Aseptic Meningitis: A Seasonal Concern
by James L. Moeller, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 7 - JULY 97
In Brief: Outbreaks of aseptic meningitis-like illnesses have
occurred in high school football players for reasons that may include the
close contact among players and the overlap of football season with the peak
enterovirus season. The main symptoms are fever, headache, and neck or back
stiffness; physical findings may include signs of meningeal irritation.
Evaluation of the cerebrospinal fluid can confirm the diagnosis. Treatment of
viral meningitis is generally supportive, and patients usually do well, while
other forms of aseptic meningitis may require drug treatment or removal of
inciting medications. Not sharing water bottles may help reduce risk.
Aseptic meningitis is a
relatively uncommon, but not rare, syndrome that is usually seen in the
enterovirus season--July, August, and September (1). Populations that appear
to be more susceptible to aseptic meningitis, particularly viral meningitis,
include children and elderly persons who interact or live in group settings.
High school football players may also be at increased risk, perhaps because
of the timing of football season and sharing of water bottles (2,3). Thus
physicians should be alert to this possibility if players present with
meningitis-like symptoms. Because of the ominous prognosis of bacterial
meningitis, prompt and accurate diagnosis of meningitis in any form is
necessary so that proper treatment can be initiated.
There are many causes of aseptic meningitis (table 1: not shown).
"Viral" and "aseptic" are often used interchangeably when
referring to meningitis, even though "aseptic" simply means
"nonbacterial." Although several different pathogens, including Mycobacterium
tuberculosis and various fungi, can cause aseptic meningitis, most cases
are viral. Enteroviruses cause over half of the confirmed cases of viral
meningitis (1,4,5). Viral meningitis can occur at any age, but usually occurs
in people under the age of 40 (1,4), with those aged 5 to 15 most commonly
The types of enteroviruses causing viral meningitis vary annually.
Transmission is primarily fecal-oral with infection occurring across mucous
membranes (1,5). After the virus has replicated within the gastrointestinal
tract (1), viremia is established, followed by viral crossover at the
blood-brain barrier into the subarachnoid space (1,5). Alterations in the
blood-brain barrier then allow white blood cells (WBCs) and other
inflammatory components into the cerebrospinal fluid (CSF) (5).
Most patients show some obvious signs and symptoms of meningitis. Fever,
headache, vomiting (1,4,5), neck or back stiffness, photophobia (1,5), and
mental states ranging from lethargy (1,4) to coma are often present.
The onset of symptoms may be acute (less than 24 hours) or subacute
(occurring over 1 to 7 days). When a patient presents with acute meningitis,
immediate treatment is the first consideration (1). A more specific diagnosis
can be pursued after treatment has begun.
A subacute onset of symptoms usually causes physicians to consider a
nonbacterial etiology. All types of meningitis, however, may develop acutely
or subacutely, with most cases developing subacutely. In fact, up to 75% of
patients who have bacterial meningitis have a subacute onset (1). The
remainder of this article focuses on the subacute presentation.
Important elements of the history include the patient's age (5), the time
of year (1,5), exposure to vectors such as mosquitoes and ticks, medications
taken currently or recently, systemic illnesses, exposure to tuberculosis,
travel out of the country, human immunodeficiency virus (HIV) risk factors,
and history of meningitis (5). Inquiry should also be made about recent
contact with anyone who had an acute illness, especially meningitis.
On physical examination, a patient who has meningitis is generally febrile
and uncomfortable (5). Mental status is usually normal, but varying degrees
of abnormal mental status may be present (1). A full neurologic examination
should be performed whenever meningitis is suspected. Impaired sensorium or
focal neurologic findings should raise suspicion of encephalitis or a
space-occupying lesion such as a brain abscess (5). Fundoscopic examination
for papilledema is important. Papilledema is very rare in meningitis, and its
presence should raise the suspicion of a mass lesion. The possibility of an
abscess should be considered when findings such as otitis media or sinusitis
are present (5).
Signs of meningeal irritation should also be sought whenever meningitis is
suspected. Kernig's sign and Brudzinski's sign are common with meningeal
irritation (4,5). Kernig's sign is positive if resistance to passive leg
extension occurs when the patient is seated or when the hip is flexed.
Brudzinski's sign is positive if involuntary flexion of the hips occurs when
the supine patient's neck is passively flexed abruptly.
Some other physical findings may increase suspicion of particular
etiologic agents: Parotitis is associated with mumps, herpangina with
Coxsackie virus, and herpetic lesions with herpesvirus (3).
