eMedicine Specialties > Neurology > Neurological Infections
Viral Meningitis: Treatment & Medication
Updated: Oct 28, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
Treatment for viral meningitis is mostly supportive. Rest, hydration, antipyretics, and pain or anti-inflammatory medications may be given as needed. The most important decision is whether to initiate antimicrobial therapy empirically for bacterial meningitis while waiting for the cause to be identified. Intravenous (IV) antibiotics should be administered promptly if bacterial meningitis is suspected. Patients with signs and symptoms of meningoencephalitis should receive acyclovir early to possibly curtail HSV encephalitis. Therapy can be modified as the results of Gram stain, cultures, and PCR testing become available. Patients in unstable condition need critical care unit admission for airway protection, neurologic checks, and prevention of secondary complications.
Enteroviruses and HSV are both capable of causing viral septic shock in newborns and infants. In these young patients, broad-spectrum antibacterial coverage and acyclovir should be instituted as soon as the diagnosis is suspected. Special attention should be paid to fluid and electrolyte balance (especially sodium), since SIADH has been reported. Fluid restriction, diuretics, and rarely hypertonic saline infusion may be used to correct the hyponatremia. Prevention of secondary infections of urinary tract and pulmonary systems is of paramount importance.
- Waiting for lumbar puncture results should not delay administration of antibiotics when warranted on clinical grounds. Broad-spectrum coverage is attained with ampicillin and a third-generation cephalosporin (ceftriaxone or cefotaxime; ceftazidime can also be used). Aminoglycosides are used in severe infections in neonates or children. Antituberculous, antifungal, and antiretroviral medications are reserved for clinically-suggested or laboratory-confirmed cases. Please see the article on bacterial meningitis for specific recommendations.
- Seizures should be treated immediately with IV anticonvulsants such as lorazepam, phenytoin, midazolam, or a barbiturate. Unconscious patients with viral encephalitis may be in nonconvulsive status epilepticus, and EEG is used to reveal and monitor subclinical seizures. Cerebral edema does occur in cases of severe encephalitis and may require intracranial pressure control by infusion of mannitol (1 g/kg initial dose followed by 0.25-0.5 g/kg q6h), IV dexamethasone, or intubation and mild hyperventilation, with arterial PCO2 around 28-30 mm Hg. Placement of an intracranial pressure monitor with transduced intraparenchymal pressure is recommended in these cases.
- Multiple antiviral medications are currently being tested in the general population; their impact on preventing the potential rare sequelae of viral meningitis have not yet been established.
- In herpetic viral infections, acyclovir is significantly beneficial only if given very early in the course of the infection. Suspected cases should be treated as soon as possible; in cases complicated by seizures, encephalitis is assumed and acyclovir should be initiated.
- Anti-HIV therapy is initiated when the history or associated risk factors suggest the early phases of HIV meningoencephalitis.
- Ganciclovir for CMV-related infections is reserved for severe cases with positive CMV culture or when a congenital infection or an AIDS-related infection is strongly suspected.
- Administration of IVIg to neonates with overwhelming enteroviral meningitis has met with occasional success and is reserved for severe cases lacking other therapeutic options.
Surgical Care
No surgical therapy is usually indicated. In rare patients in whom viral meningitis is complicated by hydrocephalus, a CSF diversion procedure, such as ventriculoperitoneal (VP) or LP shunting, may be required. Ventriculostomy with an external collection system is indicated in the rare cases of acute hydrocephalus. Occasionally meningeal or parenchymal biopsy for definitive diagnosis of rare viral infections is required. Intracranial pressure monitoring, required for some cases of encephalitis, usually can be performed at bedside.
Consultations
- Neurology - Seizure control, EEG, management of brain edema in refractory cases, neuro-intensive care
- Neurosurgery - Placement of intracranial pressure monitor, CSF shunting or temporary drainage in cases with hydrocephalus, neuro-intensive care
- Infectious disease - Control of epidemics, isolation of patient and contacts, choice of antibiotics in refractory or atypical cases
- Neonatology - Any newborn or infant with severe viral meningitis requiring intensive care
Diet
No special diet is required.
Activity
The activity limitations should be individualized based on each patient's clinical picture. Bed rest is recommended for the acute phase of infection.
Medication
Symptomatic control with antipyretics, analgesics, and antiemetics is usually all that is needed in the management of uncomplicated viral meningitis.
