Aseptic Meningitis and Viral Meningitis




Aseptic meningitis is an inflammatory process of the meninges. It is relatively common and is caused by many different entities. The cerebrospinal fluid (CSF) is characterized by pleocytosis, normal or increased protein, and the absence of microorganisms on Gram stain and on routine culture. Usually the illnesses are self-limited; however, with some etiologies, the resulting diseases may be severe, protracted, recurrent, or progressive, and lead to disability and death. Viral meningitis, an inflammation of the leptomeninges, is the most common type of aseptic meningitis. Serous meningitis, lymphocytic meningitis, and nonparalytic poliomyelitis are terms that were used in the past to denote aseptic meningitis.


History


Aseptic meningitis is a syndrome that first was described by Wallgren in 1925. Wallgren’s criteria for this diagnosis included (1) an acute onset with obvious signs and symptoms of meningeal involvement; (2) alteration of CSF typical of meningitis, which may show a small or large number of cells; (3) absence of bacteria in the CSF, as shown by appropriate culture; (4) a relatively short, benign course of illness; (5) absence of local parameningeal infection (e.g., otitis, sinusitis, or trauma) or a general disease that might have meningitis as a secondary manifestation; and (6) absence from the community of epidemic disease, of which meningitis is a feature. In 1951, Wallgren redefined aseptic meningitis as a syndrome likely to be encountered in many different infectious diseases.


The clinical occurrence of aseptic meningitis first was recognized in epidemic poliomyelitis and in mumps at the beginning of the 20th century. Rivers and Scott reported the recovery of lymphocytic choriomeningitis virus from the CSF of several patients with aseptic meningitis in 1935, and, in 1934, Johnson and Goodpasture proved that mumps was caused by a virus. The discovery of coxsackieviruses in 1948 by Dalldorf and Sickles and the introduction of tissue culture in 1949 by Enders and colleagues, which resulted in the discovery of echoviruses, paved the way for the widespread investigation into the etiology of aseptic meningitis.


Rasmussen reported on 374 cases evaluated at the Walter Reed Army Institute of Research laboratory between 1941 and 1946 and found the probable or definite etiology in 26% of “viral” disease of the central nervous system (CNS). Mumps and lymphocytic choriomeningitis viruses were the two etiologic agents identified in his study.


In 1953, Adair and associates reviewed 480 additional cases of aseptic meningitis occurring in military personnel and their dependents from 1947 through 1952 and were able to confirm the etiology in 25% of those patients. Herpes simplex virus (HSV) and Leptospira spp. were added to the previously identified mumps and lymphocytic choriomeningitis viruses as causes of aseptic meningitis. Meyer and associates extended these studies to include 713 more children and adults with acute CNS syndromes of “viral” etiology admitted to military and Veterans Administration hospitals between 1953 and 1958. Of these 713 patients, 430 had the clinical syndrome of aseptic meningitis. Approximately 80% of these patients were hospitalized in the United States. An etiologic diagnosis was determined in 71% of patients with aseptic meningitis. In addition to the agents identified earlier, poliovirus, coxsackieviruses of groups A and B, echoviruses, and arthropod-borne viruses were identified as causes of aseptic meningitis.


Lepow and colleagues reported the probable viral etiology in 54% of the 407 patients they studied in Cleveland between 1955 and 1958. In 1958, Lennette and associates determined a viral etiology in 65% of 511 children and adults with presumed viral CNS system disease in Los Angeles; 368 of these patients were diagnosed as having aseptic meningitis. Sköldenberg analyzed 3117 patients admitted to the Hospital for Infectious Diseases in Stockholm between 1955 and 1964 with the diagnosis of aseptic meningitis, with or without encephalitis or myelitis, and a virologic or clinical diagnosis (or both) of an associated viral infection was established in 72.6%. Berlin and associates performed a surveillance study of aseptic meningitis in pediatric ambulatory clinics and emergency departments of three Baltimore hospitals between July 1986 and December 1990. They identified a single viral agent in 169 (62%) of the 274 cases with laboratory study; 168 enteroviruses and 1 adenovirus were identified. Today, with the use of polymerase chain reaction (PCR) and culture and appropriate serologic study, the etiology of most cases of aseptic meningitis can be determined.




Etiology


Box 35.1 lists infectious agents and other causes of aseptic meningitis. At present, the diagnostic workup of aseptic meningitis usually is not undertaken vigorously, and the etiologic agent is identified in only approximately 10% of all cases. Epidemiologic study and intensive investigations at some centers indicate, however, that most cases result from viral infections. Enteroviruses account for approximately 85% of all cases of aseptic meningitis. The following enteroviruses have been associated with aseptic meningitis: polioviruses 1 to 3; coxsackie­viruses A 1 to 14, 16 to 18, 21, 22, and 24; coxsackieviruses B 1 to 6; echoviruses 1 to 9, 11 to 21, 24 to 27, and 29 to 33; and enterovirus 71. Recently described parechoviruses are closely related to enteroviruses and have also been associated with aseptic meningitis. Although 16 genotypes of parechoviruses have been characterized, CNS infections in young infants, including meningitis, are most frequently the result of human parechovirus 3 infections.



Box 35.1

Etiologic Agents, Factors, and Diseases Associated With Aseptic Meningitis


Viruses





  • Adenoviruses (1, 2, 3, 5, 6, 7, 12, 14, 32)



  • Arboviruses (in the United States: West Nile, St. Louis, California, Colorado tick fever, eastern equine, western equine, Venezuelan equine, and Powassan) a


    a In other areas of the world, many other arboviruses are important.




  • Coronaviruses



  • Cytomegalovirus



  • Encephalomyocarditis



  • Enteroviruses (echoviruses, coxsackieviruses A and B, polioviruses, enteroviruses)



  • Epstein-Barr



  • Hendra and Nipah



  • Herpes simplex type 1



  • Herpes simplex type 2



  • Human herpesvirus–6



  • Human herpesvirus–7



  • Human immunodeficiency virus (HIV-1)



  • Human parechoviruses



  • Human T-cell lymphotrophic virus (HTLV-1)



  • Influenza A and B



  • Lymphocytic choriomeningitis



  • Measles



  • Mumps



  • Parechoviruses



  • Parainfluenza



  • Parvovirus B19



  • Rhinoviruses



  • Rotaviruses



  • Rubella



  • Varicella zoster



  • Variola



Bacteria


Atypical Mycobacteria





  • Bartonella henselae



  • Borrelia spp. (relapsing fever)



  • Borrelia burgdorferi (Lyme disease)



  • Brucella spp.



  • Leptospira spp. (leptospirosis)



  • Mycobacterium tuberculosis



  • Nocardia spp. (nocardiosis)



Pyogenic: Partially Treated





  • Treponema pallidum (syphilis)



Rickettsia





  • Anaplasma phagocytophila



  • Coxiella burnetii



  • Ehrlichia chaffeensis



  • Rickettsia rickettsii (Rocky Mountain spotted fever)



  • Rickettsia prowazekii (typhus)



Mycoplasma





  • Mycoplasma hominis



  • Mycoplasma pneumoniae



Chlamydia





  • Chlamydia pneumoniae



  • Chlamydia psittaci



Ureaplasma





  • Ureaplasma urealyticum



Fungi





  • Blastomyces dermatitidis



  • Candida spp.



  • Coccidioides immitis



  • Cryptococcus neoformans



  • Histoplasma capsulatum



  • Other: Acremonium spp., Alternaria spp., Aspergillus spp., Blastoschizomyces capitus , Cephalosporium spp., Cladosporium trichoides , Drechslera hawaiiensis , Fusarium spp., Paecilomyces spp., Paracoccidioides brasiliensis , Penicillium marneffei , Phaeohyphomycosis , Pseudallescheria boydii , Sporothrix schenckii , Trichosporon beigelii , Ustilago spp., Zygomycetes spp.



Parasites (Eosinophilic Meningitis)





  • Flukes: Paragonimus westermani , schistosomiasis, fascioliasis



  • Roundworms: Angiostrongylus cantonensis, Gnathostoma spinigerum, Baylisascaris procyonis, Strongyloides stercoralis, Trichinella spiralis, Toxocara canis



  • Tapeworms: Cysticercosis



  • Protozoa and free-living amoeba (noneosinophilic meningitis)



  • Acanthamoeba



  • Naegleria fowleri



  • Toxoplasma gondii (toxoplasmosis)



Vaccine Associated





  • Measles



  • Mumps



  • Polio



  • Rabies



  • Vaccinia



Parameningeal Infection


Malignancy





  • Central nervous system tumor



  • Leukemia



Immune Diseases





  • Behçet syndrome



  • Lupus erythematosus



  • Sarcoidosis



Medications





  • Antimicrobial agents (e.g., trimethoprim-sulfamethoxazole)



  • Intrathecal injections (e.g., contrast media, antibiotics)



  • Nonsteroidal antiinflammatory drugs



  • Other drugs



Miscellaneous





  • Epidermoid, dermoid, other cysts



  • Foreign bodies (shunt, reservoir)



  • Heavy metal poisoning



  • Kawasaki disease




In recent years, multiple outbreaks of aseptic meningitis caused by enteroviruses have been described, including outbreaks caused by echovirus 30 in several countries throughout Eastern and Western Europe, China, Japan, Korea, Australia, the Arabian Gulf, the United States, and Brazil. *


* References .

Echovirus 13 was responsible for reported outbreaks of aseptic meningitis in the United States, England, Wales, Germany, Belgium, Spain, France, Lithuania, Israel, Japan, Korea, and Australia. †

† References .

Enterovirus 71 caused a major epidemic in Taiwan from 1998 to 1999, with multiple cases of hand, foot, and mouth syndrome associated with aseptic meningitis and other neurologic manifestations. Similar outbreaks of aseptic meningitis caused by enterovirus 71 were reported in Malaysia, Japan, Hong Kong, and Australia. Other enteroviruses involved in more recent outbreaks include echovirus 4 in Italy, Greece, Israel, Palestine, and Australia ; echovirus 6 in China ; echovirus 9 in Japan and regions of the United States ; echovirus 11 among institutionalized children in Israel ; echovirus 16 in Cuba ; echovirus 18 in Taiwan and Missouri ; echovirus 33 in New Zealand ; coxsackievirus A9 in Latvia and China ; and coxsackievirus B3 in China. In the United States, the most common serotypes are coxsackievirus A6, human parechovirus 3, echovirus 11 and 18, coxsackieviruses A9 and B4, and echoviruses 30 and 6, with echoviruses 9 and 30 being the most frequently identified etiologies of aseptic meningitis since 2003.


Sharing seasonality with the enteroviruses, several arboviruses cause CNS disease in North America. Although encephalitis is the most recognizable manifestation of many of these infections, some arboviruses commonly are associated with aseptic meningitis as well. Since the mid-1990s, outbreaks of West Nile virus (WNV) meningitis and encephalitis have occurred in Romania, Russia, and Israel. First detected in the Western Hemisphere in 1999 in New York City, WNV subsequently spread across North America from the Atlantic to the Pacific coasts and into Canada and Mexico. Between 1999 and 2008, almost 29,000 cases were reported in the United States, with more than 1100 deaths. An estimated 1/150 infections results in severe neurologic illness, with meningitis as the primary manifestation in 16% to 40% of hospitalized patients. Although the incidence of neuroinvasive disease increases with age, WNV is more likely to manifest as meningitis in children than in older adults and occurred in at least one-quarter of the 150 pediatric cases diagnosed in the United States in 2002. Even in regions with increased incidence of WNV, episodes of meningitis caused by enterovirus greatly outnumber those caused by WNV.


Before the introduction of WNV, arboviruses accounted for approximately 5% of cases of aseptic meningitis in North America, with St. Louis encephalitis virus being the most common. Infection with La Crosse encephalitis virus (a California encephalitis virus subtype) often resembles herpes encephalitis, but it may manifest as aseptic meningitis in children. Unlike WNV, the majority of severe La Crosse encephalitis virus cases occur in children 15 years of age and younger, and in a study of 282 patients with La Crosse encephalitis virus infections in the Eastern United States from 2003 to 2007, 17% had aseptic meningitis. Other California serogroup viruses, such as Jamestown Canyon virus and snowshoe hare virus, and other arboviruses, such as Colorado tick fever, result in aseptic meningitis more frequently than encephalitis. Tick-borne encephalitis can manifest as aseptic meningitis in endemic areas. Tick-borne encephalitis virus cases were reported more recently in studies conducted in Poland, Slovenia, and Sweden, and, in mild cases, the clinical presentation was that of aseptic meningitis. Toscana virus, a sandfly-transmitted phlebovirus, is an emerging pathogen and cause of CNS infection, including aseptic meningitis, during the warm season in Mediterranean countries.


Aseptic meningitis is an occasional manifestation of acute and recurrent genital infections with herpes simplex virus type 2 (HSV-2). In contrast to HSV-1 CNS infections, which without treatment usually are fatal, HSV-2 aseptic meningitis in otherwise immunocompetent patients is a benign, self-limited illness. Herpes family viruses other than HSV-1 and HSV-2 also are potential causes of aseptic meningitis. Although neurologic involvement in primary varicella-zoster virus (VZV) infections usually is encephalitis rather than benign meningitis, herpes zoster infection occasionally does present with concurrent meningitis. VZV has been identified by PCR in the CSF of patients who had acute aseptic meningitis without cutaneous lesions, and meningitis associated with the VZV vaccine strain has been described. *


* References .

One report detected VZV vaccine strain in a young patient with viral meningitis 11 years after vaccination. A variety of neurologic disorders, including aseptic meningitis, are rare complications of Epstein-Barr virus infection. Most noncongenital infections with cytomegalovirus in nonimmunocompromised patients are unrecognized; however, occasional instances of aseptic meningitis have been noted.


The role of human herpesvirus–6 (HHV-6) in causing meningitis is unclear; although HHV-6 has been found in CSF samples from infants with meningitis, the virus also is detectable in the CSF of asymptomatic individuals. Similarly PCR identified HHV-7 in the CSF of six children with neurologic diseases, including aseptic meningitis, meningoencephalitis, facial palsy, vestibular neuritis, and febrile seizures. The role of HHV-7 as a causative agent in aseptic meningitis remains to be determined.