Lab Tests Hold the Key
It is virtually impossible to distinguish between bacterial and aseptic
meningitis with clinical findings alone (6). The most important laboratory
test for diagnosing meningitis--and the most useful tool for distinquishing
between aseptic and bacterial forms--is prompt CSF analysis. The CSF should
be studied for cell count and differentials, glucose levels (as compared with
a simultaneous serum glucose), lactate, and protein levels. Various cultures,
stains, and assays are also important, depending on the setting.
CSF cell count. In patients who have aseptic meningitis, the CSF
cell count is usually less than 1,200 per mm3 (5). Mononuclear cells are
usually predominant in these patients, but polymorphonuclear (PMN) cells may
predominate early in the course of the disease (5,6,8). Bacterial meningitis,
like aseptic meningitis in early stages, causes pleocytosis (usually greater
than 1,000 per mm3 (1,6), along with a predominance of PMNs (6). Because of
similarities between CSF results in aseptic and bacterial meningitis, many
feel that, with a subacute presentation in an otherwise stable patient,
repeat evaluation of the CSF to look for a shift from PMNs to mononuclear
cells is warranted prior to antibiotic therapy (5,6,8). The total cell count
is usually, but not always, higher in bacterial meningitis.
CSF protein. CSF protein elevations are common with both bacterial
and aseptic meningitis. Meningitis caused by viral agents often produces a
smaller increase in CSF protein levels, but as with cell counts, frequent
similarities between protein levels in aseptic and bacterial meningitis raise
doubts about the usefulness of CSF protein counts in distinquishing
meningitis types (5).
CSF glucose. CSF glucose levels should be compared with
simultaneous serum glucose levels. A ratio of CSF glucose to serum glucose of
approximately 66% is considered normal (5,6). In patients who have aseptic
meningitis, CSF serum glucose ratios are usually within the normal range, (5)
whereas bacterial meningitis causes a decrease in CSF glucose (1,6,8).
However, as with cell counts, differentials, and protein measurements, the
ranges of glucose values for the two types overlap considerably.
It is difficult to diagnose bacterial vs aseptic meningitis on the grounds
of CSF cell count, differential, protein, and glucose evaluations alone. Test
results in 30% to 40% of patients who have nontuberculous bacterial
meningitis will fall in the range of values typical of tuberculous, fungal,
and viral meningitis (1).
CSF lactate. Tests for CSF lactate and serum C-reactive protein
(CRP) concentrations may be helpful for distinguishing between bacterial and
viral meningitis. CSF lactate levels of greater than 6 mmol/L indicate
bacterial meningitis, in contrast to lactate levels in viral meningitis of
less than 3 mmol/L (17). Bacterial meningitis will cause a CRP level higher
than 20 mg/L (18).
Cultures and stains. Cultures of the CSF are extremely helpful for
determining specific bacterial causes of meningitis, and may be the only
laboratory results that clearly differentiate bacterial from viral
meningitis. Bacterial cultures should always be performed (1,5), and
culturing for fungi and staining for AFB should be considered (5). Other
tests for M tuberculosis, such as high-performance liquid
chromatography, which uses fluorescence for detection of mycolic acids
(9-11), or polymerase chain reaction (PCR) assays (12,13), may assist rapid diagnosis
in cases of tuberculous meningitis. Gram's staining is helpful if bacteria
are present. India ink studies to look for cryptococcus may also need to be
obtained. Viral cultures may be of use but are very difficult; the isolation
rate of enteroviruses ranges from 43% to 77%, depending on the serotype (19).
Viral serology is not helpful in the acute setting as obtaining acute and
convalescent sera takes 3 weeks (5), but it may be helpful in making a final
diagnosis of viral vs other forms of aseptic meningitis. PCR can enable rapid
detection of herpes simplex virus (HSV) in the CSF (14,15). Rapid HSV
detection is important because, although infection with HSV-2 is usually self
limited, HSV-1 infections may cause a rapidly progressing, fatal encephalitis
WBC counts. Peripheral WBC counts have not been shown to be helpful
in distinguishing bacterial from aseptic meningitis (5,6). In either form,
the WBC count can be normal, slightly elevated, or greatly elevated. The
differential of the peripheral WBC count has not proven to be of benefit
The most important step in treating subacute aseptic meningitis is a fast
and accurate diagnosis. Treatment for patients who have viral meningitis is
generally supportive, and the course is usually benign (5). Intravenous
hydration and antipyretics may be required.
