eMedicine Specialties > Neurology > Neurological Infections
Viral Meningitis: Follow-up
Updated: Oct 28, 2009
Follow-up
Further Inpatient Care
- If the CSF Gram stain result is negative but moderate to severe pleocytosis is noted (WBC >1000 x 109/L), a repeat LP should be considered in 12-18 hours if patient is not clinically improved. All patients with suspected bacterial meningitis should be treated empirically with appropriate antibiotics. After the bacterial Gram stain, latex antigen tests, and cultures return negative, antibacterial therapy can be discontinued. If results of PCR testing of CSF and viral culture for herpes simplex are negative, acyclovir can be discontinued; otherwise a 10-day course is recommended. If no clinical improvement is noted and all the common bacterial and viral pathogens have been ruled out, the following tests should be performed and the therapy modified depending on their results:
- CSF - Venereal Disease Research Laboratories test (VDRL), PCR for CMV, acid-fast stain
- Skin - Purified protein derivative (PPD) to help exclude tuberculosis
- Blood - HIV antibody and PCR, rapid plasma reagent (RPR), Lyme antibody (in areas of endemic disease or if history suggestive), toxoplasmosis antibody (especially in infants and newborns)
- Prevention of secondary infections, control of seizures, management of electrolyte abnormalities such as SIADH, and adequate nutritional support are paramount for successful management of these patients.
Further Outpatient Care
- Although most patients with signs of meningitis are hospitalized, a subgroup with aseptic meningitis are treated appropriately in an ambulatory setting. Absolute criteria for discharge of these patients from the emergency department (ED) have not been established, but recent investigations in children suggest that age > 1 year, nontoxic clinical appearance, normal serum WBC count, mild CSF pleocytosis, negative CSF Gram stain, adequate control of symptoms, and a reliable family setting may serve as some useful factors in the decision to discharge. Prospective studies would aid in further delineating guidelines for patient discharge and follow-up. Most admissions are for IV hydration, empiric antibiotics, and observation, or if a diagnosis other than viral meningitis is being considered.
- Arrange follow-up with the primary care physician in 1-3 days with explicit instructions to return to the ED in case of any clinical worsening. A follow-up call in a day to report on the status of the patient seems like a common-sense recommendation.
- In selected patients, additional serum specimens 10-21 days later may reveal a specific viral antibody titer rise, which is useful in arboviral, LCMV, and some nonviral causes of aseptic meningitis.
- In cases complicated by seizures, outpatient anticonvulsants should be continued and close follow-up should be considered in the first week after discharge.
Inpatient & Outpatient Medications
Outpatient supplies of antipyretics such as acetaminophen and antiemetics such as promethazine may be given to ambulatory patients who do not appear clinically toxic. No strict criteria exist for discharging patients with viral meningitis. Outpatient medications also may include anticonvulsants in cases complicated by seizures. Inpatient medications include empiric antibiotics in selected cases as already discussed.
Transfer
- Patients with focal signs, severe lethargy, or headache should be transferred to the closest institution with CT capability. Children younger than 1 year and neonates should be transferred to a hospital equipped with pediatric intensive care capability.
- Medications should be instituted prior to transfer in select cases, particularly empiric therapy for bacterial meningitis, if indicated.
Deterrence/Prevention
Pregnant women should avoid exposure to rodents, rats, and house mice, which carry LCMV. Some investigators even suggest avoidance of young children and public pools by pregnant women in the third trimester to decrease the risk of enteroviral colonization and transmission to the fetus. Neonates should be kept away from exposure to mosquitos for prevention of arboviral infection.
Complications
- Communicating hydrocephalus is a rare complication of viral meningitis, and is due to obstruction of arachnoid granulations by inflammatory debris. The usual time of onset is within weeks of the original symptoms. VP shunting is usually successful in relieving the hydrocephalus. Less common is acute hydrocephalus with onset within hours to days of original symptoms, which may require ventriculostomy with an external collection system.
- Long-term neurological sequelae from uncomplicated viral meningitis are rare. Sequelae including seizure disorders, hydrocephalus, sensorineural hearing loss, weakness, paralysis, cranial nerve palsy, learning disabilities, blindness, behavior disorders, and speech delay in children have been reported in the literature, especially for infants and young children.
