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Differential diagnosis of aseptic meningitis syndrome Infectious etiologies Noninfectious causes Viruses Enteroviruses - Polio, coxsackievirus, Nonsteroidal anti-inflammatory drugs echovirus HSV types 1 and 2 Varicella-zoster virus Adenovirus Epstein-Barr virus LCMV HIV Influenza virus types A and B Bacteria Partially treated meningitis Parameningeal infection Endocarditis Mycoplasma pneumoniae M tuberculosis Ehrlichiosis - Monocytic, granulocytic Borrelia burgdorferi Treponema pallidum Brucella species Fungi C neoformans Histoplasma capsulatum Coccidioides immitis Blastomyces dermatitides Parasites Toxoplasma gondii Taenia solium (cysticercosis) Sarcoidosis Leptomeningeal cancer Posttransplantation lymphoproliferative disorder Systemic lupus erythematosus Wegener granulomatosis CNS vasculitis Behçet disease Drugs (NSAIDs) Trimethoprim-sulfamethoxazole, Vaccina- References: 1. ^ synd/1537 at Who Named It? 2. ^ P. Mollaret. Méningite endothélio-leucocytaire multirécurrente bénigne. Syndrome nouveau ou maladie nouvelle? (Documents cliniques). Revue neurologique, Paris, 1944, 76: 57-76. MollaretsMeningitis.org Support Organization Informational Pamphlet tion Allopurinol Systemic diseases Sarcoidosis amoxicillin OKT3 Azathioprine Intravenous immunoglobulin Isoniazid Intrathecal methotrexate Intrathecal cystine arabinoside 4. ^ Mollaret's meningitis at patient.co.uk 5. http://emedicine.medscape.com/article/1169489overview (Recurrent Viral/Aseptic Meningitis) Mollaret's Systemic diseases Sarcoidosis Leptomeningeal cancer Posttransplantation lymphoproliferative disorder Systemic lupus erythematosus Wegener granulomatosis CNS vasculitis Behçet disease Vogt-Koyanagi-Harada syndrome 3. ^ Tarakad S Ramachandran, MBBS, FRCP(C), FACP (Feb 12, 2010). "Aseptic Meningitis". Emedicine. http://emedicine.medscape.com/article/1169489overview. Retrieved 9 January 2011. Miscellaneous Arachnoiditis Migraine Postinfectious syndromes Mollaret’s Meningitis Support Organization ~Daily Support Designed to HELP Mollaret's Meningitis Sufferers HTTP:// MOLLARETSMENINGITIS.ORG Meningitis Mollaret’s Meningitis WHAT IS MOLLARET’S MENINGITIS? Diagnosis Drug-induced aseptic meningitis Signs / Symptoms / Diagnosis Investigations include blood tests (electrolytes, liver and kidney function, inflammatory markers and a complete blood count) and usually X-ray examination of the chest. The most important test in identifying or ruling out meningitis is analysis of the cerebrospinal fluid (fluid that envelops the brain and the spinal cord) through lumbar puncture (LP). However, if the patient is at risk for a cerebral mass lesion or elevated intracranial pressure (recent head injury, a known immune system problem, localizing neurological signs, or evidence on examination of a raised ICP), a lumbar puncture may be contraindicated because of the possibility of fatal brain herniation. In such cases a CT or MRI scan is generally performed prior to the lumbar puncture to exclude this possibility. Otherwise, the CT or MRI should be performed after the LP, with MRI preferred over CT due to its superiority in demonstrating areas of cerebral edema, ischemia, and meningeal inflammation. The incidence of drug-induced meningitis (DIAM) is unknown. Many antimicrobials, such as trimethoprim-sulfamethoxazole, ciprofloxacin, cephalexin, metronidazole, amoxicillin, penicillin, and isoniazid, are causes of aseptic meningitis. In addition, the xanthine oxidase inhibitor allopurinol has been implicated in causing aseptic meningitis. DIAM is a complication in which numerous other drugs, namely nonsteroidal anti-inflammatory drugs (NSAIDs), ranitidine, carbamazepine, vaccines against hepatitis B and mumps, immunoglobulins, OKT3 monoclonal antibodies (ie, directed against the T3 receptor and, therefore, pan T-cell antibodies), co-trimoxazole, radiographic agents, and muromonab-CD3, also have been associated. A high index of suspicion is needed to make an accurate diagnosis of DIAM. Diagnostic accuracy in clinical care depends on a complete history and physical examination. Mollaret's meningitis is a rare form of recurrent meningitis originally described by Mollaret in 1944. According to Bryun, who further refined the clinical diagnostic criteria, the condition is characterized by (1) recurrent episodes of severe headache, meningismus, and fever; (2) CSF pleocytosis with large endothelial cells (ie, Mollaret cells), neutrophils, and lymphocytes; (3) recurrent attacks separated by symptom-free periods of weeks to months; (4) spontaneous remission of symptoms and signs; and (5) no known causative agent. Cases without fever, with increased CSF gamma globulin and transient neurological signs and symptoms, have been reported. Transient neurological abnormalities, including seizures, diplopia, pathologic reflexes, cranial nerve pareses, hallucinations, and coma, occur in as many as 50% of patients. Mollaret cells, considered by many to be the hallmark of Mollaret meningitis (although not pathognomonic), are observed early and may comprise 60-70% of cells in the CSF. These cells are usually present for only the first 24 hours and can be missed easily. After the first 24 hours, the CSF shows a lymphocytic predominance with cell counts usually less than 3000/mm3. Hypoglycorrhachia (ie, low CSF glucose concentration) is reported in one third of the paMollaret’s Cell tients. CSF protein usually is elevated mildly. Recent data suggest that HSV-2 and, less frequently, HSV-1 may be etiologic in some if not most cases of Mollaret's Meningitis. Hence, acyclovir (intravenous or oral) or valacyclovir (oral only) are worthy of consideration for both therapy and prophylaxis. Mollaret's Meningitis is suspected based on clinical criteria and confirmed by HSV 1 or HSV 2 on PCR of CSF, although not all cases test positive. Aseptic meningitis syndrome is not caused by pyogenic bacteria, but can be caused by multiple conditions including infectious viral and nonviral causes and many noninfectious etiologies. Hence, this term is no longer synonymous with viral meningitis, although the two often are used interchangeably. The clinical presentation does not help in differentiating DIAM from infectious meningitis. The CSF profile (ie, neutrophilic pleocytosis) does not allow DIAM to be distinguished from infectious meningitis. Systemic lupus erythematosus is the single most frequent underlying condition associated with DIAM. Recurrent DIAM is well known; females usually predominate, and the frequency varies with the different underlying conditions.
