A 57 year‐old woman presented for a headache and nausea for 2 weeks. PMH was significant for depression, SLE controlled on no treatment, and previous episodes of aseptic meningitis. Vitals were stable, and complete physical and neurological exam were normal. She was started on ceftriaxone and vancomycin. The differential diagnosis was bacterial, viral, or lupus induced meningitis. Head CT scan, brain MRI and MRA were all negative. Labs were significant for a CSF RBC of 341, WBC of 591 with 100% lymphocytes, glucose of 55, and proteins of 97 (high). Consequently, the patient was placed off antibiotics, and aseptic meningitis was considered again as the most probable diagnosis. Autoimmune workup, routine EEG, CSF Cryplococcus antigen, HSV1 PCR, CSF culture, Gram stain, and India ink were all negative. However, HSV‐2 PCR was positive. Symptomatic treatment was advised, and the patient was discharged 4 days later stable and asymptomatic. Of note, she had had 3 previous admissions — 2 years ago, 3 years ago, and 4.5 years ago — for the same symptoms of recurrent headaches, nausea, and neck stiffness, with no focal neurological deficits. On each of these admissions, antibiotics and droplet precautions were first implemented, then stopped after the CSF results. These results were similar to the above, except HSV PCR that was not ordered at that time. A diagnosis of aseptic meningitis due to NSAIDS or To SLE was repetitively considered, and the patient was discharged only a couple of days after each visit in a stable condition.
Benign recurrent meningitis was first described by Pierre Mollaret in 1944. A rare disease with around 100 cases reported in the literature, it is characterized by greater than 3 episodes of fever, headache, and meningismus lasting 2‐5 days. Symptom‐free time can vary from weeks to years. Our patient intervals were around 1 year each. More than 50% of patients have associated neurological findings: seizures, change in mental status, coma, hallucinations, and cranial nerve palsies. Our patient did not have any. When first described, there were no identifiable infecting agent, and it was considered an aseptic meningitis. Currently, the most common etiology found is HSV2. Other rare cases were a result of HSV1, EBV, and reactivation of latent cerebral Toxoplasmosis. CSF demonstrates large, friable endothelial cells described by Pierre Mollaret as “fantomes cellulaires“ (i.e., cell ghosts). Although no studies have been done given the rarity of this entity, acyclovir remains the main agent for treatment and prophylaxis. Prognosis is usually excellent
Mollaret's meningitis, a rare entity, is more of importance to a hospitalist practitioner rather than a primary care physician, as patients with a suspicion of meningitis are usually treated on an inpatient basis. The above differential and an accurate diagnosis is what usually faces a hospitalist during his or her daily patient care.
K. Harasiuk, none; F. Abi‐Fadel, none; M. Ng, none; A. Gottesman, none.