In some patients, other medications may be used. Certain types of viruses
should be treated with antiviral agents, but this is usually when
encephalitis is present. With HSV infection, acyclovir is the treatment of
choice. When meningitis is caused by M tuberculosis, isoniazid and
rifampin are the major components of therapy (16).
When the diagnosis is uncertain, antibiotics can be started while cultures
are pending (1). Antibiotic choices are generally based on the age of the
patient as well as pathogens common to the hospital or region. If a bacterial
cause is ruled out, antibiotics may be withdrawn. Currently, however, many
feel that for patients who present subacutely, evaluation of the CSF should
be repeated 6 to 24 hours after the initial examination and before starting
antibiotics--particularly when CSF findings are indeterminate and Gram's
stain is negative (5,6,8).
A Football Connection?
There have been multiple reports of aseptic meningitis-like illnesses in
high school football players. Between 1978 and 1980, seven outbreaks in four
states were reported (2,3).
For several reasons, high school football players may be at greater risk
of aseptic meningitis. Factors that may increase the risk are the concurrence
of football practice and games with peak enterovirus season, frequent
physical contact among football players, sharing of water bottles, and the
greater physical exertion among football players as compared with participants
in other sports. The latter factor may predispose these athletes to aseptic
meningitis where other athletes exposed to the same enterovirus might have a
milder clinical illness (2). Other team sports are played in the enterovirus
season and present similar aseptic meningitis risk factors, but there have
been no reports of outbreaks among these players. Perhaps the amount of head
contact in football increases the risk.
Changes in CSF cell count and biochemistry consistent with aseptic
meningitis have been noted following brain and spinal cord injury (20,21). It
is hypothesized that these injuries may cause bleeding into the CSF coupled
with an inflammatory response, resulting in increased WBC count (20,21). A
study of patients who had spinal cord injuries showed a corrected WBC count
of 48.9 per mm3 in patients whose lumbar punctures were performed within 7
days of injury. The majority of the cells were PMNs (57.8%), followed by
lymphocytes (23.4%), and finally monocytes (19.6%). Elevated CSF protein was
also found (mean elevation 125 mg/dL) (21). The patients in these studies
(20,21) were all victims of non-sports-related trauma. The similarities,
however, may lead to the question: Does head trauma from football or other
collision sports alter CSF cell count and biochemistry, potentially mimicking
aseptic meningitis in laboratory tests? The available evidence leaves this
Aseptic meningitis has also been shown to result from exposure to certain medications
(4,5,7,22) and other chemicals (1,7). Chemical-induced aseptic meningitis
generally occurs because of direct contact of the irritant with the meninges.
Substances that may cause this entity include radiologic contrast dyes,
chemotherapeutic agents (1,7) various other drugs, detergents, preservatives,
and even talc (table 2: not shown) (7).
Aseptic meningitis induced by nonsteroidal anti-inflammatory drugs
(NSAIDs) appears to be a hypersensitivity reaction (4,7,22) and is most
commonly seen in patients who have concomitant diseases such as systemic
lupus erythematosus (7,22) or connective tissue disease (7). Ibuprofen in
particular is one of the more common causes of drug-induced aseptic
meningitis (4,7,22). Because many people use over-the-counter ibuprofen for
headaches and the aches and pains associated with physical activity, the true
etiology of aseptic meningitis in some patients may be difficult to discover.
Drug-induced aseptic meningitis is a diagnosis of exclusion (4,7,22).
Discontinuation of the offending drug usually leads to resolution of symptoms
in less than 48 hours (4,22).
Precautions for Prevention
Because the reasons for athletes' possibly increased risk of aseptic
meningitis are speculative, it is difficult to suggest how to reduce the
risk, but eliminating sharing of common drinking water and ice sources such
as hoses, water bottles, and team coolers may be of some benefit. In
addition, hand washing is good for prevention of many illnesses including
aseptic meningitis, conjunctivitis, flu, and gastroenteritis.
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Dr Moeller is associate director of primary care sports medicine and an
assistant professor in the departments of family medicine and orthopedic
surgery at the University of Pittsburgh Medical Center in Pittsburgh. He is a
member of the American College of Sports Medicine and the American Medical
Society for Sports Medicine. Address correspondence to James L. Moeller, MD,
Director, Primary Care Sports Medicine, University Orthopaedics, Inc, 3471
Fifth Ave, Kaufman Bldg, Ste 1000, Pittsburgh, PA 15213; e-mail to email@example.com.
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