Recurrent Viral Meningitis

[Linda-Malmberg]

    
      Re: Recurrent Viral Meningitis
    


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Posted by CCF Neuro MD on August 16, 1997 at 23:20:40:

In Reply to: Recurrent Viral Meningitis posted by Linda Malmberg on July 25, 1997 at 23:45:42:

: I have recently had my third episode of viral meningitis.  The first episode was 2 1/2 years ago and was the most severe involving encephalitis and a mild TIA episode.  2 out of the 3 episodes required hospitalization with 10 days treatment of IV Acyclovir and Rocephin.  I have had a total of 5 lumbar punctures, all have indicated elevated WBC ranging from 90 - 235 and elevated protein 110 - 129.  Predominant lymphocytes 84 - 95%.  All cultures of CSF and blood have been negative for either bacteria or virus, however, a PCR assay for Herpes Simplex has never been done.  My question is this.  What are the pros and cons of prophylactic use of oral acyclovir as a means to avoid or reduce the severity of subsequent episodes of viral meningitis?  My doctors at this point can only assume that the source of my recurrent meningitis is HSV and are reluctant to reccommend daily oral acyclovir as a preventive.  Are there any studies on the side effects of long-term acyclovir use?  Are there any theories on the factors that may precipitate an exacerbation of the virus?  I obviously would be interested in any information regarding how best to avoid or decrease the frequency of repeat episodes of viral  meningitis.  Thanks for any help.
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Dear Linda:
Herpes simplex virus 2, and less so, herpes simplex virus 1, are important causes of recurrent lymphocytic meningitis. There are numerous other causes of recurrent/chronic meningitis, however, that are in the differential diagnosis. These include other infections such as lyme disease, sarcoidosis, Bechet’s disease, vasculitis, neurosurgical causes (csf fistulae, cystic tumors), and drug-induced meningitis (e.g. ibuprofen, sulfonamides). Although HSV 2 is a reasonable diagnostic consideration in your case, this cannot be conclusively established unless a positive PCR or a high csf titer of anti-HSV antibodies is demonstrated.
Long term acyclovir has been used successfully as suppressive therapy  for recurrent genital herpes (HSV 2) and recurrent herpes keratitis (corneal, HSV 1), and in immunosuppressed states. The medication has not been studied, to my knowledge, for suppression/prevention of recurrent meningitis. Acyclovir is a relatively non-toxic drug (except for renal adverse effects), and may be a reasonable therapeutic consideration for recurrent lymphocytic meningitis if the etiological agent is known to be HSV. In your case, however, one might be reluctant to use it when the cause is not firmly established.
Valacyclovir is a pro-drug of acyclovir with pharmacokinetic characteristics that might make it the preferred drug for oral use.
I do not know of any specific precipitants of recurrent meningitis.
If you live near Cleveland, you are welcome to see one of the neurologists at the Cleveland Clinic for a second opinion. We also have a very renowned and large infectious diseases department that could help answer some of your questions. The number to call for appointments is [phone], or [phone].
This information is provided for general medical education purposes only. Please consult your physician for diagnostic and treatment options of your specific medical condition.