Mollaret's meningitis associated with acute Epstein-Barr virus mononucleosis

Mollaret's Meningitis: A Rare Entity

We report on a patient with Mollaret’s meningitis to highlight the appropriate diagnostic criteria and benign prognosis without empiric antiviral therapy. An 83-year-old man with a history of aseptic meningitis of unknown etiology followed by full recovery presented with a two-day history of fevers, generalized weakness, and neurologic abnormalities. Cerebral spinal fluid (CSF) analysis demonstrated lymphocytic pleocytosis consistent with aseptic meningitis. Given his prior noninfectious aseptic meningitis and symptom-free interval, Mollaret’s meningitis was suspected and empiric treatment for herpes simplex viruses (HSV) encephalitis with acyclovir was deferred. All CSF studies, including polymerase chain reactions for HSV-1 and HSV-2, returned negative with clinical improvement by the fourth day of admission. For patients suspected to have Mollaret’s meningitis, lumbar puncture should be conducted promptly to facilitate diagnosis. Although several reports describe patients with CSF infection, the diagnosis of Mollaret’s meningitis should be reserved for noninfectious cases. In such cases, empiric antiviral therapy for HSV encephalitis may be deferred and complete recovery is expected.

A Rare Case of Mollaret's Meningitis Complicated by Chronic Intractable Migraine and Papilledema: Case Report and Review of Literature

Mollaret’s meningitis is characterized by recurrent episodes of aseptic meningitis that last two to seven days and resolve spontaneously without any residual neurological deficit or complication. Viruses are the most common cause of aseptic meningitis and herpes simplex virus (HSV) type 2 has been noted as the most commonly associated virus in Mollaret’s meningitis. We describe a rare case of a female who had four episodes of meningitis in a five-year period associated with chronic intractable migraine and papilledema attributed to Mollaret’s meningitis.

Viral meningitis: current issues in diagnosis and treatment

PURPOSE OF REVIEW

The purpose of this review is to give an overview of viral meningitis and then focus in on some of the areas of uncertainty in diagnostics, treatment and outcome.

RECENT FINDINGS

Bacterial meningitis has been declining in incidence over recent years. Over a similar time period molecular diagnostics have increasingly been used. Because of both of these developments viral meningitis is becoming relatively more important. However, there are still many unanswered questions. Despite improvements in diagnostics many laboratories do not use molecular methods and even when they are used many cases still remain without a proven viral aetiology identified. There are also no established treatments for viral meningitis and the one potential treatment, aciclovir, which is effective in vitro for herpes simplex virus, has never been subjected to a clinical trial.

SUMMARY

Viruses are in increasingly important cause of meningitis in the era of declining bacterial disease. The exact viral aetiology varies according to age and country. Molecular diagnostics can not only improve the rate of pathogen detection but also reduce unnecessary antibiotics use and length of hospitalization. Further research is required into treatments for viral meningitis and the impact in terms of longer term sequelae.

CSF in acute and chronic infectious diseases

Infections of the nervous system are an important and challenging aspect of clinical neurology. Immediate correct diagnosis enables to introduce effective therapy, in conditions that without diagnosis may leave the patient with severe neurological incapacitation and sometimes even death. The cerebrospinal fluid (CSF) is a mirror that reflects nervous system pathology and can promote early diagnosis and therapy. The present chapter focuses on the CSF findings in neuro-infections, mainly viral and bacterial. Opening pressure, protein and glucose levels, presence of cells and type of the cellular reaction should be monitored. Other tests can also shed light on the causative agent: serology, culture, staining, molecular techniques such as polymerase chain reaction. Specific examination such as panbacterial and panfungal examinations should be examined when relevant. Our chapter is a guide-text that combines clinical presentation and course with CSF findings as a usuaful tool in diagnosis of neuroinfections.

The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults

Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.

