viral meningitis jurnal neuro

8/13/2019 Viral Meningitis Jurnal Neuro

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Viral meningitis

David R. Chadwick*

Author Affiliations

Department of Infection & Travel Medicine, The James Cook University Hospital,

Middlesbrouh T!" #$%, U

*Correspondence to: David R. Chadwick, Department of Infection & Travel edicine, The

!ames Cook "niversit# $ospital, iddles%rouh T'( )+, ". Tel.: -(( /(0 12())34 fa5:

-(( /(0 12((/04 e6mail: davidr.chadwick7stees.nhs.uk

Accepted 8ovem%er 01, 0992.

8e5t 'ection

Abstract

iruses pro%a%l# account for most cases of acute meninitis. iral meninitis is often

assumed to %e a larel# %enin disease. ;or the commonest pathoens causin meninitis,

enteroviruses, this is usuall# the case4 however, for man# of the other pathoens causin viral

meninitis, and for common pathoens in the immunocompromised or infants, viral

meninitis is fre


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Introduction

iral meninitis is an important cause of admission to hospital, with an estimated incidence

of around 2>2 cases per 99 999 per #ear in the " ? @. The reported incidence almost

certainl# underestimates the true level, particularl# for enteroviral meninitis, the commonest

pathoen identified. f the remainin causes of viral meninitis and central nervous s#stem

BC8' infections, herpes simple5 virus B$' and flaviviral meninoencephalitis are the

most important in terms of mor%idit# and mortalit#, althouh mumps infection has recentl#

reemered as an important pathoen in #oun adults in the ". ther sinificant causes of

viral meninitis are illustrated in Ta%le . ost viruses causin meninitis e5hi%it a marked

seasonalit#, with a num%er also havin specific eoraphical distri%utions, underlinin the

importance of o%tainin an accurate travel histor# in patients presentin with aseptic

meninitis.

iew this ta%le:

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Table 1

Aetiolo#, epidemiolo# and potential complications of the more sinificant causes of viral

meninitis

Distinuishin viral from %acterial meninitis on presentation or admission to hospital, on the

%asis of clinical features and initial cere%rospinal fluid BC'; parameters, presents a

considera%le challene. There are considera%le %enefits in makin this distinction swiftl#, in

terms of %oth reducin anti%iotic usae and hospital %ed occupanc# and reassurin contactsof cases and health care staff of a non6%acterial cause ?0@. ;or the purposes of this review, the

term viral meninitis will %e used to descri%e %oth acute and chronic meninitis as well as

meninoencephalitis. Althouh some viruses cause a pure encephalitis, m#elitis or post6

infectious encephalitis, discussion of these disorders is %e#ond the scope of this review.

=revious 'ection8e5t 'ection

Pathophysiology

iruses enter the C8' throuh several mechanisms ?)@. an#, such as enteroviruses,replicate outside the C8' and then invade %# haematoenous spread. iral particles pass

directl# across the %lood>%rain %arrier, or are carried across in infected leukoc#tes Be..

mumps, measles or herpesviruses, and then infect vascular endothelial cells. ther viruses

invade throuh peripheral and cranial nerves, as for polio and $', respectivel#. nce within

the C8', viruses ma# spread throuh the su%arachnoid space in C';, with conse


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to increased permea%ilit# of the %lood>%rain %arrier also permit entr# of circulatin

immunolo%ulins. iruses ma# evade effective immune response either throuh immune

tolerance or throuh escape of immune surveillance. T l#mphoc#te responses are an essential

part of the immune response to some viruses, as illustrated %# the increased fre@. The# are now classified into five species: human enteroviruses A>D

Bincludin echoviruses and co5sackieviruses and polio. Jnteroviruses are thouht to cause

over 2 999 cases of meninitis in the "'A each #ear and cause su%stantial mor%idit# in

adults as well as children ?@. Jnteroviral meninitis is the commonest cause of aseptic

meninitis, with %oth epidemic and endemic patterns of disease, and the predominant

serot#pes identified are echoviruses /, 3, , ), 3 and )9. The reported incidence is almost

certainl# a reat underestimate %ecause most cases are mild and do not result in hospital

admission and dianostic lum%ar puncture. Jarlier this decade, there were lare summer

epidemics of enteroviral meninitis in the ", due mostl# to the t#pe enteroviruses:echovirus t#pes ) and )9 ?@. In temperate climates, enteroviral infections are commonest

durin the summer and autumn months, and spread is predominantl# throuh the faecal>oral

route, with infections often commonl# ac


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time taken to return to work ?@. 8onetheless, severe complications of enteroviral meninitis

are e5tremel# rare and mostl# seen in the immunocompromised.

