History

Fact Explanation
Introduction Meninges are the lining that covers the brain and spinal cord. Meningitis is inflammation of the meninges around the brain and spinal cord. It is usually caused by an infectious pathogens such as bacteria, virus, fungi and parasites. [1] Benign recurrent meningitis is a rare recurrent nature with symptom-free intervals between episodes and is characterized by short episodes of meningitis with CSF lymphocytosis. [6,7] Attacks occur suddenly, maximal within few hours and may last for three days or longer. Duration of the disease may span from 1-11 years or longer. Interval between an episode may vary, but may be longer at the onset of the disease and latter part of the disease. [6]
Headache Benign recurrent meningitis is associated with chronic, recurrent episodes of headache. [6] Headache is non specific symptom occurring due to meningeal irritation. [10]
Fever [1] Inflammation of the meninges and endothelium releases pyrogens causing fever. [1]
Vomiting Vomiting is a common finding in the meningitis. [2]
Sensitivity to light (photophobia), Pain during retraction of the neck [1] Inability to tolerate light [6] is known as photophobia. These are symptoms of meningeal irritation. [1]
Phonophobia, vertigo, syncope [6] Phonophobia is as a persistent, abnormal, and unwarranted fear of sound. [9] Vertigo and syncopy are also associated features of meningitis.
Seizures [1,6] Altered cerebral perfusion pressure can cause reduction of the cerebral blood flow and ischaemia. [1,2] These are transient neurological deficits and may be in the form of grandmal seizures. [6]
Decreased alertness and drowsiness [1] This may be due to raised intracranial pressure & cerebral edema [1] causing parahippocampal gyri herniation. Neuronal cell death may also contribute to the drowsiness. [1]
Excessive crying, refusing the feeds Infants and young children present with nonspecific features. [3]
Hearing loss Inflammation can extends to the cranial nerves, when the 8th nerve is involved that causes sensorineural type hearing loss. [2]
Visual problems Visual problems Involvement of the optic and other cranial nerves related to the vision can be the cause. [4] Blurred vision is due to raised ICP causing shift of midline structures, [11] and inflammation of nerve roots giving rise to 3rd & 6th cranial nerve palsy etc.
History of immunodeficiency People with immune deficiency [8] like malignancy, chemotherapy, long term steroid use, organ transplant and HIV AIDS are particularly vulnerable for the disease. [5]
References
  1. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  2. GUPTA V, SHARMA AK, SUREKA RK, BHUYAN SK, SINGH PK. Chronic meningitis with multiple cranial neuropathies: A rare initial presentation of Wegener's granulomatosis Ann Indian Acad Neurol [online] 2013, 16(3):411-413 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.116920
  3. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  4. MOHANASUNDARAM K, NARAYANAN S, KUMARASAMY S. Bilateral Thalamic Hyperintensities in a case of Viral Encephalitis J Glob Infect Dis [online] 2010, 2(3):310-311 [viewed 16 August 2014] Available from: doi:10.4103/0974-777X.68541
  5. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  6. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  7. DYLEWSKI J. A recurrent headache Can J Infect Dis Med Microbiol [online] 2006, 17(1):27-28 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095052
  8. LOGAN SA, MACMAHON E. Viral meningitis BMJ [online] 2008 Jan 5, 336(7634):36-40 [viewed 12 November 2014] Available from: doi:10.1136/bmj.39409.673657.AE
  9. ASHA’ARI ZA, MAT ZAIN N, RAZALI A. Phonophobia and Hyperacusis: Practical Points from a Case Report Malays J Med Sci [online] 2010, 17(1):49-51 [viewed 12 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216140
  10. ONUR OO, DEMIR H, GUNEYSEL Ö. Asymptomatic pneumocephalus after head trauma: case report BMJ Case Rep [online] :bcr10.2008.1028 [viewed 14 November 2014] Available from: doi:10.1136/bcr.10.2008.1028
  11. KRETZ A, PREUL C, FRICKE HJ, WITTE OW, TERBORG C. Unilateral optic neuropathy following subdural hematoma: a case report J Med Case Reports [online] :19 [viewed 14 November 2014] Available from: doi:10.1186/1752-1947-4-19