Prognosis
The prognosis for viral meningitis is usually excellent, with most cases resolving in 7-10 days. Implicit in the diagnosis is the self-limited nature of this disease. The exception falls with the neonatal patients, in whom viral meningitis can be fatal or associated with significant morbidity. Children with viral meningitis may suffer from neuromuscular impairment (ie, mild paresis or loss of coordination) as well as learning disabilities as reported in the literature. Concomitant encephalitis adds significant potential for adverse outcomes. Concurrent systemic manifestations such as pericarditis and hepatitis are other indicators of poor prognosis.
Patient Education
- Vaccination remains the most potent means of combating infections by polio, measles, mumps, and varicella viruses.
- Strict handwashing is effective in controlling the spread of enterovirus-related infections, but maintaining public hygiene remains a problem in some developing countries. Although enteroviruses are ubiquitous, some reports suggest pregnant women in the third trimester should avoid public swimming pools to decrease the risk of enteroviral colonization.
- The education of sex partners about the use of barrier devices can significantly decrease the incidence of HSV-2 infections.
- Protection against mosquito exposure (using insect sprays, netting, eradication of breeding sites) should be exercised to prevent arbovirus infection, and is especially important in vulnerable patients such as the young.
- Avoidance of exposure to rodents can decrease the incidence of LCMV meningoencephalitis. Infected pets, house mice, and rats pose a risk to pregnant women.
- For excellent patient education resources, visit eMedicine's Brain and Nervous System Center, Children's Health Center, and Bites and Stings Center. Also, see eMedicine's patient education articles Meningitis in Adults, Meningitis in Children, Encephalitis, and Ticks.
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize partially treated bacterial meningitis, fungal meningitis, tuberculous meningitis, and other causes associated with significant morbidity and mortality
- Failure to start antibiotics early to prevent potentially treatable causes of meningitis
- Failure to examine the patient, arrange follow-up, keep adequate records, or act with or convey the necessary degree of urgency
- Complications following LP in a patient with an intracranial lesion; in many cases obtaining neuroimaging prior to LP is prudent
Special Concerns
The signs and symptoms in the very young are not "textbook," and a high index of suspicion is required for accurate diagnosis and management. The elderly also may present with atypical signs and symptoms.
More on Viral Meningitis |
| Overview: Viral Meningitis |
| Differential Diagnoses & Workup: Viral Meningitis |
| Treatment & Medication: Viral Meningitis |
 Follow-up: Viral Meningitis |
| Multimedia: Viral Meningitis |
| References |
| « Previous Page | Next Page » |
References
CDC. Final 2008 West Nile Virus Activityin the United States. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/ncidod/dvbid/westnile/surv&controlCaseCount08_detailed.htm. Accessed September 1, 2009.
Hviid A, Rubin S, Mühlemann K. Mumps. Lancet. Mar 15 2008;371(9616):932-44. [Medline].
INTERNATIONAL NOTEGLOBAL ADVISORY COMMITTEE ON VACCINE SAFETY, 11-12 JUNE, 2003. Canada Communicable Disease Report; April 1, 2004. [Full Text].
Weekly Epidemiological Record. No. 3, 2007, 82. World Health Organization; January 19, 2007. 18-22. [Full Text].
Landry ML, Greenwold J, Vikram HR. Herpes simplex type-2 meningitis: presentation and lack of standardized therapy. Am J Med. Jul 2009;122(7):688-91. [Medline].
US Food and Drug Administration. FDA Clears Rapid Test for Meningitis. FDA. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108870.htm. Accessed September 1, 2009.
King RL, Lorch SA, Cohen DM, Hodinka RL, Cohn KA, Shah SS. Routine cerebrospinal fluid enterovirus polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days of age or younger. Pediatrics. Sep 2007;120(3):489-96. [Medline].
Nigrovic, Kuppermann, Macias et al. Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis. JAMA. Jan 3, 2007;297:52-60. [Full Text].
Kanegaye JT, Nigrovic LE, Malley R, Cannavino CR, Schwab SH, Bennett JE, et al. Diagnostic value of immature neutrophils (bands) in the cerebrospinal fluid of children with cerebrospinal fluid pleocytosis. Pediatrics. Jun 2009;123(6):e967-71. [Medline].