Occasionally meningitis or meningoencephalitis occurs as a manifestation of acute illness with HIV-1 infection. Neurologic manifestations develop 3 to 6 weeks after primary infection at the same time as an infectious mononucleosis–like illness.


Lymphocytic choriomeningitis virus was an important historical cause of aseptic meningitis. In 1974, eight cases of aseptic meningitis caused by lymphocytic choriomeningitis virus were found in New York state. Today it is rarely recognized as a cause of meningitis, which is likely a result of both decreasing incidence of disease and decreased detection. Seroprevalence studies conducted more than 2 decades ago found seroprevalence of 4.7%, whereas more recent studies show a much lower seroprevalence of 0.4%. Nevertheless physicians should be alert to the possibility in all situations of rodent (pet or wild) exposure and test appropriately. Encephalomyocarditis virus is another rodent virus that rarely is recognized in humans. It is associated with a variety of neurologic manifestations, including aseptic meningitis.


Adenoviral types 1, 2, 3, 4, 5, 6, 7, 11, 12, 14, and 32 have been associated with meningitis and meningoencephalitis. *


* References .

Although they occur infrequently, adenoviral CNS infections tend to be more severe than enteroviral infections. Rarely aseptic meningitis has been noted during illnesses caused by influenza A viruses, including 2009 pandemic influenza (H1N1), influenza B, rhinoviruses, parainfluenza viruses, parvovirus B19 virus, rotaviruses, and coronaviruses. †

† References .

Most infections with measles, rubella, and variola viruses that involve the CNS are encephalitic.


In the prevaccine era, mumps virus was the agent responsible for the greatest number of cases of aseptic meningitis; today, in the United States, use of vaccine has rendered mumps rare, although mumps outbreaks with associated cases of aseptic meningitis occur occasionally. Aseptic meningitis and encephalitis resulting from administration of mumps vaccine have been noted in Canada, Brazil, Japan, and Europe. ‡


‡ References .

The Leningrad 3, Urabe Am 9, and three Japanese strains of vaccine viruses have been implicated. In the United States, where the Jeryl Lynn vaccine strain has been used exclusively, the rate of encephalitis in vaccinees has been no higher than that of the observed background incidence of similar illness in the population. A preliminary analysis of the Vaccine Safety Datalink project showed a possible increased risk for developing aseptic meningitis 8 to 14 days after receiving immunization with Jeryl Lynn mumps vaccine strain. A follow-up case-control evaluation of hospitalized cases failed to show an increased risk, however.


Neurologic illness is a rare complication of measles, smallpox, polio, and rabies viral vaccines. In most instances, the illnesses are complex and severe, but occasionally aseptic meningitis is the only manifestation. A case of aseptic meningitis caused by vaccine-derived poliovirus was reported in the Philippines in 2001. It was in association with two pediatric cases of acute flaccid paralysis that occurred during the same time period. Viral isolates from all three patients revealed type 1 poliovirus derived from the Sabin vaccine strain.


Certain bacteria are important to recognize as etiologic agents in aseptic meningitis because the illnesses are treatable and early initiation of therapy is crucial. Of greatest importance is tuberculous meningitis. Early treatment of this illness nearly always results in complete cure, whereas diagnostic delay or inadequate treatment frequently results in permanent neurologic sequelae. Lyme disease, relapsing fever, brucellosis, leptospirosis, and rickettsial infections are illnesses acquired either directly or indirectly from animals, in which aseptic meningitis may be a part of the disease process. *


* References .

Mycoplasma pneumoniae has been implicated as a causative agent of neurologic illness. Pönkä noted that 8/560 hospitalized patients with M. pneumoniae infections had aseptic meningitis and 18 had encephalitis or meningoencephalitis. Despite numerous case reports and case series, the role of M. pneumoniae is thought by some experts to be unknown. Mycoplasma hominis and Ureaplasma urealyticum are rare causes of neonatal meningitis. Meningitis and meningoencephalitis have been associated with Chlamydia pneumoniae infections. Partially treated common bacterial meningitides are a common cause of meningitis in which cultures of CSF fail to grow organisms. Antigen detection systems, such as latex agglutination, can be useful in identifying the causative agents in some of these cases.


Numerous fungi and yeasts cause meningitis. Although many fungal meningitides occur almost exclusively in immunocompromised patients, children and adults with normal immune status may experience meningitis caused by Blastomyces dermatitidis, Coccidioides immitis, Cryptococcus neoformans, Cladosporium spp., Histoplasma capsulatum, Paracoccidioides brasiliensis, and Aspergillus spp . In infants who are premature or younger than 1 month of age, Candida albicans is an important cause of meningitis and is associated with significant morbidity and mortality.


Parasites occasionally cause aseptic meningitis. Eosinophilic meningitis is caused by Angiostrongylus cantonensis, a rat lungworm. Aseptic meningitis caused by A. cantonensis has been observed on several islands in the Pacific, and the infection may be acquired by the consumption of freshwater shrimp.


A sterile CSF pleocytosis occurs in 12% to 13% of young infants with bacterial urinary tract infections and in approximately one-third of patients with Kawasaki disease who undergo lumbar puncture. Numerous drugs and biologics have been implicated in aseptic meningitis. †


† References .

Of most importance in pediatrics are trimethoprim-sulfamethoxazole and intravenous immunoglobulin. Other causes of aseptic meningitis are listed in Box 35.1 . ‡

‡ References .





Epidemiology


No unified epidemiologic pattern exists because so many different types of organisms cause aseptic meningitis. The epidemiology of the specific individual infectious agents or diseases is presented in detail in the various chapters of this book, and only a brief overview is presented here.


Because approximately 85% of all cases of aseptic meningitis are caused by enteroviral infections, the basic epidemiologic pattern of aseptic meningitis reflects these agents. In temperate climates, most cases occur in the summer and fall; infection with enteroviruses is spread directly from person to person, and the incubation period usually is 4 to 6 days. Epidemiologic considerations in aseptic meningitis caused by agents other than enteroviruses depend markedly on season, geography, climatic conditions, animal exposures, and many other factors related to the specific pathogens.




Clinical Manifestations


Aseptic meningitis has many causes (see Box 35.1 ), and clinical manifestations vary with the different diseases. In some instances, the signs and symptoms resulting from meningeal inflammation dominate the clinical illness, whereas in other instances the main signs and symptoms reflect other organ system involvement. Clinical manifestations in aseptic meningitis, regardless of etiology, also vary markedly by patient age.


Enteroviruses


Enteroviruses are the most common cause of aseptic meningitis, and they can be considered the prototype for a description of general clinical manifestations of aseptic meningitis. *


* References .

Even among the enteroviruses, however, significant differences in clinical manifestations exist among the different viral types. Some general aspects of epidemic enteroviral aseptic meningitis are presented by viral type in Chapter 165 .


The onset of illness generally is acute, although it may be insidious over the course of a week or so or may be preceded by a nonspecific acute febrile illness of a few days’ duration. Almost all children have fever, and most older children have headache, which most often is retro-orbital or frontal in location. Photophobia is common. Temperature elevation varies, ranging from 38°C to 40.5°C (100.4°F to 105°F), and usually lasts approximately 5 days. Occasionally, fever is biphasic, with the initial elevation occurring before the onset of neurologic signs and symptoms. Anorexia, nausea, and vomiting are common, and abdominal pain and diarrhea also are reported frequently.


Meningeal signs (i.e., stiff neck and back, tightness of the hamstring muscles, and Brudzinski and Kernig signs) usually are present, but deep tendon reflexes usually are normal or hyperactive. Seizures occur occasionally, usually when concomitant high fever is present. Muscle weakness rarely is reported, but myalgia occasionally is noted. In young children, fever, irritability, and lethargy are the most common findings. Infants may be irritable and show resentment to handling, and the fontanelle may be tense.


Other manifestations of enteroviral infections also occur in children with aseptic meningitis. The most common is pharyngitis, which may occur during infection with all of the neurotropic enteroviral types. Rash occurs commonly but varies by viral type. With echovirus 9 meningitis, 30% to 50% of children have rashes, whereas with echovirus 6, exanthem is rare. Cases of meningitis caused by enterovirus 71 and coxsackie virus A16 frequently are accompanied by hand, foot, and mouth syndrome. Enanthem, pleurodynia, pericarditis, myocarditis, and conjunctivitis are other findings noted in children with enteroviral aseptic meningitis. Illness often is biphasic, with fever, an interlude, then return of fever and neurologic manifestations.


CSF leukocyte counts vary from a few cells to a few thousand cells; the median is in the range of 100 to 500 cells/mm 3 . The percentage of neutrophils also varies greatly. Initially a predominance of neutrophils commonly occurs; later, CSF examinations show a decline in the percentage of neutrophils. The CSF protein usually is elevated mildly, and the glucose concentration usually is normal; rarely hypoglycorrhachia is noted.


The duration of illness varies. Usually disability because of neurologic involvement lasts 1 to 2 weeks.


Aseptic Meningitis Caused by Other Agents


Of 1478 pediatric WNV cases reported from 1999 through 2007, 30% were classified as West Nile neuroinvasive disease (WNND). Unlike in older adults who often have encephalitis, most WNND in pediatric patients manifests as meningitis. Seizures occur more commonly in arboviral meningitides than in enteroviral illnesses of otherwise comparable severity. The CSF findings generally are similar to those in enteroviral disease, although some reports suggest that neutrophils are more commonly seen with WNV than with other viral entities. Examination of the CSF in mild cases of mumps often reveals pleocytosis, and mumps is one of the few viral infections that can cause hypoglycorrhachia. When neurologic disease caused by mumps is recognized, usually evidence of brain involvement is present.


Tuberculous meningitis usually has a gradual onset over the course of 2 to 3 weeks. Initially, personality changes, irritability, anorexia, listlessness, and low-grade fever may be present, followed by signs of increased intracranial pressure, such as drowsiness, stiff neck, cranial nerve palsies, inequality of the pupils, vomiting, and seizures. Finally, coma, irregular pulse and respirations, and high fever occur. In fungal diseases, the course of meningitis is similar to the course of tuberculosis. In tuberculosis and several fungal meningitides, such as those caused by C. immitis, H. capsulatum, and C. neoformans, historical and radiographic evidence of pulmonary disease may be present.


Aseptic meningitis associated with M. pneumoniae is unique in that it frequently occurs a few days to 3 weeks after a respiratory illness (i.e., pharyngitis, bronchitis, or pneumonia). Generally the likelihood of a predominance of neutrophils is less in other aseptic meningitides, and low glucose levels are likely in parameningeal bacterial infections, partially treated bacterial meningitides, brain tumors, leukemic infiltration, M. pneumoniae infections, fungal infections, and tuberculosis.


Recurrent Aseptic Meningitis (Mollaret Meningitis)


In 1944, Mollaret described three patients with recurrent aseptic meningitis whom he had observed over the course of 15 years. Subsequently many other cases have been reported, and some cases have been noted in children. The illness is characterized by recurrent attacks of fever with meningeal signs and symptoms. The attacks last several days and are separated by symptom-free periods lasting weeks or months. In addition to a lymphocyte-predominant pleocytosis, CSF samples obtained from certain patients contain large mononuclear cells (Mollaret cells). The disease remits spontaneously. HSV-2 has been identified by PCR or DNA probes in the CSF of most patients with recurrent meningitis. Other viruses, such as HSV-1 and Epstein-Barr virus, and noninfectious causes, such as systemic lupus erythematosus, intracranial cysts, antibiotics such as amoxicillin, and environmental exposures, also have been identified as less frequent etiologies of recurrent meningitis.




Differential Diagnosis


Careful analysis of the history and epidemiologic circumstances may point toward one of the specific causes listed in Box 35.1 . During the summer and autumn, the presence of pleurodynia, herpangina, or unexplained febrile eruptions in the community suggests the possibility of enteroviral infections. Acute paralytic disorders in other patients suggests poliomyelitis, enterovirus 71, or WNV. Exposure to mosquitoes and encephalitis in horses implicates certain arboviruses, and exposure to ticks may be suggestive of Lyme disease, relapsing fever, or rickettsial disease, depending on the geographic location and other symptoms of the illness. A history of swimming in waters contaminated by urine from infected animals and exposure to rats in urban slums suggest leptospiral infection. Knowledge of clear-cut exposure to or concurrent evidence of mumps or of one of the common exanthems is helpful in delineating the differential diagnosis. The association of pneumonia or other respiratory illness preceding aseptic meningitis strongly suggests the possibility of M. pneumoniae as the etiologic agent.


Most difficult from the diagnostic, therapeutic, and prognostic points of view are instances of incipient or partially treated bacterial (especially when caused by Haemophilus influenzae ) or mycobacterial meningitis. The clinical findings; the dosage of antibiotic previously used; the spinal fluid smear, latex agglutination, or other rapid antigen identification test; the culture; and the glucose level may be helpful in diagnosing bacterial meningitis. The quantitative determination of C-reactive protein in the CSF also may be useful in differentiating bacterial from viral meningitis. Lindquist and associates found that the determination of CSF concentrations of lactate was the most useful test in differentiating bacterial from nonbacterial causes of meningitis. Studies suggest that the presence of tumor necrosis factor-α in the CSF is rare in viral infections but common in bacterial disease. When tuberculous meningitis is suspected, a careful evaluation of contacts, a careful examination of an appropriately stained smear from the pellicle of the CSF that was allowed to settle, and a positive tuberculin reaction or positive interferon-γ release assay may confirm the diagnosis. Because combined bacterial and viral infection has occurred, examinations of CSF should be repeated if any doubt exists. The possibility that the observed meningeal reaction is of neither viral nor bacterial origin must be considered. Finally, CNS tumor must be considered in the differential diagnosis, particularly if hypoglycorrhachia and prominent signs of increased intracranial pressure are present.




Specific Diagnosis


Obtaining a meticulous history is essential. The clinician must evaluate exposure of the patient in the past 2 to 3 weeks to illness in contacts; exposure to mosquitoes, ticks, and animals during recent vacations, picnics, and so on; awareness of illness in animals, especially horses and other Equidae, in the patient’s environment; recent travel from the home area; recent injections or medications of any kind; and the possibility of accidental exposure to heavy metals.