Mollaret meningitis may be caused by reactivation of latent cerebral toxoplasmosis

Mollaret meningitis (MM) occurs mainly in females and is characterized by recurrent episodes of headache, transient neurological abnormalities, and the cerebrospinal fluid containing mononuclear cells. HSV-2 was usually identified as the causative agent. Recently, we found that recurrent headaches in non-HIV-infected subjects were due to acquired cerebral toxoplasmosis (CT). The aim of the study was therefore to focus on molecular pathomechanisms that may lead to reactivation of latent CT and manifest as MM. Literature data cited in this work were selected to illustrate that various factors may affect latent CNS Toxoplasma gondii infection/inflammation intensity and/or host defense mechanisms, i.e., the production of NO, cytokines, tryptophan degradation by indoleamine 2,3-dioxygenase, mechanisms mediated by an IFN-gamma responsive gene family, limiting the availability of intracellular iron to T. gondii, and production of reactive oxygen/nitrogen species, finally inducing choroid plexitis and/or vasculitis. Examples of triggers revealing MM and accompanying disturbances of IFN-gamma-mediated immune responses that control HSV-2 and T. gondii include: female predominance (female mice are more susceptible to T. gondii infection than males); HSV-2 infection (increased IFN-gamma, IL-12); metaraminol (increased plasma catecholamine levels, changes in cytokine expression favoring T(H)2 cells responses); probably cholesterol contained in debris from ruptured epidermoid cysts (decreased NO; increased TNF-alpha, IL-6, IL-8). These irregularities induced by the triggers may be responsible for reactivation of latent CT and development of MM. Thus, subjects with MM should have test(s) for T. gondii infection performed obligatorily.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

Mollaret's meningitis: cytopathologic analysis of fourteen cases

Mollaret's meningitis (MM) is a rare disease of benign nature characterized by recurrent episodes of aseptic meningitis. Cerebrospinal fluid (CSF) examination remains the sole diagnostic modality. Eighteen CSF samples from 14 patients were studied along with the clinical data. Specimens were prepared by cytocentrifugation and Millipore filtration and were stained with Diff-Quik and Papanicolaou stains. Eight patients were men and six were women, with an age range of 17-74 yr (mean age 37 yr). Most common clinical presentation was recurrent episodes of headaches and photophobia followed by a sustained mild fever lasting 5-7 days. The CSF showed markedly increased cellularity with pleocytosis. The differential count showed predominant monocytosis ranging from 84% to 100% (mean 96). In our series, two patients had herpes simplex virus type 2 (HSV-2) DNA detected by polymerase chain reaction (PCR) in the CSF. The monocytes were seen predominantly singly, but three cases showed a strong tendency to aggregate in small groups. Phenotypically, these cells had bean-shaped bilobed nuclei as well as multiple deep nuclear clefts depicting the so-called "footprint" appearance. In four cases, multiple blunt-tipped cytoplasmic pseudopods were noted. Degenerated monocytes with the appearance of the so-called "ghost cells" were noted in one-half of the cases. Background cells were mostly small mature lymphocytes; however, one-half of cases showed a significant amount of plasma cells and/or polymorphonuclear leukocytes (PMNs). Lysed blood with hemosiderin-laden macrophages and numerous leptomeningeal cells were seen in two cases. CSF examination of MM presents a spectrum of cytomorphologic features. When interpreted in light of the appropriate clinical setting. the latter, although nonspecific, provides an accurate diagnosis. The differential diagnosis includes various degenerative, inflammatory/infectious, and lymphoproliferative disorders of the central nervous system.

Central nervous system infections: a critical care approach

Central nervous system (CNS) infections are diverse. CNS infections can cause significant morbidity and mortality and are markedly different from systemic infections. The closed anatomic space of the CNS, its immunologic isolation from the rest of the body, and the often nonspecific nature of the key manifestations present a challenge to the clinician. Early recognition and aggressive management are essential to patient recovery and prevention of long-term neurologic sequelae. This review discusses the major types of CNS infections and focuses on critical care management, with emphasis on current epidemiologic trends.

The Acute Aseptic Meningitis Syndrome

The aseptic meningitis syndrome (AMS) is as a diagnostic and management challenge. Since the initial description of AMS in 1925, the differential diagnosis of infectious and noninfectious agents associated with this syndrome has progressed. Although most cases of aseptic meningitis have a benign outcome, several etiologies require urgent therapy if the patient is to survive and be cured. This review will address the differential diagnosis of AMS and focus on recent empiric data that may aid the clinician treating these patients.