The decision to start antibacterial therapy for treatment of possible bacterial meningitis is the most crucial; empiric antibacterial therapy for likely pathogens should be considered in the context of the clinical setting (see articles on bacterial meningitis for details).
Acyclovir should be used in cases suspicious for HSV (patients with herpetic lesions), and is usually used empirically in more severe cases complicated by encephalitis or sepsis.
Anti-HIV therapy is initiated when the history is strongly suggestive and/or confirmatory tests have proven an infection. These medications are covered in other articles. Ganciclovir for CMV-related infections is reserved for severe cases with positive CMV culture, congenital infection, or immunocompromised patients.
Pleconaril is an antipicornavirus drug that held potential for treatment of enteroviral meningitis. A multicenter, randomized, double-blind, placebo-controlled study in 607 patients with enteroviral meningitis found that pleconaril shortened the course of illness, especially in the early disease course; however, the benefit was achieved only modestly in a subgroup analysis of patients with more severe disease after adjusting for confounding variables.10 Pleconaril trials have now shifted focus to treatment of rhinovirus upper respiratory infections.
Administration of IVIg to neonates with overwhelming enteroviral meningitis has met with only occasional success and is not covered in this section. For anticonvulsant therapy, refer to articles covering status epilepticus and pediatric seizure disorders.
Antiemetic agents
These agents are used mostly to prevent chemotherapy-induced nausea and vomiting.
Ondansetron (Zofran)
Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. Has efficacy in patients who do not respond well to other antiemetics.
Adult
4-8 mg IV q8h/q12h
Pediatric
0.1 mg/kg slow IV maximum of 4 mg/dose; may repeat q12h
Stimulators of cytochrome P-450 system, including barbiturates, rifampin, phenytoin, and phenylbutazone, change clearance; inhibitors of hepatic P-450 system, such as cimetidine, allopurinol, and disulfiram, increase toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Should be scheduled rather than given prn; data support prevention of chemotherapy-induced nausea and vomiting rather than delayed treatment; administer for prevention of nausea and vomiting, not for rescue of nausea and vomiting
Droperidol (Inapsine)
Neuroleptic agent that may reduce emesis by blocking dopamine stimulation of chemoreceptor trigger zone. Also has antipsychotic and sedative properties.
Adult
2.5-5 mg IV/IM q4-6 prn
Pediatric
<6 months: Not established
> 6 months: 0.05-0.06 mg/kg/dose IV/IM q4-6 prn
Atropine and lithium increase toxicity; fentanyl and other analgesics may cause increased BP (administration with epinephrine may decrease BP)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Safety in children <6 mo not established; caution in patients with seizures, bone marrow suppression, or severe liver disease; significant hypotension can occur; tardive dyskinesia, extrapyramidal reactions, Parkinson-like state, and akathisia have been reported, especially in elderly; orthostatic hypotension and altered state of mind can occur, especially in elderly
May cause QT prolongation (delayed recharging of heart between beats) within minutes following injection at doses at or below recommended levels; prolonged QT can cause potentially fatal heart arrhythmia known as torsades de pointes (TdP); all patients should undergo a 12-lead ECG prior to administration of drug to determine if QT interval is prolonged (ie, QTc >440 msec for males or 450 msec for females); if QT interval is prolonged, droperidol should not be administered; for patients in whom potential benefit of droperidol treatment is felt to outweigh risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2-3 h after completing treatment to monitor for arrhythmias
Antiviral agents
Anti-enteroviral therapy is under investigation for viral meningitis and may soon become available. Anti-HIV and anti-tuberculosis regimens are not covered here, but should be instituted if these infections are strongly suggested clinically or confirmed by testing. Empiric therapy can be discontinued once the cause of viral meningitis has been established and bacterial meningitis excluded.
Acyclovir (Zovirax)
To be started as soon as diagnosis of herpetic meningoencephalitis suspected. Inhibits activity of both HSV-1 and HSV-2.
Adult
30 mg/kg/d IV divided q8h for 10-14 d
Pediatric
30 mg/kg/d IV divided q8h for 10 d
Probenecid or zidovudine prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure or when using nephrotoxic drugs
More on Viral Meningitis |
| Overview: Viral Meningitis |
| Differential Diagnoses & Workup: Viral Meningitis |
 Treatment & Medication: Viral Meningitis |
| Follow-up: Viral Meningitis |
| Multimedia: Viral Meningitis |
| References |
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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