+hilst acute and chronic complications of enteroviral meninitis appear to %e unusual in the

immunocompetent, durin epidemics of hand, foot and mouth disease, enterovirus

meninitis has led to sinificant mor%idit# and mortalit# in children ? (@. There is someuncertaint# reardin the lon6term outcome in children with enteroviral meninitis,

particularl# those who had meninitis as infants. There is some evidence that in children with

meninitis under #ear of ae, su%tle neurodevelopmental pro%lems such as lanuae ma#

later %e detected ?1@. A " stud# of children with meninitis in the first #ear of life found

that (0K of children with echovirus meninitis had mild or moderate neuroloical disa%ilit#

%# the ae of 2 #ears ?3@.

ne well6reconiGed roup of patients developin a more severe and chronic form of

infection, particularl# associated with echovirus , are those with primar# immune

deficiencies, mostl# L6linked aammalo%ulinaemia ?9@. This complication has ac


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indicators of $' meninitis or encephalitis include a low Nlasow coma scale at

presentation, e5tremes of ae and a dela# in startin antimicro%ial therap#.

ther herpesviruses associated with meninoencephalitis include Jpstein>arr virus BJ,

C, H and human herpesvirus / B$$6/. C8' infections with these viruses are mostl#

seen in the immunocompromised, and C in particular has %een associated with a chronicmeninoencephalitis in advanced human immunodeficienc# virus B$I infection. C and

H ma# also cause a m#elitis or, occasionall#, a ventriculitis, and H has %een associated

with a lare6vessel cere%ral vasculitis causin strokes, particularl# in the elderl#. '#stemic

clinical features ma# point to the possi%ilit# of a herpesviral cause: a mononucleosis6like

s#ndrome would suest the possi%ilit# of J or C, a widespread vesicular rash H

and infantum roseola $$6/ infection.

Flaviviruses

These mos


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immunocompromised and Bfor +est 8ile virus dia%etics. Around 29K of those with

meninoencephalitis are left with lon6term neuroloical disa%ilit# or ps#chiatric se2 times more likel# than females to develop this infection, and children are most

commonl# affected, althouh a recent resurence in cases in the " has larel# affected late

teenaers and #oun adults who did not receive a full course of measles>mumps>ru%ella

BR or mumps vaccine. eninitis is a more common manifestation than mumps

encephalitis, t#picall# associated with fever and vomitin4 however, parotid or other salivar#

land enlarement is onl# evident in around half of all cases. er# few of those affected

develop complications such as encephalitis, neuropathies, m#elitis or Nuillain>arrO

s#ndrome, and mortalit# is rare. Aseptic meninitis is also a rare conse


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ma# complicate adenovirus, influenGa and parainfluenGa viral infections, and influenGa

vaccination has %een associated with an acute aseptic meninitis. Althouh man# other

viruses are known to cause an acute meninoencephalitis, includin rha%doviruses Bra%ies,

parvovirus 3, 8ipah and $endra viruses BMorbillivirus, %un#aviruses and toaviruses,

meninitis due to these infections is ver# rare, especiall# in Jurope.

=revious 'ection8e5t 'ection

Diagnosis

The most useful investiations to esta%lish the cause of viral meninitis re


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C'; samples have %een developed, the# have #et to %ecome esta%lished as their main

dianostic modalit#.

+hen o%tainin C'; is difficult, culture of throat and stool samples is helpful in dianosin

enteroviral infections4 however, the correlation %etween positive cultures and proven

enteroviral meninitis is not well esta%lished. 8evertheless, one stud# indicated that RT>=CRof stool samples ma# %e useful Bin addition to C'; samples in enteroviral meninitis when

patients present later ?03@. Immunoassa#s on serum BQC'; samples are currentl# the main

method for dianosin several virus causin meninitis. 'eroloical assa#s are the most

widel# used method for dianosin meninitis due to mumps, flaviviruses Band other

ar%oviruses, $I and C. These tests ma# %e neative durin the earl# staes of

infection, so the# re


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those travellers at a hih risk of infection. Those travellin to areas of the world with a hih

incidence of flaviviral infections should %e advised to take strinent precautions to prevent

mos


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