The CSF must be examined carefully to exclude disorders that respond to specific therapy. Smears for bacteria, appropriate rapid antigen identification tests, and cultures of the CSF are mandatory; the history and clinical findings may indicate the need for performing acid-fast stain and culture of the sediment for mycobacteria. Other circumstances may indicate the need for excluding fungal or protozoal infection; atypical cells may require cytopathologic study to exclude neural neoplasms, which may manifest acutely.


The introduction of PCR has facilitated the etiologic diagnosis of CNS viral infections, particularly infections caused by enteroviruses and herpesviruses. PCR detects enterovirus in the CSF more rapidly than does cell culture and has been shown to shorten the duration of hospitalization for children with meningitis, thus reducing costs. Enterovirus PCR tests do not detect human parechoviruses; specific PCR testing for human parechoviruses should be ordered in the appropriate population (especially children younger than 3 years). The absence of pleocytosis occurs rarely in patients with enteroviral meningitis but is relatively common in infants with meningitis resulting from human parechovirus.


PCR is the test of choice for detecting CNS infections caused by HSV, and molecular techniques also have been used to identify in CSF such causes of meningitis and meningoencephalitis as VZV, HHV-6, parvovirus B19, and rotavirus.


For many arboviruses, serologic examination is more sensitive than molecular methods, especially for arboviruses that have a short period of viremia and presence in the CSF, such as WNV. Molecular methods may have a complementary role, as in one study in which WNV PCR analysis had a 57% sensitivity and 100% specificity.


In any patient suspected to have viral meningitis, spinal fluid, serum, feces, and throat swabs should be collected and either held in the hospital laboratory or sent to a public health laboratory with viral diagnostic services. An additional serum specimen should be collected 10 to 21 days later so that paired sera can be examined for antibody titer increases. This pairing is particularly useful in arboviral, lymphocytic choriomeningitis, encephalomyocarditis, leptospiral, borrelial, rickettsial, mycoplasmal, and toxoplasmal infections. Although these studies may not provide an immediate diagnosis, they may give early warning of a specific epidemic, and they are useful for prognostication, particularly in very young infants.




Treatment


Hospitalization usually is necessary because of the possibility of treatable bacterial disease, the frequent need for fluid therapy for dehydration, and sometimes for analgesics. Headache and hyperesthesia are treated with rest; analgesics; and a reduction in room light, noise, and visitors. Antipyretics are recommended for fever. Using acetaminophen rather than aspirin is prudent because of the risk for developing Reye syndrome associated with the latter antipyretic. Codeine, morphine, and the phenothiazine derivatives often are used for pain and vomiting but are rarely necessary in children and should be avoided because they may induce misleading signs and symptoms. The investigational antiviral drug pleconaril has been shown effective in the treatment of enteroviral meningitis; however, this drug presently is unavailable. Treatment for illnesses such as tuberculous meningitis, fungal meningitides, and other illnesses for which specific therapies are available is covered in specific chapters of this book.


Several weeks after the patient has apparently recovered, a careful neuromuscular assessment should be conducted to ensure that muscular weakness is not a sequela. Bilateral audiometry is recommended, especially when mumps virus was involved.




Prognosis


The prognosis in aseptic meningitis depends on the etiology. Some illnesses have an ominous prognosis (i.e., tuberculous meningitis, parameningeal infections, rickettsial infections), but patients usually do well if appropriate specific therapy is instituted early in the course of the illness. In C. immitis meningitis, the prognosis for cure is guarded even with early optimal therapy.


In enteroviral and other viral meningitides, children usually recover completely. Some patients complain of fatigue, irritability, decreased ability to concentrate, muscle pain, muscle weakness and spasm, and incoordination for several weeks after an acute illness. Although the outcome of enteroviral meningitis most often is without residual, some infants who have enteroviral meningitis in the first few months of life have an increased risk for altered language development. Formally evaluating such children at age 3 to 6 years is important.




Prevention


The universal use of polio and mumps vaccines in children clearly is effective in controlling these two diseases. Control of insect vectors by suitable spraying methods and eradication of insect breeding sites is important in the control of many arboviruses. The control of animal vectors such as mice and rats alters the incidence of infections with lymphocytic choriomeningitis and encephalomyocarditis viruses.


References



  1. 1. Abedi GR, Watson JT, Pham H, et al: Enterovirus and human parechovirus surveillance – United States, 2009–2013. MMWR Morb Mortal Wkly Rep 2015; 64: pp. 940-943

  2. 2. Aberle SW, Aberle JH, Steininger C, et al: Quantitative real time PCR detection of varicella-zoster virus DNA in cerebrospinal fluid in patients with neurological disease. Med Microbiol Immunol 2005; 194: pp. 7-12

  3. 3. Abhilash KP, Gunasekaran K, Mitra S, et al: Scrub typhus meningitis: an under-recognized cause of aseptic meningitis in India. Neurol India 2015; 63: pp. 209-214

  4. 4. Abramson JS, Hampton KD, Babu S, et al: The use of C-reactive protein from cerebrospinal fluid for differentiating meningitis from other central nervous system diseases. J Infect Dis 1985; 151: pp. 854-858

  5. 5. Abzug MJ, Levin MJ, and Rotbart HA: Profile of enterovirus disease in the first two weeks of life. Pediatr Infect Dis J 1993; 12: pp. 820-824

  6. 6. Abzug MJ, Loeffelholz M, and Rotbart HA: Diagnosis of neonatal enterovirus infection by polymerase chain reaction. J Pediatr 1995; 126: pp. 447-450

  7. 7. Adair CV, Gauld RL, and Smadel JE: Aseptic meningitis, a disease of diverse etiology: clinical and etiologic studies on 854 cases. Ann Intern Med 1953; 39: pp. 675-704

  8. 8. Adler-Shohet FC, Cheung MM, Hill M, et al: Aseptic meningitis in infants younger than six months of age hospitalized with urinary tract infections. Pediatr Infect Dis J 2003; 22: pp. 1039-1042

  9. 9. Akalin H, Akdis AC, Mistik R, et al: Cerebrospinal fluid interleukin-1 beta/interleukin-1 receptor antagonist balance and tumor necrosis factor-alpha concentrations in tuberculous, viral and acute bacterial meningitis. Scand J Infect Dis 1994; 26: pp. 667-674

  10. 10. Akasu Y: Outbreak of aseptic meningitis due to ECHO-9 in northern Kyushu island in the summer of 1997. Kurume Med J 1999; 46: pp. 97-104

  11. 11. Al-Zein N, Boyce TG, Correa AG, et al: Meningitis caused by lymphocytic choriomeningitis virus in a patient with leukemia. J Pediatr Hematol Oncol 2008; 30: pp. 781-784

  12. 12. Amvrosieva TV, Titov LP, Mulders M, et al: Viral water contamination as the cause of aseptic meningitis outbreak in Belarus. Cent Eur J Public Health 2001; 9: pp. 154-157

  13. 13. Anagnostou V, and Papa A: Seroprevalence of Toscana virus among residens of Aegean Sea islands, Greece. Travel Med Infect Dis 2013; 11: pp. 98-102

  14. 14. Anonymous : Mumps meningitis and MMR vaccination. Lancet 1989; 2: pp. 1015-1016

  15. 15. Ansari A, Li S, Abzug MJ, et al: Human herpesviruses 6 and 7 and central nervous system infection in children. Emerg Infect Dis 2004; 10: pp. 1450-1454

  16. 16. Antinori S, Corbellino M, Meroni L, et al: [object Object]. J Infect 2013; 66: pp. 218-238

  17. 17. Anton E, Otegui A, and Alonso A: Meningoencephalitis and . Eur J Neurol 2000; 7: pp. 586

  18. 18. Archimbaud C, Ouchchane L, Mirand A, et al: Improvement of the management of infants, children and adults with a molecular diagnosis of enterovirus meningitis during two observational study periods. PLoS ONE 2013; 8: pp. 1-8

  19. 19. Arisoy ES, Demmler GJ, Thakar S, et al: Meningitis due to parainfluenza virus type 3: report of two cases and review. Clin Infect Dis 1993; 17: pp. 995-997

  20. 20. Arruda WO, and Kondageski C: Aseptic meningitis in a large MMR vaccine campaign (590,609 people) in Curitiba, Parana, Brazil, 1998. Rev Inst Med Trop Sao Paulo 2001; 43: pp. 301-302

  21. 21. Asnis DS, Muana O, Kim DG, et al: Lymphocytic choriomeningitis virus meningitis, New York, NY, USA, 2009. Emerg Infect Dis 2010; 16: pp. 328-330

  22. 22. Atia WA, Ratnatunga CS, Greenfield C, et al: Aseptic meningitis and herpes simplex proctitis: a case report. Br J Vener Dis 1982; 58: pp. 53-58

  23. 23. Atwood WJ, Berger JR, Kaderman R, et al: Human immunodeficiency virus type 1 infection of the brain. Clin Microbiol Rev 1993; 6: pp. 339-366

  24. 24. Auxier GG: Aseptic meningitis associated with administration of trimethoprim and sulfamethoxazole. Am J Dis Child 1990; 144: pp. 144-145

  25. 25. Bailly JL, Brosson D, Archimbaud C, et al: Genetic diversity of echovirus 30 during a meningitis outbreak, demonstrated by direct molecular typing from cerebrospinal fluid. J Med Virol 2002; 68: pp. 558-567

  26. 26. Barah F, Vallely PJ, Chiswick ML, et al: Association of human parvovirus B19 infection with acute meningoencephalitis. Lancet 2001; 358: pp. 729-730

  27. 27. Bariola JR, Perry P, Pappas PG, et al: Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era. Clin Infect Dis 2010; 50: pp. 797-804

  28. 28. Barton LL, and Hyndman NJ: Lymphocytic choriomeningitis virus: reemerging central nervous system pathogen. Pediatrics 2000; 105: pp. 835

  29. 29. Benjamin DK, Stoll BJ, Fanaroff AA, et al: Neonatal candidiasis among extremely low birth weight infants: risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months. Pediatrics 2006; 117: pp. 84-92

  30. 30. Bergman I, Painter MJ, Wald ER, et al: Outcome in children with enteroviral meningitis during the first year of life. J Pediatr 1987; 110: pp. 705-709

  31. 31. Bergstrom T, Vahlne A, Alestig K, et al: Primary and recurrent herpes simplex virus type 2-induced meningitis. J Infect Dis 1990; 162: pp. 322-330

  32. 32. Berlin LE, Rorabaugh ML, Heldrich F, et al: Aseptic meningitis in infants < 2 years of age: diagnosis and etiology. J Infect Dis 1993; 168: pp. 888-892

  33. 33. Bernit E, de Lamballerie X, Zandotti C, et al: Prospective investigation of a large outbreak of meningitis due to echovirus 30 during summer 2000 in Marseilles, France. Medicine (Baltimore) 2004; 83: pp. 245-253

  34. 34. Bharti AR, Nally JE, Ricaldi JN, et al: Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis 2003; 3: pp. 757-771

  35. 35. Biggar RJ, Woodall JP, Walter PD, et al: Lymphocytic choriomeningitis outbreak associated with pet hamsters: fifty-seven cases from New York State. JAMA 1975; 232: pp. 494-500

  36. 36. Bingham PM, Galetta SL, Athreya B, et al: Neurologic manifestations in children with Lyme disease. Pediatrics 1995; 96: pp. 1053-1056

  37. 37. Bitnun A, and Richardson SE: [object Object]. Curr Infect Dis Rep 2010; 12: pp. 282-290

  38. 38. Black S, Shinefield H, Ray P, et al: Risk of hospitalization because of aseptic meningitis after measles-mumps-rubella vaccination in one- to two-year-old children: an analysis of the Vaccine Safety Datalink (VSD) Project. Pediatr Infect Dis J 1997; 16: pp. 500-503

  39. 39. Bonthius DJ: Lymphocytic choriomeningitis virus: an underrecognized cause of neurologic disease in the fetus, child, and adult. Semin Pediatr Neurol 2012; 19: pp. 89-95

  40. 40. Boorugu H, Chrispal A, Gopinath KG, et al: Central nervous system involvement in scrub typhus. Trop Doct 2014; 44: pp. 36-37

  41. 41. Bowen AP: A cluster of children with lyme meningitis presenting to one emergency department in a Boston suburb. J Emerg Nurs 2002; 28: pp. 355-357

  42. 42. Bowen GS, Fisher MC, DeForest A, et al: Epidemic of meningitis and febrile illness in neonates caused by ECHO type 11 virus in Philadelphia. Pediatr Infect Dis 1983; 2: pp. 359-363

  43. 43. Bruhn FW: Lyme disease. Am J Dis Child 1984; 138: pp. 467-470

  44. 44. Brunel D, Leveque N, Jacques J, et al: Clinical and virological features of an aseptic meningitis outbreak in North-Eastern France, 2005. J Clin Virol 2008; 42: pp. 225-228

  45. 45. Bruner KE, Coop CA, and White KM: Trimethoprim-sulfamethoxazole-induced aseptic meningitis – not just another sulfa allergy. Ann Allergy Asthma Immunol 2014; 113: pp. 520-526

  46. 46. Bruyn GW, Straathof LJ, and Raymakers GM: Mollaret’s meningitis: differential diagnosis and diagnostic pitfalls. Neurology 1962; 12: pp. 745-753

  47. 47. Buck PA, Sockett P, Barker IK, et al: West Nile virus: surveillance activities in Canada. Ann Epidemiol 2003; 13: pp. 582

  48. 48. Calisher CH: Medically important arboviruses of the United States and Canada. Clin Microbiol Rev 1994; 7: pp. 89-116

  49. 49. Carlson J, and Wiholm BE: Trimethoprim associated aseptic meningitis. Scand J Infect Dis 1987; 19: pp. 687-691

  50. 50. Caserta MT, Hall CB, Schnabel K, et al: Neuroinvasion and persistence of human herpesvirus 6 in children. J Infect Dis 1994; 170: pp. 1586-1589

  51. 51. Cassinotti P, Schultze D, Schlageter P, et al: Persistent human parvovirus B19 infection following an acute infection with meningitis in an immunocompetent patient. Eur J Clin Microbiol Infect Dis 1993; 12: pp. 701-704

  52. 52. Castro CM, Oliveira DS, Macedo O, et al: Echovirus 30 associated with cases of aseptic meningitis in state of Para, Northern Brazil. Mem Inst Oswaldo Cruz 2009; 104: pp. 444-450

  53. 53. Centers for Disease Control : Neurotropic diseases surveillance: summary 1974–1976. https://stacks.cdc.gov/view/cdc/43830

  54. 54. Deleted in review.

