Approach Considerations

Management of pediatric aseptic meningitis is primarily supportive. Consultation with a pediatrician, an infectious disease specialist, a critical care specialist, or combinations thereof may be needed.

Administer adequate analgesia. Treat seizures with appropriate emergency therapies. Referral to a specialized pediatric intensive care unit (ICU) is appropriate if the level of consciousness is reduced and the airway cannot be maintained.

If meningoencephalitis is suspected, administer high-dose intravenous (IV) acyclovir until herpes simplex virus (HSV) infection can be excluded.

If bacterial meningitis cannot be excluded on the basis of the initial history, examination, and investigation, antibiotics should be given. Use an IV third-generation cephalosporin in combination with IV vancomycin until a pyogenic (ie, primarily pneumococcal or meningococcal) bacterial cause is ruled out. Practice guidelines for the management of bacterial meningitis are available from the Infectious Diseases Society of America (IDSA).^[67] The National Institute for Health and Clinical Excellence (NICE) guidelines "Bacterial meningitis and meningococcal septicaemia: Management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care ” are also available for the United Kingdom.^[47]

If tuberculous meningitis is suspected or proved, administer specific antimicrobial therapy and IV corticosteroids. In pediatric patients older than 3 months, the use of steroids is recommended for bacterial meningitis.^[47] (See Pediatric Bacterial Meningitis.) Steroids are not recommended for use in aseptic meningitis.

Pleconaril, is capsid binding anti-viral agent with activity against most strains of enterovirus (EV). One small randomized controlled trial of pleconaril in newborns with suspected enterovirus has shown some efficacy although further data is needed.^[68]Many potential targets for anti-enteroviral treatments have been identified however a very small number have been pursued in clinical trials.^[69]

EV-71 specific immunoglobulin has been trialed in mice however clinical trials in humans are awaited.^[70] Vaccines are also in development against EV-71 and have been trialed in China with promising results.^{[71, 72]} The vaccines appeared safe and reduced the burden of associated hand, foot and mouth disease and herpangina. Further data is needed to assess the vaccines impact on neurologic disease caused by EV-71.

Recovery can be prolonged, and rest is occasionally advised. Children with suspected viral meningitis who appear well may receive care as outpatients, with only symptomatic treatment required. Routine follow-up is not required unless there are specific indications.

Medication

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Media Gallery

Skin lesions due to echovirus type 9 on neck and chest of young girl. Echoviruses belong to genus Enterovirus and are associated with illnesses including aseptic meningitis, nonspecific rashes, encephalitis, and myositis.

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Author

Daniel Owens, BM, MRCPCH(UK) Clinical Research Fellow, NIHR Clinical Research Facility, Southampton General Hospital, UK

Disclosure: Nothing to disclose.

Coauthor(s)

Katrina Cathie, MD, MRCPCH(UK), BM(Hons) Consultant in General Pediatrics and Pediatric Research, University Hospital Southampton NHS Foundation Trust, UK

Katrina Cathie, MD, MRCPCH(UK), BM(Hons) is a member of the following medical societies: Royal College of Paediatrics and Child Health

Disclosure: Nothing to disclose.

Saul N Faust, MA, MBBS, PhD, MRCPCH(UK) Senior Lecturer in Pediatric Immunology and Infectious Diseases, University of Southampton Faculty of Medicine; Director, NIHR Clinical Research Facility, Southampton University Hospital NHS Foundation Trust, UK

Saul N Faust, MA, MBBS, PhD, MRCPCH(UK) is a member of the following medical societies: British Paediatric Allergy, Immunity and Infection Group, European Society for Paediatric Infectious Diseases, International Society for Infectious Diseases, Royal College of Paediatrics and Child Health

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Pfizer meningococcal vaccines<br/>Received research grant from: Pfizer<br/>Institution (no personal fees) received consulting fees from Pfizer, Sanofi, Seqrius, Merck, Medimmune, AstraZeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

David Stuart Baguley, MBChB Critical Care Registrar, The Alfred Hospital, Australia

Disclosure: Nothing to disclose.

Acknowledgements

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa