Case Presentation: A 53-year-old female elementary school teacher with a history of genital herpes and aseptic viral meningitis presented with two days of severe headache, neck stiffness, fever, nausea, vomiting, bilateral leg weakness and back pain. Her headache was sudden, severe (10/10) and diffuse, progressed to neck stiffness and was associated with photophobia, fever, chills and myalgias. She had two episodes of vomiting which were non-bilious and non-bloody, associated with nausea. She had similar symptoms in 2017 but denies any recent outbreaks of genital herpes. Her most recent outbreak was 1 year ago and she has been in a monogamous relationship with her husband for the past 4 years. On presentation, the patient was febrile (38.1℃), tachycardic and tachypneic. Complete blood count and metabolic panel were unremarkable. Lumbar puncture showed a xanthochromic sample with elevated protein and white blood cells (WBC) with normal glucose. Sample was predominantly lymphocytic. Cerebrospinal fluid (CSF) gram stain was positive for many WBCs but no organisms. Cultures did not show any growth. A viral panel including serological studies was negative for HIV, legionella, syphilis and coccidioides but positive for HSV-2. MRI brain showed no significant intracranial abnormality. She was initially started on broad spectrum coverage for meningitis including vancomycin, ampicillin, and ceftriaxone but they were discontinued after lumbar puncture results. Due to her previous medical history she was treated with IV acyclovir. Over the next 48 hours the patient had complete resolution of symptoms and she was discharged with a 14 day course of valacyclovir.
Discussion: Aseptic viral meningitis in adults is most commonly caused by HSV-2. A form of recurrent benign aseptic meningitis secondary to HSV-2 is known as Mollaret’s Meningitis. It is a rare condition, defined by more than three episodes of fever and meningismus, including nuchal rigidity, headache or photophobia lasting two to five days, followed by spontaneous resolution. 50% of patients may also exhibit signs of neurological involvement including seizures, diplopia, hallucinations or altered sensorium. CSF usually shows lymphocytic predominant pleocytosis and a normal glucose level. While 50% of patients with HSV-2 meningitis have a history of genital lesions, they are usually absent at time of presentation, as seen in our patient. Most patients experience a good prognosis, but some studies have noted a subset of patients who encounter adverse psychological and cognitive outcomes. Although antiviral therapy with acyclovir or valacyclovir is typically administered due to its low risk, the benefit of such treatment remains unclear, particularly in immunocompetent hosts. The time to symptom recurrence varies significantly between patients, ranging from weeks to years. The use of suppressive therapy varies from one patient to another and while it leads to a decrease in genital outbreaks, current data does not support the use of antiviral treatment for recurrent meningitis. In our patient, antivirals were provided for prevention of genital lesions.
Conclusions: Mollaret’s meningitis is commonly observed in young females with a history of genital herpes. As such, absence of lesions does not rule out aseptic meningitis. Mollaret’s meningitis does not always require treatment due to spontaneous resolution of symptoms as well as insufficient evidence regarding the role of antivirals in minimizing recurrence of meningitis, however supportive care is indicated.