  55. 55. Centers for Disease Control : Enterovirus surveillance, summary 1970–9. https://stacks.cdc.gov/view/cdc/6759

  56. 56. Deleted in review.

  57. 57. Centers for Disease Control : Measles surveillance report no. 11, 1977–1981. Atlanta, GA: US Department of Health and Human Services, Public Health Service, 1982.

  58. 58. Centers for Disease Control : Arboviral infections of the central nervous system: United States, 1985. MMWR Morb Mortal Wkly Rep 1986; 35: pp. 341-350

  59. 59. Centers for Disease Control : ACIP: mumps prevention. MMWR Morb Mortal Wkly Rep 1989; 38: pp. 388-400

  60. 60. Centers for Disease Control : Arboviral surveillance: United States, 1990. MMWR Morb Mortal Wkly Rep 1990; 39: pp. 593-598

  61. 61. Centers for Disease Control : Outbreak of Hendra-like virus: Malaysia and Singapore—1998–1999. MMWR Morb Mortal Wkly Rep 1999; 48: pp. 265-269

  62. 62. Centers for Disease Control : Enterovirus surveillance: United States, 1997–1999. MMWR Morb Mortal Wkly Rep 2000; 49: pp. 913-916

  63. 63. Centers for Disease Control : Outbreak of aseptic meningitis associated with multiple enterovirus serotypes: Romania, 1999. MMWR Morb Mortal Wkly Rep 2000; 49: pp. 669-671

  64. 64. Centers for Disease Control : Acute flaccid paralysis associated with circulating vaccine-derived poliovirus: Philippines, 2001. MMWR Morb Mortal Wkly Rep 2001; 50: pp. 874-875

  65. 65. Centers for Disease Control : Echovirus type 13: United States, 2001. MMWR Morb Mortal Wkly Rep 2001; 50: pp. 777-780

  66. 66. Centers for Disease Control and Prevention : Outbreaks of aseptic meningitis associated with echoviruses 9 and 30 and preliminary surveillance reports on enterovirus activity: United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52: pp. 761-764

  67. 67. Centers for Disease Control and Prevention : Update: multistate outbreak of mumps—United States, January 1–May 2, 2006. MMWR Morb Mortal Wkly Rep 2006; 55: pp. 559-563

  68. 68. Centers for Disease Control and Prevention : Increased detections and severe neonatal disease associated with coxsackievirus B1 infection: United States, 2007. MMWR Morb Mortal Wkly Rep 2008; 57: pp. 553-556

  69. 69. Centers for Disease Control and Prevention : Nonpolio enterovirus and human parechovirus surveillance: United States, 2006–2008. MMWR Morb Mortal Wkly Rep 2010; 59: pp. 1577-1580

  70. 70. Centers for Disease Control and Prevention : West Nile virus disease and other arboviral diseases: United States, 2010. MMWR Morb Mortal Wkly Rep 2011; 60: pp. 1009-1013

  71. 71. Cernescu C, Tardei G, Ruta S, et al: An outbreak of aseptic meningitis due to ECHO 30 virus in Romania during the 1999 summer. Rom J Virol 1999; 50: pp. 99-106

  72. 72. Chan LG, Parashar UD, Lye MS, et al: Deaths of children during an outbreak of hand, foot, and mouth disease in Sarawak, Malaysia: clinical and pathological characteristics of the disease. Outbreak Study Group. Clin Infect Dis 2000; 31: pp. 678-683

  73. 73. Char DF, and Rosen L: Eosinophilic meningitis among children in Hawaii. J Pediatr 1967; 70: pp. 28-35

  74. 74. Chaves SS, Haber P, Walton K, et al: Safety of varicella vaccine after licensure in the United States: experience from reports to the vaccine adverse event reporting system, 1995–2005. J Infect Dis 2008; 197: pp. S170-S177

  75. 75. Cheon DS, Lee J, Lee K, et al: Isolation and molecular identification of echovirus 13 isolated from patients of aseptic meningitis in Korea, 2002. J Med Virol 2004; 73: pp. 439-442

  76. 76. Chieochansin T, Vichiwattana P, Korkong S, et al: Molecular epidemiology, genome characterization, and recombination event of human parechovirus. Virology 2011; 421: pp. 159-166

  77. 77. Childs JE, Glass GE, Ksiazek TG, et al: Human-rodent contact and infection with lymphocytic choriomeningitis and Seoul viruses in an inner-city population. Am J Trop Med Hyg 1991; 44: pp. 117-121

  78. 78. Choi YJ, Park KS, Baek KA, et al: Molecular characterization of echovirus 30-associated outbreak of aseptic meningitis in Korea in 2008. J Microbiol Biotechnol 2010; 20: pp. 643-649

  79. 79. Chomel JJ, Antona D, Thouvenot D, et al: Three ECHOvirus serotypes responsible for outbreak of aseptic meningitis in Rhone-Alpes region, France. Eur J Clin Microbiol Infect Dis 2003; 22: pp. 191-193

  80. 80. Chowers MY, Lang R, Nassar F, et al: Clinical characteristics of the West Nile fever outbreak, Israel, 2000. Emerg Infect Dis 2001; 7: pp. 675-678

  81. 81. Cinque P, Bossolasco S, and Lundkvist A: Molecular analysis of cerebrospinal fluid in viral diseases of the central nervous system. J Clin Virol 2003; 26: pp. 1-28

  82. 82. Civen R, Villacorte F, Robles DT, et al: West Nile virus infection in the pediatric population. Pediatr Infect Dis J 2006; 25: pp. 75-78

  83. 83. Cizman M, Mozetic M, Radescek-Rakar R, et al: Aseptic meningitis after vaccination against measles and mumps. Pediatr Infect Dis J 1989; 8: pp. 302-308

  84. 84. Cohen BA, Rowley AH, and Long CM: Herpes simplex type 2 in a patient with Mollaret’s meningitis: demonstration by polymerase chain reaction. Ann Neurol 1994; 35: pp. 112-116

  85. 85. Coleman WS, Lischner HW, and Grover WD: Recurrent aseptic meningitis without sequelae. J Pediatr 1975; 87: pp. 89-91

  86. 86. Connor JD, Buchta RM, DeGenaro F, et al: Specialty conference: potpourri of adenoviral infections. West J Med 1974; 120: pp. 55-61

  87. 87. Corrall CJ, Pepple JM, Moxon ER, et al: C-reactive protein in spinal fluid of children with meningitis. J Pediatr 1981; 99: pp. 365-369

  88. 88. Craig CP, and Nahmias AJ: Different patterns of neurologic involvement with herpes simplex virus types 1 and 2: isolation of herpes simplex virus type 2 from the buffy coat of two adults with meningitis. J Infect Dis 1973; 127: pp. 365-372

  89. 89. Craver RD, Gohd RS, Sundin DR, et al: Isolation of parainfluenza virus type 3 from cerebrospinal fluid associated with aseptic meningitis. Am J Clin Pathol 1993; 99: pp. 705-707

  90. 90. Croker C, Civen R, Keough K, et al: Aseptic meningitis outbreak associated with echovirus 30 among high school football players – Los Angeles County, California, 2014. MMWR Morb Mortal Wkly Rep 2015; 63: pp. 1228

  91. 91. Cui A, Yu D, Zhu Z, et al: An outbreak of aseptic meningitis caused by coxsackievirus A9 in Gansu, the People’s Republic of China. Virol J 2010; 7: pp. 72

  92. 92. da Cunha SS, Rodrigues LC, Barreto ML, et al: Outbreak of aseptic meningitis and mumps after mass vaccination with MMR vaccine using the Leningrad-Zagreb mumps strain. Vaccine 2002; 20: pp. 1106-1112

  93. 93. Dalldorf G, and Sickles GM: An unidentified, filtrable agent isolated from the feces of children with paralysis. Science 1948; 108: pp. 61-62

  94. 94. da Silveira CM, Kmetzsch CI, Mohrdieck R, et al: The risk of aseptic meningitis associated with the Leningrad-Zagreb mumps vaccine strain following mass vaccination with measles-mumps-rubella vaccine, Rio Grande do Sul, Brazil, 1997. Int J Epidemiol 2002; 31: pp. 978-982

  95. 95. Davies JW, McDermott A, and Severs D: Epidemic virus meningitis due to ECHO 9 virus in Newfoundland. Can Med Assoc J 1958; 79: pp. 162-167

  96. 96. Davis LE, DeBiasi R, Goade DE, et al: West Nile virus neuroinvasive disease. Ann Neurol 2006; 60: pp. 286-300

  97. 97. de Beer FC, Kirsten GF, Gie RP, et al: Value of C reactive protein measurement in tuberculous, bacterial, and viral meningitis. Arch Dis Child 1984; 59: pp. 653-656

  98. 98. de Crom SCM, van Furth AM, Peeters MF, et al: Characteristics of pediatric patients with enterovirus meningitis and no cerebral fluid pleocytosis. Eur J Pediatr 2012; 171: pp. 795-800

  99. 99. Deibel R, and Flanagan TD: Central nervous system infections: etiologic and epidemiologic observations in New York State, 1976–1977. N Y State J Med 1979; 79: pp. 689-695

  100. 100. Deibel R, Flanagan TD, and Smith V: Central nervous system infections in New York State: etiologic and epidemiologic observations, 1974. N Y State J Med 1975; 75: pp. 2337-2342

  101. 101. Deibel R, Flanagan TD, and Smith V: Central nervous system infections: etiologic and epidemiologic observations in New York State, 1975. N Y State J Med 1977; 77: pp. 1398-1404

  102. 102. Deibel R, Woodall JP, Decher WJ, et al: Lymphocytic choriomeningitis virus in man: serologic evidence of association with pet hamsters. JAMA 1975; 232: pp. 501-504

  103. 103. Dengler LD, Capparelli EV, Bastian JF, et al: Cerebrospinal fluid profile in patients with acute Kawasaki disease. Pediatr Infect Dis J 1998; 17: pp. 478-481

  104. 104. Derbes SJ: Trimethoprim-induced aseptic meningitis. JAMA 1984; 252: pp. 2865-2866

  105. 105. Desmond RA, Accortt NA, Talley L, et al: Enteroviral meningitis: natural history and outcome of pleconaril therapy. Antimicrob Agents Chemother 2006; 50: pp. 2409-2414

  106. 106. Dickey M, Jamison L, Michaud L, et al: Rotavirus meningoencephalitis in a previously healthy child and a review of the literature. Pediatr Infect Dis J 2009; 28: pp. 318-321

  107. 107. Diedrich S, and Schreier E: Aseptic meningitis in Germany associated with echovirus type 13. BMC Infect Dis 2001; 1: pp. 14

  108. 108. Dimmitt DC, Fishbein DB, and Dawson JE: Human ehrlichiosis associated with cerebrospinal fluid pleocytosis: a case report. Am J Med 1989; 87: pp. 677-678

  109. 109. Do AN, Green PA, and Demmler GJ: Herpes simplex virus type 2 meningitis and associated genital lesions in a three-year-old child. Pediatr Infect Dis J 1994; 13: pp. 1014-1016

  110. 110. Dos Santos GP, Skraba I, Oliveira D, et al: Enterovirus meningitis in Brazil, 1998–2003. J Med Virol 2006; 78: pp. 98-104

  111. 111. Dourado I, Cunha S, Teixeira MG, et al: Outbreak of aseptic meningitis associated with mass vaccination with a urabe-containing measles-mumps-rubella vaccine: implications for immunization programs. Am J Epidemiol 2000; 151: pp. 524-530

  112. 112. Dulkerian SJ, Kilpatrick L, Costarino AT, et al: Cytokine elevations in infants with bacterial and aseptic meningitis. J Pediatr 1995; 126: pp. 872-876

  113. 113. Dupouey J, Bichaud L, Ninove L, et al: Toscana virus infections: a case series from France. J Infect 2014; 68: pp. 290-295

  114. 114. Dylewski JS, and Bekhor S: Mollaret’s meningitis caused by herpes simplex virus type 2: case report and literature review. Eur J Clin Microbiol Infect Dis 2004; 23: pp. 560-562

  115. 115. Echevarria JM, Casas I, Tenorio A, et al: Detection of varicella-zoster virus-specific DNA sequences in cerebrospinal fluid from patients with acute aseptic meningitis and no cutaneous lesions. J Med Virol 1994; 43: pp. 331-335

  116. 116. Enders JF: Mumps. In Rivers TM, and Horsfall FL (eds): Viral and rickettsial infections of man. Philadelphia: J. B. Lippincott, 1959. pp. 780-789

  117. 117. Enders JF, Weller TH, and Robbins FC: Cultivation of the Lansing strain of poliomyelitis virus in cultures of various human embryonic tissues. Science 1949; 109: pp. 85-87

  118. 118. Eppes SC, Nelson DK, Lewis LL, et al: Characterization of Lyme meningitis and comparison with viral meningitis in children. Pediatrics 1999; 103: pp. 957-960

  119. 119. Esposito S, Rahamat-Langendoen J, Ascolese B, et al: Pediatric parechovirus infections. J Clin Virol 2014; 60: pp. 84-89

  120. 120. Estrada-Franco JG, Navarro-Lopez R, Beasley DW, et al: West Nile virus in Mexico: evidence of widespread circulation since July 2002. Emerg Infect Dis 2003; 9: pp. 1604-1607