Abnormal visual evoked potentials in children with "Alice in Wonderland" syndrome due to infectious mononucleosis

Visual illusions characterized by distortion of form, size, reciprocal position of objects, movement, or color, labeled as "Alice in Wonderland" syndrome, were discussed in children with infectious mononucleosis, as well as in other clinical conditions, such as migraine, epilepsy, use of certain hallucinogenic drugs, etc. The purpose of our study was to investigate for the first time visual evoked potential results in children with "Alice in Wonderland" syndrome associated with infectious mononucleosis. Five children with "Alice in Wonderland" syndrome associated with infectious mononucleosis underwent visual evoked potential studies during and after their clinical symptoms. Visual evoked potential results during the disease demonstrated statistically significant high amplitudes of P100-N145 in all children compared to the control group. A few weeks later, repeated studies after the resolution of the complaints were normal. Since the same findings can be observed in patients with migraine, we postulate that a common pathophysiologic underlying abnormality, which can cause transient focal decreased cerebral perfusion, could be involved in the disease process of these two conditions.

Overview of acute and chronic meningitis

Meningitis can be subdivided based on time course of onset and duration, cerebrospinal fluid (CSF) profile, and underlying origins into acute aseptic and septic meningitis, recurrent meningitis, and chronic meningitis. These are distinct syndromes that require different management strategies. Most cases of meningitis are caused by infection. The causal agent is generally predictable based on the type of meningitis, host factors, and clues from the history and examination. CSF examination remains the critical diagnostic test.

Herpes simplex virus type 2 DNA detected in cerebrospinal fluid of 9 patients with Mollaret's meningitis

We present clinical and virological data on 9 patients, 7 women and 2 men aged 31-56 years, with recurrent aseptic meningitis (Mollaret's meningitis). Polymerase chain reaction detected Herpes simplex virus type 2 DNA in cerebrospinal fluid samples from all patients collected during their latest attacks of meningitis. Six patients had no history of genital herpes. Only 1 patient was offered prophylactic antiviral treatment during the study period (45 months).

Recurring episodes of meningitis (Mollaret's meningitis) with one showing an association with herpes simplex virus type 2

Benign recurrent aseptic (Mollaret's) meningitis is a rare disease of unknown aetiology. We report the case of a 27-year-old woman who experienced three episodes of lymphocytic meningitis. Human Simplex Virus (HSV) type 2 DNA was detected in the CSF by PCR amplification indicating the diagnosis of recurrent HSV type 2 meningitis. Our observation suggests that search of herpes virus DNA by PCR amplification on CSF may be useful in unexplained recurrent meningitis.

Herpes simplex type 2 in a patient with Mollaret's meningitis: demonstration by polymerase chain reaction

We describe a patient with recurrent self-limited aseptic meningitis meeting the criteria for Mollaret's syndrome, in whom extensive serological investigation and cerebrospinal fluid analysis failed to reveal a specific cause. Using polymerase chain reaction techniques to amplify herpes simplex viral DNA, we were able to identify the presence of herpes simplex virus type 2 in the cerebrospinal fluid. The duration of clinical illness may have been shortened by treatment with intravenous acyclovir. We suggest that herpes simplex virus may be a more common cause of aseptic meningitis than has been demonstrated by current commonly available serological and culture techniques.

Cytology of Mollaret meningitis

The diagnosis of Mollaret meningitis was established by cytologic examination of the cerebrospinal fluid (CSF) in a patient with recurrent aseptic meningitis. The characteristic features of the "Mollaret cell," an activated monocyte, are presented; theories of etiology are reviewed.

Alice in Wonderland syndrome as an initial manifestation of Epstein-Barr virus infection

We present a patient with serologically confirmed Epstein-Barr virus (EBV) infection who had illusions of size, shape, and colour of objects but none of the typical symptoms and signs peculiar to infectious mononucleosis (IM) except sore throat which developed 2 weeks after the initial visual disturbances. The bizarre feelings about the images of body and objects are called the 'Alice in Wonderland syndrome' due to the similarity with Alice's dreams. The same symptomatology including visual metamorphosia is defined in patients with migraine, epilepsy, intoxication due to hallucinogenic drugs, schizophrenia, hyperpyrexia, and cerebral lesions. Alice in Wonderland syndrome has also been reported in the course of IM.

Relapsing acute disseminated encephalomyelitis associated with chronic Epstein-Barr virus infection: MRI findings

A 25-year-old women had a fever, left cervical lymphadenopathy, neurological symptoms and signs, CSF pleocytosis and persistent high serum antibodies to the Epstein-Barr virus (EBV); she had a recurrence 1 year later. She was thought to have relapsing acute disseminated encephalomyelitis associated with chronic EBV infection. MRI revealed abnormalities, mainly in the right basal ganglia and left midbrain. At the time of the recurrence, further abnormalities appeared in the opposite basal ganglia and right cerebral white matter.