: Viral meningitis (C0025297)

Definition (MSHFRE) Infections virales des leptoméninges et de l'espace sous-arachnoïdien. Ce type d'infections peut être dû aux virus de la famille des Togaviridae (Rubéole), Flaviviridae, Bunyaviridae, Orbivirus, Picornaviridae, Orthomyxoviridae, Rhabdoviridae, Arenaviridae, Herpesviridae, Adenoviridae, JC virus et Retroviridae. Les manifestations cliniques sont : fièvre, céphalées, douleurs cervicales, vomissements, photophobie, et tout autre signe d'irritation méningée. (From Joynt, Clinical Neurology, 1996, Ch26, pp1-3)
Definition (CSP) viral infections of the leptomeninges and subarachnoid space.
Definition (MSH) Viral infections of the leptomeninges and subarachnoid space. TOGAVIRIDAE INFECTIONS; FLAVIVIRIDAE INFECTIONS; RUBELLA; BUNYAVIRIDAE INFECTIONS; ORBIVIRUS infections; PICORNAVIRIDAE INFECTIONS; ORTHOMYXOVIRIDAE INFECTIONS; RHABDOVIRIDAE INFECTIONS; ARENAVIRIDAE INFECTIONS; HERPESVIRIDAE INFECTIONS; ADENOVIRIDAE INFECTIONS; JC VIRUS infections; and RETROVIRIDAE INFECTIONS may cause this form of meningitis. Clinical manifestations include fever, headache, neck pain, vomiting, PHOTOPHOBIA, and signs of meningeal irritation. (From Joynt, Clinical Neurology, 1996, Ch26, pp1-3)
Concepts Disease or Syndrome (T047)
MSH D008587
ICD9 047.9
ICD10 A87 , A87.9
SnomedCT 154321007, 266097006, 192672003, 266190006, 267575007, 154984006, 187403007, 186490006, 154985007, 267680008, 58170007
English Meningitides, Viral, Meningitis, Viral, Viral Meningitides, Unspecified viral meningitis, Viral Meningitis, Meningitis - viral NOS, Viral meningitis, unspecified, Viral meningitis,unspecifd, [X]Viral meningitis, unspecified, [X]Viral meningitis,unspecifd, MENINGITIS VIRAL, viral meningitis, viral meningitis (diagnosis), Meningitis, Viral [Disease/Finding], aseptic meningitis viral, aseptic viral meningitis, meningitis - viral, meningitis viral, Meningitis viral NOS, Meningitis - viral NOS (disorder), Viral meningitis NOS (disorder), [X]Viral meningitis, unspecified (disorder), Meningitis viral, Abacterial meningitis, Aseptic meningitis, viral, Viral meningitis (disorder), abacterial; meningitis, infection; viral, central nervous system, meningitis, meningitis; abacterial, meningitis; viral, viral; infection, central nervous system, meningitis, virus; meningitis, Viral meningitis, Viral meningitis NOS
French MENINGITE VIRALE, Méningite virale SAI, Méningite virale non précisée, Méningite virale
Portuguese MENINGITE VIRAL, Menigite viral NE, Meningite vírica NE, Meningite a vírus, Meningite viral, Meningite Viral
Dutch meningitis viraal NAO, virale meningitis, niet-gespecificeerde virale meningitis, abacterieel; meningitis, infectie; viraal, centraal zenuwstelsel, meningitis, meningitis; abacterieel, meningitis; virus, viraal; infectie, centraal zenuwstelsel, meningitis, virus; meningitis, Virale meningitis, niet gespecificeerd, meningitis viraal, Meningitis, virale, Virale meningitis
German Meningitis viral NNB, unspezifische virale Meningitis, MENINGITIS DURCH VIREN, Virusmeningitis, nicht naeher bezeichnet, virale Meningitis, Meningitis, Virus-, Virusmeningitis
Italian Meningite virale non specificata, Meningite virale NAS, Meningite virale
Spanish Meningitis viral, Meningitis vírica no especificada, Meningitis vírica NEOM, meningitis vírica, meningitis virósica, meningitis - viral, SAI, meningitis - viral, SAI (trastorno), meningitis viral, SAI (trastorno), [X]meningitis viral, no especificada (trastorno), [X]meningitis viral, no especificada, meningitis viral, SAI, meningitis abacteriana, meningitis aséptica, viral, meningitis viral (trastorno), meningitis viral, Meningitis vírica, Meningitis Viral
Japanese ウイルス性髄膜炎NOS, 詳細不明のウイルス性髄膜炎, ショウサイフメイノウイルスセイズイマクエン, ウイルスセイズイマクエン, ウイルスセイズイマクエンNOS, 髄膜炎-ウイルス性, ウイルス性髄膜炎
Swedish Hjärnhinneinflammation, viral
Czech meningitida virová, Virová meningitida, Blíže neurčená virová meningitida, Virová meningitida NOS
Finnish Virusmeningiitti
Korean 바이러스 수막염, 상세불명의 바이러스 수막염
Polish Zapalenie opon wirusowe
Hungarian Viralis meningitis, virusos meningitis, viralis meningitis k.m.n., nem meghatározott viralis meningitis
Norwegian Virusmeningitt

Ontology: Meningitis herpes (C0863159)

Concepts Disease or Syndrome (T047)
Italian Meningite da Herpes
Japanese ヘルペス性髄膜炎, ヘルペスセイズイマクエン
Czech Herpetická meningitida
English Meningitis herpes, herpes meningitis, meningitis herpes
Hungarian herpeses meningitis
Portuguese Meningite herpética
Spanish Meningitis herpética
Dutch herpesmeningitis
French Méningite herpétique
German Meningitis durch Herpes