Examination

Fact Explanation
Febrile [1] Fever is one of the most common presenting features. [1] Temperature may high as 40 centigrades during an episode. [3,7]
Stiff neck [3] Due to the meningeal irritation. [2,3]
Kernig sign This is a bedside diagnostic sign used to evaluate suspected cases of meningitis. Patient is kept in supine position, hip and knee are flexed, the knee is slowly extended by the examiner. It is positive if there is a resistance or pain during extension. [1]
Brudzinki sign Another sign of meningeal irritation. First one hand is kept behind the patient's head and the other on chest in order to prevent the patient from rising, passive flexion of the neck produces reflex flexion of the patient's hips and knees in a positive Brudzinski's sign.[1]
Focal neurological signs Focal neurogical signs occur due to raised ICP or due to inflammatory exudates along nerve roots and cerebral ischemia due to vascular inflammation and thrombosis. These are transient and may resolve within seven days. [7]
Hydrocephalus [6] There can be involvement of the ventricles causing ventriculitis. [2] Inflamed areas are gradually fibrosed with creating an obstruction to the cerebrospinal fluid outflow, leading to hydrocephalus.
Papilloedema This is the optic disc swelling due to the increased intracranial pressure. [6]
Sensorineural hearing loss Permanent neurological impairments are rare in benign recurrent meningitis. [3]
Signs of immunodeficiency : febrile, Respiratory system-crepitations, features of fungal infections, skin ulcers People with immune deficiency [8] like malignancy, chemotherapy, long term steroid use, organ transplant and HIV AIDS are particularly vulnerable for the disease. [6]
References
  1. MEHNDIRATTA M, NAYAK R, GARG H, KUMAR M, PANDEY S. Appraisal of Kernig's and Brudzinski's sign in meningitis Ann Indian Acad Neurol [online] 2012, 15(4):287-288 [viewed 11 August 2014] Available from: doi:10.4103/0972-2327.104337
  2. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-0
  3. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  4. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  5. LIU TB, PERLIN D, XUE C. Molecular mechanisms of cryptococcal meningitis Virulence [online] 2012 Mar 1, 3(2):173-181 [viewed 11 August 2014] Available from: doi:10.4161/viru.18685
  6. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  7. DYLEWSKI J. A recurrent headache Can J Infect Dis Med Microbiol [online] 2006, 17(1):27-28 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095052
  8. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08

Differential Diagnoses

Fact Explanation
Meningitis due to other infectious causes Neisseria meningitidis, Haemophilus influenzae and Streptococcus pneumoniae are the most common causative pathogens for bacterial meningitis. [6] Organisms may differ according to the age of the patient. Eg:- During neonatal period-E.coli, gram negative bacilli, Listeria monocytogens and Group B streptococci, children older than 3 months-Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae, children between 1-3 months with the organisms from both above mentioned groups. [5]
Aseptic recurrrent meningitis This is caused by epidermoid tumours. This type of meningitis is difficult to differentiate from the benign recurrent meningitis as cysts rupture and release cell debris that appear similar to ghost cells in benign recurrent meningitis and diagnosis will be therefore difficult. [4] But dermatological manifestations, ocular abnormalities and mucous membrane ulcerartions are not seen in benign recurrent meningitis. [4]
Encephalitis Encephalitis [1] is an acute, usually diffuse, inflammatory process of the brain, mainly associated with herpes simplex virus (HSV-1). [3] They also present with the fever, headache, and clouding of consciousness associated with seizures and focal neurology in some patients. Meningoencephalitis may give the same picture as in meningitis making diagnosis difficult. [2]
Encephalopathy due to non infectious causes Same clinical features of encephalitis presents with a history of anoxic/ischaemic damage, nutritional deficiency, alcoholism, critical illness, malignant hypertension, traumatic brain injury or epileptic (non-convulsive status). [2] Fever, headache, focal neurologic signs are uncommon in encephalopathy and depressed mental status is steadily deteriorating in encephalopathy rather than fluctuating in encephalitis/ meningitis. Types of seizures are usually generalised. [2] Acute encephalopathy may cause biphasic seizures. [9]
Non infectious causes - Systemic vasculitides eg. Lupus erythematosus, Wegener's granulomatosis, sarcoidosis etc. & neoplastic meningitis. Systemic inflammatory response gives rise to various non‐specific systemic manifestations including fever, night sweats, malaise, weight loss, arthralgia, myalgia. Investigations reveal normocytic and normochromic anaemia, leucocytosis, thrombocytosis, and raised erthyrocyte sedimentation rate (ESR) and C reactive protein (CRP). [7] Mollaret cells also have been seen in sarcoidosis like condition. [8]
References
  1. AKKA S, VEENA S, ATMAKURI R, EISENHUT M. Characteristic abnormalities in cerebrospinal fluid biochemistry in children with cerebral malaria compared to viral encephalitis Cerebrospinal Fluid Res [online] :8 [viewed 16 August 2014] Available from: doi:10.1186/1743-8454-3-8
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. BANATVALA JANGU E. Herpes simplex encephalitis. The Lancet Infectious Diseases [online] 2011 February, 11(2):80-81 [viewed 16 August 2014] Available from: doi:10.1016/S1473-3099(11)70012-3
  4. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  5. KLEIN NJ, HEYDERMAN RS, LEVIN M. Antibiotic choices for meningitis beyond the neonatal period. Arch Dis Child [online] 1992 Feb, 67(2):157-159 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793401
  6. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  7. SURESH E. Diagnostic approach to patients with suspected vasculitis Postgrad Med J [online] 2006 Aug, 82(970):483-488 [viewed 12 November 2014] Available from: doi:10.1136/pgmj.2005.042648
  8. SENDI P, GRABER P. Mollaret's meningitis CMAJ [online] 2006 Jun 6, 174(12):1710-1712 [viewed 12 November 2014] Available from: doi:10.1503/cmaj.051688
  9. YADAV SS, LAWANDE MA, KULKARNI SD, PATKAR DA. Acute encephalopathy with biphasic seizures and late reduced diffusion J Pediatr Neurosci [online] 2013, 8(1):64-66 [viewed 14 November 2014] Available from: doi:10.4103/1817-1745.111429