  121. 121. Evans AS, and Niederman JC: Epstein-Barr virus. In Evans AS (eds): Viral infections of humans: epidemiology and control, 2nd ed. New York: Plenum Medical, 1982. pp. 253-281

  122. 122. Faulkner R, and Van Rooyen CE: Adenoviruses types 3 and 5 isolated from the cerebrospinal fluid of children. Can Med Assoc J 1962; 87: pp. 1123-1125

  123. 123. Faustini A, Fano V, Muscillo M, et al: An outbreak of aseptic meningitis due to echovirus 30 associated with attending school and swimming in pools. Int J Infect Dis 2006; 10: pp. 291-297

  124. 124. Finkelstein Y, Mosseri R, and Garty BZ: Concomitant aseptic meningitis and bacterial urinary tract infection in young febrile infants. Pediatr Infect Dis J 2001; 20: pp. 630-632

  125. 125. Fobelo MJ, Corzo Delgado JE, Romero Alonso A, et al: Aseptic meningitis related to valacyclovir. Ann Pharmacother 2001; 35: pp. 128-129

  126. 126. Forbes JA: Meningitis in Melbourne due to E.C.H.O. virus. I. Clinical aspects. Med J Aust 1958; 45: pp. 246-248

  127. 127. Francesconi F, Francesconi do Valle AC, Silva MT, et al: International issues: meningoencephalitis due to . Neurology 2008; 71: pp. e65-e67

  128. 128. Francisco AM, Glaser C, Frykman E, et al: 2004 California pediatric West Nile virus case series. Pediatr Infect Dis J 2006; 25: pp. 81-84

  129. 129. Fryden A, Kihlstrom E, Maller R, et al: A clinical and epidemiological study of “rnithosis” caused by . Scand J Infect Dis 1989; 21: pp. 681-691

  130. 130. Fujimoto H, Asaoka K, Imaizumi T, et al: Epstein-Barr virus infections of the central nervous system. Intern Med 2003; 42: pp. 33-40

  131. 131. Fujimoto T, Chikahira M, Yoshida S, et al: Outbreak of central nervous system disease associated with hand, foot, and mouth disease in Japan during the summer of 2000: detection and molecular epidemiology of enterovirus 71. Microbiol Immunol 2002; 46: pp. 621-627

  132. 132. Gajdusek DC: Encephalomyocarditis virus infection in childhood. Pediatrics 1955; 16: pp. 902-906

  133. 133. Galea SA, Sweet A, Beninger P, et al: The safety profile of varicella vaccine: a 10-year review. J Infect Dis 2008; 197: pp. S165-S169

  134. 134. Garland SM, and Murton LJ: Neonatal meningitis caused by . Pediatr Infect Dis J 1987; 6: pp. 868-870

  135. 135. Garnier A, Frascari F, and Decramer S: Varicella-zoster virus meningoencephalitis without skin lesions in a paediatric kidney recipient. Nephrol Dial Transplant 2011; 26: pp. 378-379

  136. 136. Ghanem-Zoubi N, Shiner M, Shulman LM, et al: Human parechovirus type 3 central nervous system infections in Israeli infants. J Clin Virol 2013; 58: pp. 205-210

  137. 137. Gilbert GL, Dickson KE, Waters MJ, et al: Outbreak of enterovirus 71 infection in Victoria, Australia, with a high incidence of neurologic involvement. Pediatr Infect Dis J 1988; 7: pp. 484-488

  138. 138. Gilden D, Cohrs RJ, Mahalingam R, et al: Neurological disease produced by varicella zoster virus reactivation without rash. Curr Top Microbiol Immunol 2010; 342: pp. 243-253

  139. 139. Glimaker M, Johansson B, Olcen P, et al: Detection of enteroviral RNA by polymerase chain reaction in cerebrospinal fluid from patients with aseptic meningitis. Scand J Infect Dis 1993; 25: pp. 547-557

  140. 140. Glimaker M, Kragsbjerg P, Forsgren M, et al: Tumor necrosis factor-alpha (TNF alpha) in cerebrospinal fluid from patients with meningitis of different etiologies: high levels of TNF alpha indicate bacterial meningitis. J Infect Dis 1993; 167: pp. 882-889

  141. 141. Golden SE: Aseptic meningitis associated with Ehrlichia canis infection. Pediatr Infect Dis J 1989; 8: pp. 335-337

  142. 142. Gonzalez Garcia H, Ernandez Alonso JF, de Paz Garcia M, et al: Meningitis as the first and only manifestation of brucellosis. An Esp Pediatr 2000; 53: pp. 280-282

  143. 143. Gonzalez Pascual E, Villanueva Lamas J, Ros Viladoms J, et al: [Kawasaki disease: a report of 50 cases]. An Esp Pediatr 1999; 50: pp. 39-43

  144. 144. Goodpasture HC, Poland JD, Francy DB, et al: Colorado tick fever: clinical, epidemiologic, and laboratory aspects of 228 cases in Colorado in 1973–1974. Ann Intern Med 1978; 88: pp. 303-310

  145. 145. Gordon MF, Allon M, and Coyle PK: Drug-induced meningitis. Neurology 1990; 40: pp. 163-164

  146. 146. Gosbell I, Robinson D, Chant K, et al: Outbreak of echovirus 30 meningitis in Wingecarribee Shire, New South Wales. Commun Dis Intell 2000; 24: pp. 121-124

  147. 147. Goto T, Kimura H, Numazaki K, et al: A case of meningoencephalitis associated with G1P[8] rotavirus infection in a Japanese child. Scand J Infect Dis 2007; 39: pp. 1067-1070

  148. 148. Gottfredsson M, and Perfect JR: Fungal meningitis. Semin Neurol 2000; 20: pp. 307-322

  149. 149. Graham AK, and Murdoch DR: Association between cerebrospinal fluid pleocytosis and enteroviral meningitis. J Clin Microbiol 2005; 43: pp. 1491

  150. 150. Graman PS: Mollaret’s meningitis associated with acute Epstein-Barr virus mononucleosis. Arch Neurol 1987; 44: pp. 1204-1205

  151. 151. Grist NR, Bell EJ, and Assaad F: Enteroviruses in human disease. Prog Med Virol 1978; 24: pp. 114-157

  152. 152. Guglielminotti J, Lellouche N, Maury E, et al: Severe meningoencephalitis: an unusual manifestation of . Clin Infect Dis 2000; 30: pp. 209-210

  153. 153. Guleria R, Nisar N, Chawla TC, et al: [object Object]. J Lab Clin Med 2005; 146: pp. 55-63

  154. 154. Gunther G, Haglund M, Lindquist L, et al: Tick-borne encephalitis in Sweden in relation to aseptic meningo-encephalitis of other etiology: a prospective study of clinical course and outcome. J Neurol 1997; 244: pp. 230-238

  155. 155. Guthrie N: Coxsackie B5 meningitis: report of an outbreak in a high school football squad. J Tn State Med Assoc 1962; 55: pp. 355-356

  156. 156. Haase KK, Lapointe M, and Haines SJ: Aseptic meningitis after intraventricular administration of gentamicin. Pharmacotherapy 2001; 21: pp. 103-107

  157. 157. Haddow AD, and Odoi A: The incidence risk, clustering, and clinical presentation of La Crosse virus infections in the eastern United States, 2003–2007. PLoS ONE 2009; 4: pp. e6145

  158. 158. Hammer SM, and Connolly KJ: Viral aseptic meningitis in the United States: clinical features, viral etiologies, and differential diagnosis. Curr Clin Top Infect Dis 1992; 12: pp. 1-25

  159. 159. Han JY, Hanson DC, and Way SS: Herpes zoster and meningitis due to reactivation of varicella vaccine virus in an immunocompetent child. Pediatr Infect Dis J 2011; 30: pp. 266-268

  160. 160. Handsher R, Shulman LM, Abramovitz B, et al: A new variant of echovirus 4 associated with a large outbreak of aseptic meningitis. J Clin Virol 1999; 13: pp. 29-36

  161. 161. Hanninen P, and Pohjonen R: Echovirus type 6 meningitis: clinical and virological observations during an epidemic in Turku in 1968. Scand J Infect Dis 1971; 3: pp. 121-125

  162. 162. Hardin SG, Erwin PC, Patterson L, et al: Clinical comparisons of La Crosse encephalitis and enteroviral central nervous system infections in a pediatric population: 2001 surveillance in East Tennessee. Am J Infect Control 2003; 31: pp. 508-510

  163. 163. Hauri AM, Schimmelpfennig M, Walter-Domes M, et al: An outbreak of viral meningitis associated with a public swimming pond. Epidemiol Infect 2005; 133: pp. 291-298

  164. 164. Hayes EB, and O’Leary DR: West Nile virus infection: a pediatric perspective. Pediatrics 2004; 113: pp. 1375-1381

  165. 165. Hayes EB, Sejvar JJ, Zaki SR, et al: [object Object]. Emerg Infect Dis 2005; 11: pp. 1174-1179

  166. 166. Haynes RE, Cramblett HG, and Kronfol HJ: Echovirus 9 meningoencephalitis in infants and children. JAMA 1969; 208: pp. 1657-1660

  167. 167. Haynes RE, Sanders DY, and Cramblett HG: Rocky Mountain spotted fever in children. J Pediatr 1970; 76: pp. 685-693

  168. 168. Helin I, Widell A, Borulf S, et al: Outbreak of coxsackievirus A-14 meningitis among newborns in a maternity hospital ward. Acta Paediatr Scand 1987; 76: pp. 234-238

  169. 169. Henquell C, Chambon M, Bailly JL, et al: Prospective analysis of 61 cases of enteroviral meningitis: interest of systematic genome detection in cerebrospinal fluid irrespective of cytologic examination results. J Clin Virol 2001; 21: pp. 29-53

  170. 170. Hermans PE, Goldstein NP, and Wellman WE: Mollaret’s meningitis and differential diagnosis of recurrent meningitis: report of case, with review of the literature. Am J Med 1972; 52: pp. 128-140

  171. 171. Heusner AP: Nontuberculous spinal epidural infections. N Engl J Med 1948; 239: pp. 845-854

  172. 172. Ho M: Enterovirus 71: the virus, its infections and outbreaks. J Microbiol Immunol Infect 2000; 33: pp. 205-216

  173. 173. Hochberg NS, Blackburn BG, Park SY, et al: Eosinophilic meningitis attributable to . Am J Trop Med Hyg 2011; 85: pp. 685-690

  174. 174. Hochberg NS, Park SY, Blackburn BG, et al: Distribution of eosinophilic meningitis cases attributable to . Emerg Infect Dis 2007; 13: pp. 1675-1680

  175. 175. Holzel A, Smith PA, and Tobin JO: A new type of meningo-encephalitis associated with a rhinovirus. Acta Paediatr Scand 1965; 54: pp. 168-174

  176. 176. Hoppa E, and Bachur R: Lyme disease update. Curr Opin Pediatr 2007; 19: pp. 275-280

  177. 177. Huang QS, Carr JM, Nix WA, et al: An echovirus type 33 winter outbreak in New Zealand. Clin Infect Dis 2003; 37: pp. 650-657

  178. 178. Huang YC, Huang SL, Chen SP, et al: Adenovirus infection associated with central nervous system dysfunction in children. J Clin Virol 2013; 57: pp. 300-304

  179. 179. Huang CC, Liu CC, Chang YC, et al: Neurologic complications in children with enterovirus 71 infection. N Engl J Med 1999; 341: pp. 936-942

  180. 180. Huang C, Morse D, Slater B, et al: Multiple-year experience in the diagnosis of viral central nervous system infections with a panel of polymerase chain reaction assays for detection of 11 viruses. Clin Infect Dis 2004; 39: pp. 630-635

  181. 181. Huhn GD, Sejvar JJ, Montgomery SP, et al: West Nile virus in the United States: an update on an emerging infectious disease. Am Fam Physician 2003; 68: pp. 653-660

  182. 182. Ibrahim W, Elzouki AN, Husain A, et al: Varicella zoster aseptic meningitis: report of an atypical case and literature review. Am J Case Rep 2015; 16: pp. 594-597

  183. 183. Iyer S, Mittal MK, and Hodinka RL: Herpes zoster and meningitis resulting from reactivation of varicella vaccine virus in an immunocompetent child. Ann Emerg Med 2009; 53: pp. 792-795

  184. 184. Jain RS, Kumar S, Aggarwal R, et al: Acute aseptic meningitis due to intravenous immunoglobulin therapy in Guillain-Barré syndrome. Oxf Med Case Reports 2014; 2014: pp. 132-134

  185. 185. Jean CM, Honarmand S, Louie JK, et al: Risk factors for West Nile virus neuroinvasive disease, California, 2005. Emerg Infect Dis 2007; 13: pp. 1918-1920

  186. 186. Jha S, and Ansari MK: Leptospirosis presenting as acute meningoencephalitis. J Infect Dev Ctries 2010; 4: pp. 179-182

  187. 187. Jhaveri R, Cherry JD, Phillips S, et al: Erythema migrans after ceftriaxone treatment of aseptic meningitis caused by . Pediatr Infect Dis J 2001; 20: pp. 1010-1012

  188. 188. Jhaveri R, Sankar R, Yazdani S, et al: Varicella-zoster virus: an overlooked cause of aseptic meningitis. Pediatr Infect Dis J 2003; 22: pp. 96-97

  189. 189. Johnson CD, and Goodpasture EW: An investigation of the etiology of mumps. J Exp Med 1934; 59: pp. 1-20

  190. 190. Jorbeck HJ, Gustafsson PM, Lind HC, et al: Tick-borne . Acta Paediatr Scand 1987; 76: pp. 228-233

  191. 191. Julian KG, Mullins JA, Olin A, et al: Aseptic meningitis epidemic during a West Nile virus avian epizootic. Emerg Infect Dis 2003; 9: pp. 1082-1088

  192. 192. Kaida A, Kubo H, Iritani N, et al: Isolation of Echovirus type 13 in Osaka City during 2001–2002. Jpn J Infect Dis 2004; 57: pp. 127-128

