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Ponka and Pettersson) Most are due to viral infections Of these, the most common are the enteroviral infections echovirus and Coxsackie virus These make up 80 percent of cases of aseptic meningitis in which a speci c viral cause can be established Mumps is perhaps next in frequency, followed by HSV-2, lymphocytic choriomeningitis (LCM), and adenovirus infections EBV (infectious mononucleosis), CMV, leptospirosis, HSV-1, and the bacterium Mycoplasma pneumoniae (see Chap 32) In uenza virus, adenoviruses, and numerous sporadic and otherwise innocuous agents have at times been isolated from the spinal uid in cases of aseptic meningitis The California and West Nile viruses, which are arthropod-borne viruses ( arboviruses ), are responsible for a small number of cases (usually the arboviruses cause an encephalitis or meningoencephalitis, as discussed further on) Rarely, the icteric stage of infectious hepatitis is preceded by mild meningitis, the nature of which becomes evident when the jaundice appears All these viral infections, particularly those due to the enteroviruses together with mycoplasmal infection, leptospirosis, and Lyme borreliosis account for the largest proportion of infectious cases of aseptic meningitis in which the etiology can be established, the remainder being due to tuberculosis, fungal infections and rarer organisms Chronic and recurrent meningitis constitutes a special problem, discussed below It is now well recognized that infection with HIV may present as an acute, self-limited aseptic meningitis with an infectious mononucleosis-like clinical picture While HIV has been obtained from the CSF in the acute phase of the illness, seroconversion occurs only later, during convalescence from the meningitis (see further on in this chapter) HSV-1 has been isolated from the CSF of patients with recurrent bouts of benign aseptic meningitis (so-called Mollaret meningitis), but this nding has not been consistent (Steel et al) As discussed in Chap 47, it is now believed that this virus also underlies many if not most cases of what has been traditionally considered idiopathic Bell s palsy Finally, two other aspects of the virology of aseptic meningitis should be noted; rst, in every published series of cases from virus isolation centers, a speci c cause cannot be established in one-third or more of cases of presumed viral origin; second, most agents capable of producing aseptic meningitis also sometimes cause encephalitis.

TABLE 1-4

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Clinical distinctions between the many viral causes of aseptic meningitis cannot be made with a high degree of reliability, but useful leads can be obtained by attention to certain details of the clinical history and physical examination It is important to inquire about recent respiratory or gastrointestinal symptoms, immunizations, past history of infectious disease, family outbreaks, insect bites, contact with animals, and areas of recent travel The presence of a local epidemic, the season during which the illness occurs, and the geographic location are other helpful data As already mentioned, the enteroviruses (echo, Coxsackie and, in underdeveloped countries, polio) are by far the commonest causes of viral meningitis Because these organisms grow in the intestinal tract and are spread mainly by the fecal-oral route, family outbreaks are usual and the infections are most common among children A number of echovirus and Coxsackie virus (particularly group A) infections are associated with exanthemata and may, in addition, be associated with the grayish vesicular lesions of oral

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herpangina Pleurodynia, brachial neuritis, pericarditis, and orchitis are characteristic of some cases of group B Coxsackie virus infections (but there are certainly other causes) Pain in the back and neck and in the muscles should suggest poliomyelitis Lower motor neuron weakness may occur with echo and Coxsackie virus infections, but it is usually mild and transient in nature The peak incidence of enteroviral infections is in August and September This is true also of infections due to arboviruses, but as a rule the latter cause encephalitis rather than meningitis Mumps meningitis occurs sporadically throughout the year, but the highest incidence is in late winter and spring Males are affected three times more frequently than females Other manifestations of mumps infection parotitis, orchitis, mastitis, oophoritis, and pancreatitis may or may not be present It should be noted that orchitis is not speci c for mumps but occurs occasionally with group B Coxsackie virus infections, infectious mononucleosis, and lymphocytic choriomeningitis A de nite past history of mumps aids in excluding the disease, since an attack confers lifelong immunity The natural host of the LCM virus is the common house mouse, Mus musculus Humans acquire the infection by contact with infected hamsters or with dust contaminated by mouse excreta Laboratory workers who handle rodents may be exposed to LCM The meningitis may be preceded by respiratory symptoms (sometimes with pulmonary in ltrates) The infection is particularly common in late fall and winter, presumably because mice enter dwellings at that time Wild rodents may also be the source of the so-called encephalomyocarditis virus infection, and cats, of course, of bacterial cat-scratch disease The infectious agent in leptospirosis is a spirochete, but the clinical syndrome that it produces is indistinguishable from viral meningitis (discussed in Chap 32) Infection is acquired by contact with soil or water contaminated by the urine of rats and also of dogs, swine, and cattle Although leptospirosis may appear in any season, its incidence in the United States shows a striking peak in August The presence of conjunctival suffusion, a transient blotchy erythema, severe leg and back pain, and pulmonary in ltrates should suggest leptospiral infection A more common spirochetal cause of aseptic meningitis (and meningoencephalitis) is Lyme borreliosis This is now the most common vector (tick)-borne disease in the United States Most cases occur in the northeastern states, Minnesota, and Wisconsin during the months of May to July the questing time among nymphal ixodid ticks In 60 to 80 percent of patients, a bright-red annular skin lesion at the site of the tick bite, often with secondary annular lesions, precedes the onset of meningeal signs (as discussed more extensively on page 618) There may be associated facial palsies, cauda equina symptoms such as urinary retention and sacral numbness, or a sensory neuropathy (see Chap 46) The atypical pneumonia agents M pneumoniae and Q fever (Coxiella burnetti) can also produce an aseptic meningitis that is indistinguishable from the viral form In the context of an aseptic meningitis, the presence of sore throat, generalized lymphadenopathy, transient rash, and mild icterus is suggestive of infectious mononucleosis due to EBV or, at times, CMV infection Icterus is a prominent manifestation of viral hepatitis and some serotypes of leptospirosis and, at times, of Q fever A mononucleosis type of infection (fever, rash, arthralgias, lymphadenopathy) in an individual with recent sexual exposure to a potentially infected partner or a known carrier of HIV or with.

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