Investigations - for Diagnosis

Fact Explanation
Lumbar puncture Opening pressure will be normal/elevated in meningitis. Regarding the protein content in the CSF, it is mildly elevated. There will be polymorphonuclear pleocytocis in the first 24hours and lymphocytic thereafter which also dissapears rapidly within days.[1] CSF glucose content is rarely reduced. Gram stain & culture ABST can identify the causative organism. There is a large type of cell called endothelial/Mollaret's cell. [1] Immuocytologic studies are able to identify these cells by its irregular, vague outlined nuclear and cytoplasmic membranes and tendancy to undergo rapid lysis. [4] These cells may appear as "ghosts" and will be not seen after the first few hours of onset of attack. [1]
Computer tomography(CT) scan of the head and Magnetic Resonance Imaging(MRI) CT scan will be even better as the first investigation specially to rule out the possibility of increased intracranial pressure before doing lumbar puncture. MRI will demonstrate the inflammatory dural meningeal process with enhanced uptake over the affected areas. This also show the intracranial complications such as brain edema, hydrocephalus and infarcts. [2]
PCR Important in identification of herpes simplex virus (HSV). [4] PCR is also important for diagnosing tuberculosis.
Full blood count There can be elevated leucocytosis, leucopenia and eosinophilia in the blood. [1] It is also important to exclude the other causes for the fever such as low platelets in viral infections, high white blood cells (leucocytosis) [3] in bacterial infections.
IgM/IgG level IgM/iGg level is elevated in the CSF of some patients. [1]
ESR ESR is elevated in association with inflammation of the meninges. [1] ESR is also elevated in vasculitides, tuberculosis which are differential diagnoses of benign recurrent meningitis. [5]
Blood culture and antibiogram Is important to exclude the other causes of meningitis such as bacterial meningitis and to assess the antibiotic sensitivity of the organism. [7]
Blood picture Monocytes usually occur singly or in small aggregates and show atypical cell morphology such as deeply lobated or cleft nuclei. [6] Normocytic and normochromic anaemia is seen in vascultic conditions. [5]
Chest X ray Tuberculous meningitis is the most serious manifestation of tuberculosis. [8] It gives a picture similar to that of benign recurrent meningitis. Chest x ray is important for diagnosing tuberculosis.
References
  1. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  2. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 26 August 2014] Available from: doi:10.1177/1756285609337975
  3. BROWN L, SHAW T, WITTLAKE W. Does leucocytosis identify bacterial infections in febrile neonates presenting to the emergency department? Emerg Med J [online] 2005 Apr, 22(4):256-259 [viewed 18 September 2014] Available from: doi:10.1136/emj.2003.010850
  4. DYLEWSKI J. A recurrent headache Can J Infect Dis Med Microbiol [online] 2006, 17(1):27-28 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095052
  5. SURESH E. Diagnostic approach to patients with suspected vasculitis Postgrad Med J [online] 2006 Aug, 82(970):483-488 [viewed 12 November 2014] Available from: doi:10.1136/pgmj.2005.042648
  6. LOGAN SA, MACMAHON E. Viral meningitis BMJ [online] 2008 Jan 5, 336(7634):36-40 [viewed 12 November 2014] Available from: doi:10.1136/bmj.39409.673657.AE
  7. WILLIAMS RG, HART CA. Rapid identification of bacterial antigen in blood cultures and cerebrospinal fluid. J Clin Pathol [online] 1988 Jun, 41(6):691-693 [viewed 12 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1141554
  8. PASCO PM. Diagnostic features of tuberculous meningitis: a cross-sectional study BMC Res Notes [online] :49 [viewed 12 November 2014] Available from: doi:10.1186/1756-0500-5-49