  193. 193. Kajiwara I, Kusaba T, Hayashida I, et al: [Clinical study of an outbreak of aseptic meningitis due to echovirus type 30 in Munakata City in 1997–1998]. Kansenshogaku Zasshi 2000; 74: pp. 231-236

  194. 194. Kammerer U, Kunkel B, and Korn K: Nested PCR for specific detection and rapid identification of human picornaviruses. J Clin Microbiol 1994; 32: pp. 285-291

  195. 195. Karande S, Patil S, Kulkarni M, et al: Acute aseptic meningitis as the only presenting feature of leptospirosis. Pediatr Infect Dis J 2005; 24: pp. 390-391

  196. 196. Karmacharya P, Mainali NR, Aryal MR, et al: Recurrent case of ibuprofen-induced aseptic meningitis in mixed connective tissue disease. BMJ Case Rep 2013; 10: pp. 1-3

  197. 197. Karzon DT, and Barron AL: An epidemic of aseptic meningitis syndrome due to echo virus type 6. I. Correlation of enterovirus isolation with illness. II. Clinical study. III. Sequelae. Pediatrics 1962; 29: pp. 409-417

  198. 198. Karzon DT, Eckert GL, Barron AL, et al: Aseptic meningitis epidemic due to ECHO 4 virus. Am J Dis Child 1961; 101: pp. 610-622

  199. 199. Kehle J, Metzger-Boddien C, Tewald F, et al: First case of confirmed rotavirus meningoencephalitis in Germany. Pediatr Infect Dis J 2003; 22: pp. 468-470

  200. 200. Keino M, Kanno M, Hirasawa K, et al: Isolation of echovirus type 13 from patients of aseptic meningitis. Jpn J Infect Dis 2001; 54: pp. 249-250

  201. 201. Kelsey DS: Adenovirus meningoencephalitis. Pediatrics 1978; 61: pp. 291-293

  202. 202. Kennedy DH, and Fallon RJ: Tuberculous meningitis. JAMA 1979; 241: pp. 264-268

  203. 203. Khalfan S, Aymard M, Lina B, et al: Epidemics of aseptic meningitis due to enteroviruses following national immunization days in Bahrain. Ann Trop Paediatr 1998; 18: pp. 101-109

  204. 204. Kirschke DL, Jones TF, Buckingham SC, et al: Outbreak of aseptic meningitis associated with echovirus 13. Pediatr Infect Dis J 2002; 21: pp. 1034-1038

  205. 205. Kitai I, Navas L, Rohlicek C, et al: Recurrent aseptic meningitis secondary to an intracranial cyst: a case report and review of clinical features and imaging modalities. Pediatr Infect Dis J 1992; 11: pp. 671-675

  206. 206. Klein NC, McDermott B, and Cunha BA: Varicella-zoster virus meningoencephalitis in an immunocompetent patient without a rash. Scand J Infect Dis 2010; 42: pp. 631-633

  207. 207. Kleines M, Scheithauer S, Schiefer J, et al: Clinical application of viral cerebrospinal fluid PCR testing for diagnosis of central nervous system disorders: a retrospective 11-year experience. Diagn Microbiol Infect Dis 2014; 80: pp. 207-215

  208. 208. Knust B, Macneil A, Wong SJ, et al: Exposure to lymphocytic choriomeningitis virus, New York, USA. Emerg Infect Dis 2011; 17: pp. 1324-1325

  209. 209. Kochar DK, Agarwal N, Jain N, et al: Clinical profile of neurobrucellosis: a report on 12 cases from Bikaner (north-west India). J Assoc Physicians India 2000; 48: pp. 376-380

  210. 210. Kondo K, Nagafuji H, Hata A, et al: Association of human herpesvirus 6 infection of the central nervous system with recurrence of febrile convulsions. J Infect Dis 1993; 167: pp. 1197-1200

  211. 211. Kriss TC, Kriss VM, and Warf BC: Recurrent meningitis: the search for the dermoid or epidermoid tumor. Pediatr Infect Dis J 1995; 14: pp. 697-700

  212. 212. Kumar A, Shukla D, Kumar R, et al: Molecular identification of enteroviruses associated with aseptic meningitis in children from India. Arch Virol 2013; 158: pp. 211-215

  213. 213. Kupila L, Vainionpaa R, Vuorinen T, et al: Recurrent lymphocytic meningitis: the role of herpesviruses. Arch Neurol 2004; 61: pp. 1553-1557

  214. 214. Laforest RA, McNaughton GA, Beale AJ, et al: Outbreak of aseptic meningitis (meningoencephalitis) with rubelliform rash: Toronto, 1956. Can Med Assoc J 1957; 77: pp. 1-4

  215. 215. Lanciotti RS, Kerst AJ, Nasci RS, et al: Rapid detection of West Nile virus from human clinical specimens, field-collected mosquitoes, and avian samples by a TaqMan reverse transcriptase-PCR assay. J Clin Microbiol 2000; 38: pp. 4066-4071

  216. 216. Leahy TR, Webb DW, Hoey H, et al: Varicella zoster virus associated acute aseptic meningitis without exanthem in an immunocompetent 14-year-old boy. Pediatr Infect Dis J 2008; 27: pp. 362-363

  217. 217. Lecour H, Miranda M, Magro C, et al: Human leptospirosis: a review of 50 cases. Infection 1989; 17: pp. 8-12

  218. 218. Lee KE, Umapathi T, Tan CB, et al: The neurological manifestations of Nipah virus encephalitis, a novel paramyxovirus. Ann Neurol 1999; 46: pp. 428-432

  219. 219. Lennette EH, Magoffin RL, and Knouf EG: Viral central nervous system disease: an etiologic study conducted at the Los Angeles County General Hospital. JAMA 1962; 179: pp. 687-695

  220. 220. Lepow ML, Carver DH, Wright HT, et al: A clinical, epidemiologic and laboratory investigation of aseptic meningitis during the four-year period, 1955–1958. I. Observations concerning etiology and epidemiology. N Engl J Med 1962; 266: pp. 1181-1187

  221. 221. Lepow ML, Coyne N, Thompson LB, et al: A clinical, epidemiologic and laboratory investigation of aseptic meningitis during the four-year period, 1955–1958. II. The clinical disease and its sequelae. N Engl J Med 1962; 266: pp. 1188-1193

  222. 222. Lesnicar G, Poljak M, Seme K, et al: Pediatric tick-borne encephalitis in 371 cases from an endemic region in Slovenia, 1959 to 2000. Pediatr Infect Dis J 2003; 22: pp. 612-617

  223. 223. Leveque N, Jacques J, Renois F, et al: Phylogenetic analysis of Echovirus 30 isolated during the 2005 outbreak in France reveals existence of multiple lineages and suggests frequent recombination events. J Clin Virol 2010; 48: pp. 137-141

  224. 224. Levin MJ, Dahl KM, Weinberg A, et al: Development of resistance to acyclovir during chronic infection with the Oka vaccine strain of varicella-zoster virus, in an immunosuppressed child. J Infect Dis 2003; 188: pp. 954-959

  225. 225. Levin MJ, DeBiasi RL, Bostik V, et al: Herpes zoster with skin lesions and meningitis caused by 2 different genotypes of the Oka varicella-zoster virus vaccine. J Infect Dis 2008; 198: pp. 1444-1447

  226. 226. Li H, Xu F, Gu JB, et al: A severe eosinophilic meningoencephalitis caused by infection of . Am J Trop Med Hyg 2008; 79: pp. 568-570

  227. 227. Li CC, Yang MY, Chen RF, et al: Clinical manifestations and laboratory assessment in an enterovirus 71 outbreak in southern Taiwan. Scand J Infect Dis 2002; 34: pp. 104-109

  228. 228. Liao HT, and Hung KL: Neurologic involvement in an outbreak of enterovirus 71 infection: a hospital-based study. Acta Paediatr Taiwan 2001; 42: pp. 27-32

  229. 229. Lin WC, Lee PI, Lu CY, et al: [object Object]. J Microbiol Immunol Infect 2002; 35: pp. 173-178

  230. 230. Lindsey NP, Hayes EB, Staples JE, et al: West Nile virus disease in children, United States, 1999–2007. Pediatrics 2009; 123: pp. e1084-e1089

  231. 231. Lindsey NP, Staples JE, Lehman JA, et al: Surveillance for human West Nile virus disease: United States, 1999–2008. MMWR Surveill Summ 2010; 59: pp. 1-17

  232. 232. Lindquist L, Linne T, Hansson LO, et al: Value of cerebrospinal fluid analysis in the differential diagnosis of meningitis: a study in 710 patients with suspected central nervous system infection. Eur J Clin Microbiol Infect Dis 1988; 7: pp. 374-380

  233. 233. Liu CC, Tseng HW, Wang SM, et al: An outbreak of enterovirus 71 infection in Taiwan, 1998: epidemiologic and clinical manifestations. J Clin Virol 2000; 17: pp. 23-30

  234. 234. Logar M, Arnez M, Kolbl J, et al: Comparison of the epidemiological and clinical features of tick-borne encephalitis in children and adults. Infection 2000; 28: pp. 74-77

  235. 235. Logotheti M, Pogka V, Horefti E, et al: Laboratory investigation and phylogenetic analysis of enteroviruses involved in an aseptic meningitis outbreak in Greece during the summer of 2007. J Clin Virol 2009; 46: pp. 270-274

  236. 236. Lu J, Zheng H, Guo X, et al: Elucidation of echovirus 30’s origin and transmission during the 2012 aseptic meningitis outbreak in Guangdong, China, through continuing environmental surveillance. Appl Environ Microbiol 2015; 81: pp. 2311-2319

  237. 237. Ma E, Chan KC, Cheng P, et al: The enterovirus 71 epidemic in 2008: public health implications for Hong Kong. Int J Infect Dis 2010; 14: pp. e775-e780

  238. 238. Mantadakis E, Pogka V, Voulgari-Kokota A, et al: Echovirus 30 outbreak associated with a high meningitis attack rate in Thrace, Greece. Pediatr Infect Dis J 2013; 32: pp. 914-916

  239. 239. Mao N, Zhao L, Zhu Z, et al: An aseptic meningitis outbreak caused by echovirus 6 in Anhui province, China. J Med Virol 2010; 82: pp. 441-445

  240. 240. Mardh PA: [object Object]. Sex Transm Dis 1983; 10: pp. 331-334

  241. 241. Markey PG, Davis JS, Harnett GB, et al: Meningitis and a febrile vomiting illness caused by echovirus type 4, Northern Territory, Australia. Emerg Infect Dis 2010; 16: pp. 63-68

  242. 242. Martin MA, Massanari RM, Nghiem DD, et al: Nosocomial aseptic meningitis associated with administration of OKT3. JAMA 1988; 259: pp. 2002-2005

  243. 243. Martinez AA, Castillo J, Sanchez MC, et al: Molecular diagnosis of echovirus 30 as the etiological agent in an outbreak of aseptic meningitis in Panama: May–June 2008. J Infect Dev Ctries 2012; 6: pp. 836-841

  244. 244. Mathisen G, Shelub A, Truong J, et al: Coccidioidal meningitis: clinical presentation and management in the fluconazole era. Medicine (Baltimore) 2010; 89: pp. 251-284

  245. 245. McDonald JC, Moore DL, and Quennec P: Clinical and epidemiologic features of mumps meningoencephalitis and possible vaccine-related disease. Pediatr Infect Dis J 1989; 8: pp. 751-755

  246. 246. McJunkin JE, de los Reyes EC, Irazuzta JE, et al: La Crosse encephalitis in children. N Engl J Med 2001; 345: pp. 148-149

  247. 247. McMinn P, Stratov I, Nagarajan L, et al: Neurological manifestations of enterovirus 71 infection in children during an outbreak of hand, foot, and mouth disease in Western Australia. Clin Infect Dis 2001; 32: pp. 236-242

  248. 248. Meyer HM, Johnson RT, Crawford IP, et al: Central nervous system syndromes of “vital” etiology: a study of 713 cases. Am J Med 1960; 29: pp. 334-347

  249. 249. Mifsud AJ: Drug-related recurrent meningitis. J Infect 1988; 17: pp. 151-153

  250. 250. Milia MG, Cerutti F, Gregori G, et al: Recent outbreak of aseptic meningitis in Italy due to echovirus 30 and phylogenetic relationship with other European circulating strains. J Clin Virol 2013; 58: pp. 579-583

  251. 251. Miller HG, Gibbons JL, and Stanton JB: Para-infectious encephalomyelitis and related syndromes; a critical review of the neurological complications of certain specific fevers. Q J Med 1956; 25: pp. 427-505

  252. 252. Miller E, Goldacre M, Pugh S, et al: Risk of aseptic meningitis after measles, mumps, and rubella vaccine in UK children. Lancet 1993; 341: pp. 979-982

  253. 253. Miller HG, and Stanton JB: Neurological sequelae of prophylactic inoculation. Q J Med 1954; 23: pp. 1-27

  254. 254. Mladenova Z, Buttinelli G, Dikova A, et al: Aseptic meningitis outbreak caused by echovirus 30 in two regions in Bulgaria, May–August 2012. Epidemiol Infect 2014; 142: pp. 2159-2165

  255. 255. Molavi A, and LeFrock JL: Tuberculous meningitis. Med Clin North Am 1985; 69: pp. 315-331

  256. 256. Mollaret P: La meningite endothelio-leukocytaire multirecurrente benigne: syndrome nouveau ou maladie nouvelle? Rev Neurol 1944; 72: pp. 57-76

  257. 257. Moon JH, Na JY, Kim JH, et al: Neurological and muscular manifestations associated with influenza B infection in children. Pediatr Neurol 2013; 49: pp. 97-101

  258. 258. Moore M: Centers for Disease Control. Enteroviral disease in the United States, 1970–1979. J Infect Dis 1982; 146: pp. 103-108

  259. 259. Moylett EH: Neonatal . Semin Pediatr Infect Dis 2003; 14: pp. 115-122

  260. 260. Mulford WS, Buller RS, Arens MQ, et al: Correlation of cerebrospinal (CSF) cell counts and elevated CSF protein levels with enterovirus reverse transcription-PCR results in pediatric and adult patients. J Clin Microbiol 2004; 42: pp. 4199-4203