Desmond RA, Accortt NA, Talley L, Villano SA, Soong SJ, Whitley RJ. Enteroviral meningitis: natural history and outcome of pleconaril therapy. Antimicrob Agents Chemother. Jul 2006;50(7):2409-14. [Medline]. [Full Text].
Bobek MP, Sagher O. Aseptic meningitis caused by Teflon implantation for microvascular decompression. Case report. J Neurosurg. Jan 1999;90(1):145-7. [Medline].
Cherry JD. Aseptic meningitis and viral meningitis. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 2. 4th ed. Philadelphia: Saunders; 1998:450-57.
Doherty RL, Jordan MC. Viral meningoencephalitis. In: Infectious Diseases. 5th ed. 1994:1092-100.
Eppes SC, Nelson DK, Lewis LL, Klein JD. Characterization of Lyme meningitis and comparison with viral meningitis in children. Pediatrics. May 1999;103(5 Pt 1):957-60. [Medline].
Hamilton MS, Jackson MA, Abel D. Clinical utility of polymerase chain reaction testing for enteroviral meningitis. Pediatr Infect Dis J. Jun 1999;18(6):533-7. [Medline].
Huang CC, Liu CC, Chang YC, et al. Neurologic complications in children with enterovirus 71 infection. N Engl J Med. Sep 23 1999;341(13):936-42. [Medline].
Ishii K, Kamei S, Takasu T. [Epidemiology of virus-related nervous infections in Japan]. Nippon Rinsho. Apr 1997;55(4):839-48. [Medline].
Karande S, Patil S, Kulkarni M. Acute aseptic meningitis as the only presenting feature of leptospirosis. Pediatr Infect Dis J. Apr 2005;24(4):390-1. [Medline].
Mohle-Boetani JC, Matkin C, Pallansch M, et al. Viral meningitis in child care center staff and parents: an outbreak of echovirus 30 infections. Public Health Rep. May-Jun 1999;114(3):249-56. [Medline].
Moris G, Garcia-Monco JC. The challenge of drug-induced aseptic meningitis. Arch Intern Med. Jun 14 1999;159(11):1185-94. [Medline].
Muir P, Kammerer U, Korn K. Molecular typing of enteroviruses: current status and future requirements. The European Union Concerted Action on Virus Meningitis and Encephalitis. Clin Microbiol Rev. Jan 1998;11(1):202-27. [Medline].
Norris CM, Danis PG, Gardner TD. Aseptic meningitis in the newborn and young infant. Am Fam Physician. May 15 1999;59(10):2761-70. [Medline].
Oostenbrink R, Moll HA, Moons KG. Predictive model for childhood meningitis. Pediatr Infect Dis J. Nov 2004;23(11):1070-1. [Medline].
Powell S, Schochet SS. Selected pediatric viral infections. Semin Pediatr Neurol. Sep 1995;2(3):211-9. [Medline].
Pérez-Vélez CM, Anderson MS, Robinson CC, McFarland EJ, Nix WA, Pallansch MA, et al. Outbreak of neurologic enterovirus type 71 disease: a diagnostic challenge. Clin Infect Dis. Oct 15 2007;45(8):950-7. [Medline].
Rotbart HA. Viral meningitis and the aseptic meningitis syndrome. In: Lambert HP, ed. Infections of the Central Nervous System. Philadelphia: Decker; 1991:19-39.
Sawyer MH. Enterovirus infections: diagnosis and treatment. Pediatr Infect Dis J. Dec 1999;18(12):1033-9; quiz 1040. [Medline].
Sormunen P, Kallio MJ, Kilpi T, Peltola H. C-reactive protein is useful in distinguishing Gram stain-negative bacterial meningitis from viral meningitis in children. J Pediatr. Jun 1999;134(6):725-9. [Medline].
Takeoka T. [Cerebrospinal fluid examination in the infectious meningitis and encephalitis]. Nippon Rinsho. Apr 1997;55(4):809-14. [Medline].
Waisman Y, Lotem Y, Hemmo M, et al. Management of children with aseptic meningitis in the emergency department. Pediatr Emerg Care. Oct 1999;15(5):314-7. [Medline].
Further Reading
Keywords
aseptic meningitis, serous meningitis, nonpyogenic leptomeningitis, abacterial meningitis, enterovirus, coxsackievirus, echovirus, viral meningitis, viral infection, herpes viruses, HSV-1, HSV-2, varicella zoster virus, VZV, B virus