Investigations - Fitness for Management

Fact Explanation
Renal functions and serum electrolytes [2] Syndrome of inappropriate Antidiuretic Hormone secretion is a complication of meningitis. [3] This can cause hyponatraemia. Reduced intake of fluids can cause electrolyte imbalances. Medications may alter the renal functions and therefore baseline value is also needed.
Liver function tests Medications may alter the liver functions and therefore baseline value is needed before the treatment. [2]
Random blood sugar Should be done immediately especially if the patient is drowsy, to rule out the hypoglycaemia [5] as cause for drowsiness. It is also needed to compare with CSF sugar. The normal value of CSF sugar is closer to the 1/3 of the serum value. [5] CSF sugar values are reduced in bacterial and tuberculous meningitis. [4]
References
  1. KLEIN NJ, HEYDERMAN RS, LEVIN M. Antibiotic choices for meningitis beyond the neonatal period. Arch Dis Child [online] 1992 Feb, 67(2):157-159 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793401
  2. ELWIR SM, SHAFFER CC, ARVAN SW, KUPERMAN EF. Disseminated Varicella Zoster Virus Infection with Encephalitis in a UC Patient Receiving Infliximab Gastroenterol Hepatol (N Y) [online] 2013 Jan, 9(1):54-56 [viewed 18 September 2014] Available from: http://
  3. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252www.ncbi.nlm.nih.gov/pmc/articles/PMC3975981
  4. ALKHOLI UM, ABD AL-MONEM N, ABD EL-AZIM AA, SULTAN MH. Serum Procalcitonin in Viral and Bacterial Meningitis J Glob Infect Dis [online] 2011, 3(1):14-18 [viewed 14 November 2014] Available from: doi:10.4103/0974-777X.77290
  5. MARKS V. TRUE GLUCOSE CONTENT OF LUMBAR AND VENTRICULAR CEREBROSPINAL FLUID J Clin Pathol [online] 1960 Jan, 13(1):82-84 [viewed 14 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC480002

Investigations - Followup

Fact Explanation
Renal function tests Follow up is needed as Syndrome of inappropriate Antidiuretic Hormone secretion [1], hyponatraemia and other electrolyte imbalances can occur as complications of meningitis.
Liver function tests Medications may alter the liver functions and therefore baseline value is needed before the treatment. [2]
References
  1. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252www.ncbi.nlm.nih.gov/pmc/articles/PMC3975981
  2. ELWIR SM, SHAFFER CC, ARVAN SW, KUPERMAN EF. Disseminated Varicella Zoster Virus Infection with Encephalitis in a UC Patient Receiving Infliximab Gastroenterol Hepatol (N Y) [online] 2013 Jan, 9(1):54-56 [viewed 18 September 2014] Available from: http://

Investigations - Screening/Staging

Fact Explanation
Screening for viral infections Viral infections like Epstein Bar virus, coxackie virus B2 and B5, echoviruses 7 and 9, Hepes simplex virus type 1 and 2 are known to be associated with benign recurrent meningitis. [1] PCR is done to detect HSV meningitis. [2]
Screening for vasculitides EG:- ANCA (antineutrophil cytoplasmic antibody), Cryoglobulin, Complement levels, Eosinophil counts/IgE levels Vasculitides is a differential diagnosis of benign recurrent meningitis. These are used to identify the specific cause of vasculitides. [3]
References
  1. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  2. DYLEWSKI J. A recurrent headache Can J Infect Dis Med Microbiol [online] 2006, 17(1):27-28 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095052
  3. SURESH E. Diagnostic approach to patients with suspected vasculitis Postgrad Med J [online] 2006 Aug, 82(970):483-488 [viewed 12 November 2014] Available from: doi:10.1136/pgmj.2005.042648