  261. 261. Mullane D, Williams L, Merwick A, et al: Drug induced aseptic meningitis caused by intravenous immunoglobulin therapy. Ir Med J 2012; 105: pp. 182-183

  262. 262. Muller MP, Richardson DC, and Walmsley SL: Trimethoprim-sulfamethoxazole induced aseptic meningitis in a renal transplant patient. Clin Nephrol 2001; 55: pp. 80-84

  263. 263. Mullins JA, Khetsuriani N, Nix WA, et al: Emergence of echovirus type 13 as a prominent enterovirus. Clin Infect Dis 2004; 38: pp. 70-77

  264. 264. Nagai T, Okafuji T, Miyazaki C, et al: A comparative study of the incidence of aseptic meningitis in symptomatic natural mumps patients and monovalent mumps vaccine recipients in Japan. Vaccine 2007; 25: pp. 2742-2747

  265. 265. Narkeviciute I, and Vaiciuniene D: Outbreak of echovirus 13 infection among Lithuanian children. Clin Microbiol Infect 2004; 10: pp. 1023-1025

  266. 266. Nash D, Mostashari F, Fine A, et al: The outbreak of West Nile virus infection in the New York City area in 1999. N Engl J Med 2001; 344: pp. 1807-1814

  267. 267. Nigrovic LE, and Chiang VW: Cost analysis of enteroviral polymerase chain reaction in infants with fever and cerebrospinal fluid pleocytosis. Arch Pediatr Adolesc Med 2000; 154: pp. 817-821

  268. 268. Nougairede A, Bessaud M, Thiberville SD, et al: Widespread circulation of a new echovirus 30 variant causing aseptic meningitis and non-specific viral illness, South-East France, 2013. J Clin Virol 2014; 61: pp. 118-124

  269. 269. Okumura A, and Ichikawa T: Aseptic meningitis caused by human parvovirus B19. Arch Dis Child 1993; 68: pp. 784-785

  270. 270. Ortner B, Huang CW, Schmid D, et al: Epidemiology of enterovirus types causing neurological disease in Austria 1999–2007: detection of clusters of echovirus 30 and enterovirus 71 and analysis of prevalent genotypes. J Med Virol 2009; 81: pp. 317-324

  271. 271. Ozdemir H, Karbuz A, Ciftci E, et al: Aseptic meningitis in a child due to 2009 pandemic influenza A (H1N1) infection. Turk J Pediatr 2011; 53: pp. 91-93

  272. 272. Ozkaya E, Hizel K, Uysal G, et al: An outbreak of aseptic meningitis due to echovirus type 30 in two cities of Turkey. Eur J Epidemiol 2003; 18: pp. 823-826

  273. 273. Pahud BA, Glaser CA, Dekker CL, et al: Varicella zoster disease of the central nervous system: epidemiological, clinical, and laboratory features 10 years after the introduction of the varicella vaccine. J Infect Dis 2011; 203: pp. 316-323

  274. 274. Paisley JW, Bruhn FW, Lauer BA, et al: Type A2 influenza viral infections in children. Am J Dis Child 1978; 132: pp. 34-36

  275. 275. Panicker JN, Mammachan R, and Jayakumar RV: Primary neuroleptospirosis. Postgrad Med J 2001; 77: pp. 589-590

  276. 276. Peltola HO: C-reactive protein for rapid monitoring of infections of the central nervous system. Lancet 1982; 1: pp. 980-982

  277. 277. Peltola H, Valmari P, and Serum C: reactive protein as detector of pretreated childhood bacterial meningitis. Neurology 1985; 35: pp. 251-253

  278. 278. Pena JA, Pirics ML, DiCaprio HS, et al: Varicella reactivation presenting as shingles and aseptic meningitis in an immunocompetent 11-year-old boy. Clin Pediatr (Phila) 2009; 48: pp. 435-437

  279. 279. Pereira AC, Barros RA, do Nascimento JP, et al: Two family members with a syndrome of headache and rash caused by human parvovirus B19. Braz J Infect Dis 2001; 5: pp. 37-39

  280. 280. Pereira MS, and Maccallum FO: Infection with adenovirus type 12. Lancet 1964; 1: pp. 198-199

  281. 281. Perevoscikovs J, Brila A, Firstova L, et al: Ongoing outbreak of aseptic meningitis in South-Eastern Latvia, June–August 2010. Euro Surveill 2010; 15: pp. pii:19639

  282. 282. Peter G: Leptospirosis: a zoonosis of protean manifestations. Pediatr Infect Dis 1982; 1: pp. 282-288

  283. 283. Petersen LR, and Marfin AA: West Nile virus: a primer for the clinician. Ann Intern Med 2002; 137: pp. 173-179

  284. 284. Picard FJ, Dekaban GA, Silva J, et al: Mollaret’s meningitis associated with herpes simplex type 2 infection. Neurology 1993; 43: pp. 1722-1727

  285. 285. Pinto Junior VL, Rebelo MC, Costa EV, et al: Description of a widespread outbreak of aseptic meningitis due to echovirus 30 in Rio de Janeiro state, Brazil. Braz J Infect Dis 2009; 13: pp. 367-370

  286. 286. Platonov AE, Shipulin GA, Shipulina OY, et al: Outbreak of West Nile virus infection, Volgograd region, Russia, 1999. Emerg Infect Dis 1999; 7: pp. 128-132

  287. 287. Pohl-Koppe A, Blay M, Jager G, et al: Human herpes virus type 7 DNA in the cerebrospinal fluid of children with central nervous system diseases. Eur J Pediatr 2001; 160: pp. 351-358

  288. 288. Pönkä A: Central nervous system manifestations associated with serologically verified . Scand J Infect Dis 1980; 12: pp. 175-184

  289. 289. Portolani M, Pecorari M, Pietrosemoli P, et al: Outbreak of aseptic meningitis by echo 4: prevalence of clinical cases among adults. New Microbiol 2001; 24: pp. 11-15

  290. 290. Preblud SR: Age-specific risks of varicella complications. Pediatrics 1981; 68: pp. 14-17

  291. 291. Prieto-Gonzalez S, Escoda R, Coloma E, et al: Amoxicillin-induced acute aseptic meningitis. J Clin Neurosci 2011; 18: pp. 443-444

  292. 292. Rafailidis PI, Kapaskelis A, and Falagas ME: Cytomegalovirus meningitis in an immunocompetent patient. Med Sci Monit 2007; 13: pp. CS107-CS109

  293. 293. Rafailidis PI, Mourtzoukou EG, Varbobitis IC, et al: Severe cytomegalovirus infection in apparently immunocompetent patients: a systematic review. Virol J 2008; 5: pp. 47

  294. 294. Ramers C, Billman G, Hartin M, et al: Impact of a diagnostic cerebrospinal fluid enterovirus polymerase chain reaction test on patient management. JAMA 2000; 283: pp. 2680-2685

  295. 295. Ramirez-Avila L, Slome S, Schuster FL, et al: Eosinophilic meningitis due to . Clin Infect Dis 2009; 48: pp. 322-327

  296. 296. Rao SP, Teitlebaum J, and Miller ST: Intravenous immune globulin and aseptic meningitis. Am J Dis Child 1992; 146: pp. 539-540

  297. 297. Rasmussen AF: The laboratory diagnosis of lymphocytic choriomeningitis and mumps. In (eds): Rocky Mountain Conference on Infantile Paralysis. Denver: University of Colorado School of Medicine, 1946. pp. 45

  298. 298. Rawal A, Gavin PJ, and Sturgis CD: Cerebrospinal fluid cytology in seasonal epidemic West Nile virus meningo-encephalitis. Diagn Cytopathol 2006; 34: pp. 127-129

  299. 299. Reeves WC, Quiroz E, Brenes MM, et al: Aseptic meningitis due to echovirus 4 in Panama City, Republic of Panama. Am J Epidemiol 1987; 125: pp. 562-575

  300. 300. Reimer LG, and Beller LB: CSF in herpes zoster meningoencephalitis. Arch Neurol 1981; 38: pp. 668

  301. 301. Reintjes R, Pohle M, Vieth U, et al: Community-wide outbreak of enteroviral illness caused by echovirus 30: a cross-sectional survey and a case-control study. Pediatr Infect Dis J 1999; 18: pp. 104-108

  302. 302. Renaud C, and Harrison CJ: Human parechovirus 3: the most common cause of meningoencephalitis in young infants. Infect Dis Clin North Am 2015; 29: pp. 415-428

  303. 303. Riski H, and Hovi T: Coronavirus infections of man associated with diseases other than the common cold. J Med Virol 1980; 6: pp. 259-265

  304. 304. Rivers TM, and McNair Scott TF: Meningitis in man caused by a filterable virus. Science 1935; 81: pp. 439-440

  305. 305. Romero JR, and Newland JG: Viral meningitis and encephalitis: traditional and emerging viral agents. Semin Pediatr Infect Dis 2003; 14: pp. 72-82

  306. 306. Roos KL: [object Object]. Semin Neurol 2000; 20: pp. 329-335

  307. 307. Rosen L, Loison G, Laigret J, et al: Studies on eosinophilic meningitis. III. Epidemiologic and clinical observations on Pacific islands and the possible etiologic role of . Am J Epidemiol 1967; 85: pp. 17-44

  308. 308. Rotbart HA: Enteroviral infections of the central nervous system. Clin Infect Dis 1995; 20: pp. 971-981

  309. 309. Rotbart HA: Viral meningitis. Semin Neurol 2000; 20: pp. 277-292

  310. 310. Rotbart HA, O’Connell JF, and McKinlay MA: Treatment of human enterovirus infections. Antiviral Res 1998; 38: pp. 1-14

  311. 311. Rotbart HA, Sawyer MH, Fast S, et al: Diagnosis of enteroviral meningitis by using PCR with a colorimetric microwell detection assay. J Clin Microbiol 1994; 32: pp. 2590-2592

  312. 312. Rotbart HA, and Webster AD: Treatment of potentially life-threatening enterovirus infections with pleconaril. Clin Infect Dis 2001; 32: pp. 228-235

  313. 313. Rotem CE: Meningitis of virus origin. Lancet 1957; 272: pp. 502-504

  314. 314. Rothenberg R, Murphy W, O’Brien CL, et al: Aseptic meningitis associated with ECHO virus, type 9: an outbreak in Norfolk, Virginia. South Med J 1970; 63: pp. 280-285

  315. 315. Rottach K, Scheglmann K, and Pfadenhauer K: Mollaret’s meningitis: a new aetiologic feature. Eur Neurol 1996; 36: pp. 172-173

  316. 316. Sabin AB, Krumbiegel ER, and Wigand R: ECHO type 9 virus disease. AMA J Dis Child 1958; 96: pp. 197-219

  317. 317. Salaki JS, Louria DB, and Chmel H: Fungal and yeast infections of the central nervous system: a clinical review. Medicine (Baltimore) 1984; 63: pp. 108-132

  318. 318. Samuda GM, Chang WK, Yeung CY, et al: Monoplegia caused by enterovirus 71: an outbreak in Hong Kong. Pediatr Infect Dis J 1987; 6: pp. 206-208

  319. 319. Sands ML, Ryczak M, and Brown RB: Recurrent aseptic meningitis followed by transverse myelitis as a presentation of systemic lupus erythematosus. J Rheumatol 1988; 15: pp. 862-864

  320. 320. Sarmiento L, Mas P, Goyenechea A, et al: First epidemic of echovirus 16 meningitis in Cuba. Emerg Infect Dis 2001; 7: pp. 887-889

  321. 321. Sato R, Ayabe M, Shoji H, et al: Herpes simplex virus type 2 recurrent meningitis (Mollaret’s meningitis): a consideration for the recurrent pathogenesis. J Infect 2005; 51: pp. e217-e220

  322. 322. Sawyer MH, Holland D, Aintablian N, et al: Diagnosis of enteroviral central nervous system infection by polymerase chain reaction during a large community outbreak. Pediatr Infect Dis J 1994; 13: pp. 177-182

  323. 323. Schlesinger Y, Sawyer MH, and Storch GA: Enteroviral meningitis in infancy: potential role for polymerase chain reaction in patient management. Pediatrics 1994; 94: pp. 157-162

  324. 324. Schumacher JD, Chuard C, Renevey F, et al: Outbreak of echovirus 30 meningitis in Switzerland. Scand J Infect Dis 1999; 31: pp. 539-542

  325. 325. Sejvar JJ, Labutta RJ, Chapman LE, et al: Neurologic adverse events associated with smallpox vaccination in the United States, 2002–2004. JAMA 2003; 294: pp. 2744-2750

  326. 326. Shaked Y, and Samra Y: Q fever meningoencephalitis associated with bilateral abducens nerve paralysis, bilateral optic neuritis and abnormal cerebrospinal fluid findings. Infection 1989; 17: pp. 394-395

  327. 327. Shekhar K, Lye MS, Norlijah O, et al: Deaths in children during an outbreak of hand, foot and mouth disease in Peninsular Malaysia: clinical and pathological characteristics. Med J Malaysia 2005; 60: pp. 297-304

  328. 328. Shimizu H, Utama A, Yoshii K, et al: Enterovirus 71 from fatal and nonfatal cases of hand, foot and mouth disease epidemics in Malaysia, Japan and Taiwan in 1997–1998. Jpn J Infect Dis 1999; 52: pp. 12-15

  329. 329. Shinohara M, Uchida K, Shimada S, et al: [Characterization of enterovirus type 71 isolated in Saitama Prefecture in 2000]. Kansenshogaku Zasshi 2001; 75: pp. 490-494

  330. 330. Simila S, Jouppila R, Salmi A, et al: Encephaloningitis in children associated with an adenovirus type 7 epidemic. Acta Paediatr Scand 1970; 59: pp. 310-316

  331. 331. Simms KM, Kortepeter C, and Avigan M: Lamotrigine and aseptic meningitis. Neurology 2012; 78: pp. 921-927

  332. 332. Singer JI, Maur PR, Riley JP, et al: Management of central nervous system infections during an epidemic of enteroviral aseptic meningitis. J Pediatr 1980; 96: pp. 559-563

