Introduction:
Mollaret’s meningitis, first described by Mollaret in 1944 (1), is a rare disease characterized by recurrent episodes of aseptic meningitis. Symptoms, characterized by fever, headache and meningismus, typically resolve spontaneously within 2-5 days without any clinical intervention. The most common etiologic agent is Herpes Simplex Virus type 2 (HSV-2) (2), however HSV-1 has been isolated in some cases and occasionally the etiology is unknown.(3-5) Early diagnosis may prevent prolonged hospital stay, and exposure to unnecessary medications.
Case Report:
We present a case of a 41 years old female with a history of HSV-2, who presented to the emergency department with complains of headache and neck stiffness since four days. Her headaches were generalized and throbbing in nature. She also complained of photophobia, nausea, and vomiting. Physical examination was remarkable for neck stiffness but no focal neurologic deficits. CT head was unremarkable. Having high suspicious for meningitis she received a lumbar puncture and was immediately started on ceftriaxone and acyclovir to cover for possible bacterial and viral meningitis.
Eventually cerebrospinal fluid (CSF) was clear and colorless with 360 WBCs, 11 RBCs, and 94% lymphocytes. CSF glucose was 40mg/dl, and protein was 92mg/dl. CSF was negative for cryptococcal antigen, and VDRL was non reactive. CSF viral and bacterial cultures showed no growth. HSV-2 PCR was found to be positive. CSF findings being consistent with viral meningitis, Ceftriaxone was discontinued.The patient’s symptoms resolved completely within 48 hours of symptom onset and the patient was discharged home. The patient was not placed on long-term suppressive therapy and no recurrence has been experienced so far.
Upon review of her medical records, it was noted that the patient had two previous episodes of meningitis, the first in 1999 and the second in 2005. Symptoms from her earlier meningitis episodes lasted approximately a week and subsequently resolved without any residual symptoms. The patient’s presentation this time was similar to her prior episodes. There was no evidence of an acute herpes flare up during any of her admissions. She denied any history of genital herpes. However, she stated that she is unsure of her partner's past sexual history. Spinal taps performed during her previous hospitalizations were consistent with aseptic meningitis.
Discussion:
In 1944, Mollaret became the first to describe this syndrome of benign aseptic meningitis (1), and in 1962, Bruyn and colleagues outlined the specific criteria for the diagnosis of Mollaret’s (6) which include the following:
1. Recurrent attacks of fever associated with signs and symptoms of meningitis.
2. The attacks are separated by symptom free intervals, which can last for weeks to months.
3. The attacks are accompanied by a CSF comprised of mixed pleocytosis with endothelial cells, lymphocytes, and leukocytes.
4. Each episode remits spontaneously with no residual signs or symptoms.
5. There is an absence of a causative etiological organism.
Our patient’s presentation fulfilled each of Bruyns requirements with the exception of recurrent fever criteria. Our patient did not present with a fever, nor did she report having a fever before coming to the hospital. Although rare, Mollaret’s meningitis should be considered in all patients with recurrent aseptic meningitis. This patient’s case presentation reveals that the absence of fever should not rule out a diagnosis of Mollaret’s meningitis.
References:
- Mollaret P. La meningite endothelio-leukocytaire multirecurrente benigne: syndrome nouveau ou maladie nouvelle? Rev Neurol (Paris). 1944;76:57-76.
- Schlesinger Y, Tebas P, Gaudreault-Keener M, Buller RS, Storch GA. Herpes simplex virus type 2 meningitis in the absence of genital lesions: improved recognition with use of the polymerase chain reaction. Clin Infect Dis. 1995;20(4):842-848.
- Achard JM, Duverlie G, Schmit JL, Lebon P, Veyssier P, Fournier A. Mollaret’s meningitis and herpes simplex virus type 1. N Engl J Med. 1992;326:893–894.
- Steel JG, Dix RD, Baringer JR. Isolation of herpes simplex virus type I in recurrent (Mollaret) meningitis. Ann Neurol. 1982;11:17–21.
- Yamamoto LJ, Tedder DG, Ashley R, Levin MJ. Herpes simplex virus type 1 DNA in cerebrospinal fluid of a patient with Mollaret’s meningitis. N Engl J Med. 1991;325:1082–1085.
- Bryun GW, Straathof LJ, Raymakers GM. Mollaret’s meningitis: differential diagnosis and diagnostic pitfalls. Neurology. 1962;12:745-753.
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