Management - General Measures

Fact Explanation
Immediate management This is particularly important if the patient presents with confusion and drowsiness. Airway, breathing, circulation, disability and environment need to be attended. Random blood sugar is done to exclude hypoglycaemia. [4] Lumbar puncture needs to be done before the antibiotics started [5] ( only if the possibility of increased intracranial pressure can be rule out preferably by a CT scan of the head) [10] If it is not safe to do the LP blood culture is done and antibiotics are started as soon as possible without delay.
Supportive management Antipyretics (i.e. acetaminophen) and antiemetics, i.e. promethazine) may be given. Hydration should be checked and due to the possibility of syndrome of inappropriate Antidiuretic hormone, 2/3 of maintenance is preferable. Monitoring of the vital parameters including the neurological status should be done during the initial period. Suppressing coughing and straining will be helpful. Pain relief may be needed for severe headache, [9] arthralgia, myalgia.
Management of the complications Ventriculoperitoneal (VP) shunt is placed for the symptomatic improvement in hydrocephalus. [1] If there are seizures, anticonvulsants should be continued and close follow-up should be done. If there is of rapidly increasing intracranial pressure with clinical deterioration where medical treatment failed, surgical decompression has to be considered as a life saving measure. [2]
Patient isolation Is needed for the meningococcal disease during the first 24 h of treatment. [3]
Follow up As they are vulnerable for complications such as hearing loss, vision problems, growth retardation, learning disability they need to be followed up with hearing, vision and growth assessment. [6] But these complications are less frequent than in other types of meningitis.
References
  1. CRUM-CIANFLONE N, TRUETT A, WALLACE MR. Cryptococcal Meningitis Manifesting as a Large Abdominal Cyst in a HIV-Infected Patient with a Robust CD4 Count AIDS Patient Care STDS [online] 2008 May, 22(5):359-363 [viewed 11 August 2014] Available from: doi:10.1089/apc.2007.0085
  2. KENNEDY P. VIRAL ENCEPHALITIS: CAUSES, DIFFERENTIAL DIAGNOSIS, AND MANAGEMENT J Neurol Neurosurg Psychiatry [online] 2004 Mar, 75(Suppl 1):i10-i15 [viewed 11 August 2014] Available from: doi:10.1136/jnnp.2003.034280
  3. KLEIN NJ, HEYDERMAN RS, LEVIN M. Antibiotic choices for meningitis beyond the neonatal period. Arch Dis Child [online] 1992 Feb, 67(2):157-159 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1793401
  4. BRACKENRIDGE A, WALLBANK H, LAWRENSON RA, RUSSELL‐JONES D. Emergency management of diabetes and hypoglycaemia Emerg Med J [online] 2006 Mar, 23(3):183-185 [viewed 18 September 2014] Available from: doi:10.1136/emj.2005.026252
  5. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 19 September 2014] Available from: doi:10.1128/CMR.00009-08
  6. FORD-JONES EL, MACGREGOR D, RICHARDSON S, JAMIESON F, BLASER S, ARTSOB H. Acute childhood encephalitis and meningoencephalitis: Diagnosis and management Paediatr Child Health [online] 1998, 3(1):33-40 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851260
  7. FLORET D. [Suppurative meningitis in infants and in children: adjuvant treatments and treatments of neurological forms]. Pediatrie [online] 1993, 48(1):21-7 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8392687
  8. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  9. LOGAN SA, MACMAHON E. Viral meningitis BMJ [online] 2008 Jan 5, 336(7634):36-40 [viewed 12 November 2014] Available from: doi:10.1136/bmj.39409.673657.AE
  10. NAGRA I, WEE B, SHORT J, BANERJEE AK. The role of cranial CT in the investigation of meningitis JRSM Short Rep [online] , 2(3):20 [viewed 15 October 2014] Available from: doi:10.1258/shorts.2011.010113

Management - Specific Treatments

Fact Explanation
Pharmacological treatment There is no definitive treatment. Antibiotics, acyclovir, antihiatamine, colchicine, eostrogen, phenylbutazone, and steroids are some of the drugs that are used to treat the disease [1]
Acyclovir Acyclovir is used to treat Mollaret meningitis in selected patients in a dose of 10 mg/kg three times a day for 7-10 days. Some do not recommend the use of acyclovir as often the condition is benign and self limiting. [2]
References
  1. RUBEN SJ. Mollaret's meningitis. West J Med [online] 1994 May, 160(5):459-462 [viewed 10 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022498
  2. SENDI P, GRABER P. Mollaret's meningitis CMAJ [online] 2006 Jun 6, 174(12):1710-1712 [viewed 12 November 2014] Available from: doi:10.1503/cmaj.051688