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coccal meningitis; in fully one-third of the patients, no cause could be established Charleston and colleagues reported a subgroup of these patients who were responsive to steroids; in 7 of 17 patients, medication could eventually be withdrawn without recurrence; four patients required treatment inde nitely; the remaining 6 died after many months or years The outcome and response to steroids in our cases and other reported series has been much the same These series excluded chemical or irritative meningitis, which should be considered if there has been spinal surgery or infusion of even apparently innocuous substances into the spinal space The special problem of chronic neutrophilic meningitis has been mentioned on page 622 It is usually attributable to Nocardia, Aspergillus, Actinomyces, or certain Mycobacterium species (see Peacock, cited in the preceding chapter) Our practice in the management of patients with chronic meningitis is to repeat the lumbar puncture several times in order to obtain cultures and cytology of CSF, using markers to detect uniform populations of B and T lymphocytes and tumor cells, a biochemical test that is sensitive to neoplastic meningitis (such as 2 microglobulin), PCR for ampli cation of herpesviruses, serologic tests for HIV, syphilis, Lyme disease, Brucella, etc; MRI of the brain and spinal cord with gadolinium should also be performed If hydrocephalus develops, it should be managed along the lines described in Chap 30 A trial of antiviral agents and broad-spectrum antibiotics seems reasonable, although we have had no success with them in our last several patients We resort to a biopsy of the meninges if the diagnosis has not been clari ed in 6 to 12 months or if a febrile meningitis persists for more than several weeks, but this practice has proved to be of limited value In Andersen s series, mentioned above, biopsy yielded a diagnosis in 5 of 25 patients Finally, if bacterial infection has been reasonably excluded, we try corticosteroids for several weeks or longer and then attempt to taper the dose while observing the patient and rechecking the CSF formula The CSF formula, in a number of other chronic or acutely recurring diseases of obscure origin, corresponds to that of aseptic meningitis: (1) The Vogt-Koyanagi-Harada syndrome, which is characterized by combinations of iridocyclitis, depigmentation of a hair strand (poliosis circumscripta) and skin around the eyes, loss of eyelashes, dysacusis, and deafness The course is quite benign, and the pathologic basis of the syndrome is not known (2) Mollaret recurrent meningitis, some (perhaps most) instances of which have been associated with HSV-1 (Steel) and some with HSV-2 infection (Cohen et al) These episodes of acute meningitis, with severe headache and sometimes low-grade fever, lasting for about 2 weeks, may recur for a period of several months or many years In a few such patients of ours, in whom no virus could be identi ed in the CSF, antiviral therapy met with little success, although corticosteroids seemed to reduce the severity of acute episodes, as mentioned above A proportion of these cases follow bouts of genital herpes (3) Allergic or hypersensitivity meningitis, occurring in the course of serum sickness and of connective tissue diseases, such as lupus erythematosus, and in relation to certain medications such as nonsteroidal anti-in ammatory drugs and intravenously administered immunoglobulin; and (4) Behcet disease, which is an important acute, recurrent in ammatory CNS disease It is essentially a diffuse in ammatory disease of small blood vessels and is more appropriately considered with the vasculitides (page 733) In summary, the history of the illness, the associated clinical ndings, and the laboratory tests usually provide the clues to the diagnosis of nonviral and chronic forms of aseptic meningitis It is.

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