  333. 333. Sköldenberg B: On the role of viruses in acute infectious diseases of the central nervous system: clinical and laboratory studies on hospitalized patients. Scand J Infect Dis 1975; 3: pp. 5-95

  334. 334. Sköldenberg B, Jeansson S, and Wolontis S: Herpes simplex virus type 2 and acute aseptic meningitis: clinical features of cases with isolation of herpes simplex virus from cerebrospinal fluids. Scand J Infect Dis 1975; 7: pp. 227-232

  335. 335. Socan M, Beovic B, and Kese D: [object Object]. N Engl J Med 1994; 331: pp. 406

  336. 336. Socan M, Ravnik I, Bencina D, et al: Neurological symptoms in patients whose cerebrospinal fluid is culture- and/or polymerase chain reaction-positive for . Clin Infect Dis 2001; 32: pp. E31-E35

  337. 337. Sohier R, Chardonnet Y, and Prunieras M: Adenoviruses. Status of current knowledge. Prog Med Virol 1965; 7: pp. 253-325

  338. 338. Somekh E, Cesar K, Handsher R, et al: An outbreak of echovirus 13 meningitis in central Israel. Epidemiol Infect 2003; 130: pp. 257-262

  339. 339. Somekh E, Shohat T, Handsher R, et al: An outbreak of echovirus 11 in a children’s home. Epidemiol Infect 2001; 126: pp. 441-444

  340. 340. Sosa LE, Gupta S, Juthani-Mehta M, et al: Meningitis in a college student in Connecticut, 2007. J Am Coll Health 2009; 58: pp. 12-14

  341. 341. Southern PM: Relapsing fever. In (eds): . Scranton, PA: Hoeber Medical Div., Harper & Row, 1969. pp. 1-19

  342. 342. Spiegel R, Miron D, Lumelsky D, et al: Severe meningoencephalitis due to late reactivation of varicella-zoster virus in an immunocompetent child. J Child Neurol 2010; 25: pp. 87-90

  343. 343. Spillane JD, and Wells CE: The neurology of Jennerian vaccination. a clinical account of the neurological complications which occurred during the smallpox epidemic in South Wales in 1962. Brain 1964; 87: pp. 1-44

  344. 344. Srihongse S, Grayson MA, and Deibel R: California serogroup viruses in New York State: the role of subtypes in human infections. Am J Trop Med Hyg 1984; 33: pp. 1218-1227

  345. 345. Steel JG, Dix RD, and Baringer JR: Isolation of herpes simplex virus type I in recurrent (Mollaret) meningitis. Ann Neurol 1982; 11: pp. 17-21

  346. 346. Stellrecht KA, Harding I, Woron AM, et al: The impact of an enteroviral RT-PCR assay on the diagnosis of aseptic meningitis and patient management. J Clin Virol 2002; 25: pp. S19-S26

  347. 347. Sumaya CV, and Corman LI: Enteroviral meningitis in early infancy: significance in community outbreaks. Pediatr Infect Dis 1982; 1: pp. 151-154

  348. 348. Sumaya CV, and Ench Y: Epstein-Barr virus infectious mononucleosis in children. I. Clinical and general laboratory findings. Pediatrics 1985; 75: pp. 1003-1010

  349. 349. Sundelof B, Gnarpe H, and Gnarpe J: An unusual manifestation of . Scand J Infect Dis 1993; 25: pp. 259-261

  350. 350. Suzuki N, Terada S, and Inoue M: Neonatal meningitis with human parvovirus B19 infection. Arch Dis Child Fetal Neonatal Ed 1995; 73: pp. F196-F197

  351. 351. Syrogiannopoulos GA, Grivea IN, Anastassiou ED, et al: Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infection. Pediatr Infect Dis J 2001; 20: pp. 927-930

  352. 352. Syverton JT, McLean DM, Martins Da Silva M, et al: Outbreak of aseptic meningitis caused by coxsackie B5 virus; laboratory, clinical, and epidemiologic study. JAMA 1957; 164: pp. 2015-2019

  353. 353. Tang YW, Cleavinger PJ, Li H, et al: Analysis of candidate-host immunogenetic determinants in herpes simplex virus-associated Mollaret’s meningitis. Clin Infect Dis 2000; 30: pp. 176-178

  354. 354. Tao Z, Song Y, Li Y, et al: Coxsackievirus B3, Shandong Province, China 1990–2010. Emerg Infect Dis 2012; 18: pp. 1865-1867

  355. 355. Tavakoli NP, Wang H, Nattanmai S, et al: Detection and typing of enteroviruses from CSF specimens from patients diagnosed with meningitis/encephalitis. J Clin Virol 2008; 43: pp. 207-211

  356. 356. Tayal S, Chadwick D, and Chawla G: Considering syphilis in aseptic meningitis. Clin Med 2009; 9: pp. 626-627

  357. 357. Tedder DG, Ashley R, Tyler KL, et al: Herpes simplex virus infection as a cause of benign recurrent lymphocytic meningitis. Ann Intern Med 1994; 121: pp. 334-338

  358. 358. Tena D, Gonzalez-Praetorius A, Lopez-Alonso A, et al: Acute meningitis due to . Eur J Pediatr 2006; 165: pp. 726-727

  359. 359. Terni M, Caccialanza P, Cassai E, et al: Aseptic meningitis in association with herpes progenitalis. N Engl J Med 1971; 285: pp. 503-504

  360. 360. Thoelen I, Lemey P, Van Der Donck I, et al: Molecular typing and epidemiology of enteroviruses identified from an outbreak of aseptic meningitis in Belgium during the summer of 2000. J Med Virol 2003; 70: pp. 420-429

  361. 361. Thoren A, and Widell A: PCR for the diagnosis of enteroviral meningitis. Scand J Infect Dis 1994; 26: pp. 249-254

  362. 362. Trallero G, Casas I, Avellon A, et al: First epidemic of aseptic meningitis due to echovirus type 13 among Spanish children. Epidemiol Infect 2003; 130: pp. 251-256

  363. 363. Tsai HP, Huang SW, Wu FL, et al: An echovirus 18-associated outbreak of aseptic meningitis in Taiwan: epidemiology and diagnostic and genetic aspects. J Med Microbiol 2011; 60: pp. 1360-1365

  364. 364. Tsai TF, Popovici F, Cernescu C, et al: West Nile encephalitis epidemic in southeastern Romania. Lancet 1998; 352: pp. 767-771

  365. 365. Tsiodras S, Kelesidis I, Kelesidis T, et al: Central nervous system manifestations of . J Infect 2005; 51: pp. 343-354

  366. 366. Tsutsumi H, Kamazaki H, Nakata S, et al: Sequential development of acute meningoencephalitis and transverse myelitis caused by Epstein-Barr virus during infectious mononucleosis. Pediatr Infect Dis J 1994; 13: pp. 665-667

  367. 367. Turabelidze G, Lin M, Butler C, et al: Outbreak of echovirus 18 meningitis in a rural Missouri community. Mo Med 2009; 106: pp. 420-424

  368. 368. Tyler KL: Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret’s. Herpes 2004; 11: pp. 57A-64A

  369. 369. Ushijima H, Xin KQ, Nishimura S, et al: Detection and sequencing of rotavirus VP7 gene from human materials (stools, sera, cerebrospinal fluids, and throat swabs) by reverse transcription and PCR. J Clin Microbiol 1994; 32: pp. 2893-2897

  370. 370. Uysal G, Ozkaya E, and Guven A: Echovirus 30 outbreak of aseptic meningitis in Turkey. Pediatr Infect Dis J 2000; 19: pp. 490

  371. 371. Vergnano S, Kadambari S, Whalley K, et al: Characteristics and outcomes of human parechovirus infection in infants (2008–2012). Eur J Pediatr 2015; 174: pp. 919-924

  372. 372. Vieth UC, Kunzelmann M, Diedrich S, et al: An echovirus 30 outbreak with a high meningitis attack rate among children and household members at four day-care centers. Eur J Epidemiol 1999; 15: pp. 655-658

  373. 373. Vreede RW, Schellekens H, and Zuijderwijk M: Isolation of parainfluenza virus type 3 from cerebrospinal fluid. J Infect Dis 1992; 165: pp. 1166

  374. 374. Waespe N, Steffen I, and Heininger U: Etiology of aseptic meningitis, peripheral facial nerve palsy, and a combination of both in children. Pediatr Infect Dis J 2010; 29: pp. 453-456

  375. 375. Waites KB, Duffy LB, Crouse DT, et al: Mycoplasmal infections of cerebrospinal fluid in newborn infants from a community hospital population. Pediatr Infect Dis J 1990; 9: pp. 241-245

  376. 376. Waites KB, Rudd PT, Crouse DT, et al: Chronic . Lancet 1988; 1: pp. 17-21

  377. 377. Wallach JC, Baldi PC, and Fossati CA: Clinical and diagnostic aspects of relapsing meningoencephalitis due to . Eur J Clin Microbiol Infect Dis 2002; 21: pp. 760-762

  378. 378. Wallgren A: Une nouvelle maladie infectieuse du système nerveux central? Acta Paediatr Scand 1925; 4: pp. 158-182

  379. 379. Wallgren A: [Etiology of meningoencephalitis in children, especially the syndrome of acute aseptic meningitis]. Acta Paediatr 1951; 40: pp. 541-565

  380. 380. Wang SM, Ho TS, Shen CF, et al: Echovirus 18 meningitis in southern Taiwan. Pediatr Infect Dis J 2011; 30: pp. 259-260

  381. 381. Wang JR, Tsai HP, Chen PF, et al: An outbreak of enterovirus 71 infection in Taiwan, 1998. II. Laboratory diagnosis and genetic analysis. J Clin Virol 2000; 17: pp. 91-99

  382. 382. Wang JR, Tsai HP, Huang SW, et al: Laboratory diagnosis and genetic analysis of an echovirus 30-associated outbreak of aseptic meningitis in Taiwan in 2001. J Clin Microbiol 2002; 40: pp. 4439-4444

  383. 383. Warren J: Encephalomyocarditis viruses. In Horsfall FL, and Tamm I (eds): Viral and rickettsial infections of man. Philadelphia: J. B. Lippincott, 1965. pp. 562-568

  384. 384. Weller TH: Varicella-Herpes zoster virus. In Evans AS (eds): Viral infections of humans: epidemiology and control, 2nd ed. New York: Plenum Medical, 1982. pp. 569-595

  385. 385. Weller PF: Eosinophilic meningitis. Am J Med 1993; 95: pp. 250-253

  386. 386. Wickman I: Studien über poliomyelitis acuta: Zugleich ein beitrag zur kenntnis der myelitis acuta. Engl Trans Nev Ment Dis Monog 1905; 16: pp. 1913

  387. 387. Wilfert CM, Lehrman SN, and Katz SL: Enteroviruses and meningitis. Pediatr Infect Dis 1983; 2: pp. 333-341

  388. 388. Wilfert CM, Thompson RJ, Sunder TR, et al: Longitudinal assessment of children with enteroviral meningitis during the first three months of life. Pediatrics 1981; 67: pp. 811-815

  389. 389. Williams CL, Strobino B, Lee A, et al: Lyme disease in childhood: clinical and epidemiologic features of ninety cases. Pediatr Infect Dis J 1990; 9: pp. 10-14

  390. 390. Wong JG, Hathaway SC, Paat JJ, et al: Drug-induced meningitis: a case involving trimethoprim-sulfamethoxazole. Postgrad Med 1994; 96: pp. 117-118

  391. 391. Wong ML, Kaplan S, Dunkle LM, et al: Leptospirosis: a childhood disease. J Pediatr 1977; 90: pp. 532-537

  392. 392. Wong CJ, Price Z, and Bruckner DA: Aseptic meningitis in an infant with rotavirus gastroenteritis. Pediatr Infect Dis 1984; 3: pp. 244-246

  393. 393. Yan JJ, Wang JR, Liu CC, et al: An outbreak of enterovirus 71 infection in Taiwan 1998: a comprehensive pathological, virological, and molecular study on a case of fulminant encephalitis. J Clin Virol 2000; 17: pp. 13-22

  394. 394. Yanagihara K, Tanaka-Taya K, Itagaki Y, et al: Human herpesvirus 6 meningoencephalitis with sequelae. Pediatr Infect Dis J 1995; 14: pp. 240-242

  395. 395. Yang TT, Huang LM, Lu CY, et al: Clinical features and factors of unfavorable outcomes for non-polio enterovirus infection of the central nervous system in northern Taiwan, 1994–2003. J Microbiol Immunol Infect 2005; 38: pp. 417-424

  396. 396. Yang XH, Yan YS, Weng YW, et al: Molecular epidemiology of echovirus 30 in Fujian, China between 2001–2011. J Med Virol 2013; 85: pp. 696-702

  397. 397. Yerly S, Gervaix A, Simonet V, et al: Rapid and sensitive detection of enteroviruses in specimens from patients with aseptic meningitis. J Clin Microbiol 1996; 34: pp. 199-201

  398. 398. Yildizdas D, Kendirli T, Arslankoylu AE, et al: Neurological complications of pandemic influenza (H1N1) in children. Eur J Pediatr 2011; 170: pp. 779-788

  399. 399. Yoshikawa T, Ihira M, Suzuki K, et al: Invasion by human herpesvirus 6 and human herpesvirus 7 of the central nervous system in patients with neurological signs and symptoms. Arch Dis Child 2000; 83: pp. 170-171

  400. 400. Young EJ: Human brucellosis. Rev Infect Dis 1983; 5: pp. 821-842

  401. 401. Zhao YN, Jiang QW, Jiang RJ, et al: Echovirus 30, Jiangsu Province, China. Emerg Infect Dis 2005; 11: pp. 562-567

  402. 402. Zielicka-Hardy A, Rosinska M, Kondrusik M, et al: Predictors for diagnosis of tick-borne encephalitis infection in Poland, 2009–2010. Infect Dis (Lond) 2015; 47: pp. 604-610

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Mar 9, 2019 | Posted by in PEDIATRICS | Comments Off on Aseptic Meningitis and Viral Meningitis

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