Clinical Pathways
Clinical Pathways
Suspected viral (aseptic) meningitis
Suspected viral (aseptic) meningitis

Suspected viral (aseptic) meningitis

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Decision

Low-risk clinical picture?

Yes

Discharge home with return precautions (Class III)

No

Admit to medical ward

Background

Patients With Viral Infections

For most cases of viral meningitis, the course is usually self-limited, and no directed therapy has proven to affect patient-oriented outcomes. Supportive care is the mainstay of management in patients with a presentation and workup clearly suggestive of a mild viral etiology. Patients with severe symptoms or equivocal test results in the ED should be empirically treated for bacterial meningitis, using previously described regimens, and admitted.

All patients with clinical signs of acute encephalitis should empirically receive acyclovir pending PCR results. In a randomized controlled trial of 208 patients with encephalitis due to HSV-1, patients who received acyclovir had a reduced mortality rate of 28% compared to a rate of 70% in the placebo group. If PCR for HSV-1 is negative but high suspicion remains for herpes simplex encephalitis based on risk factors or MRI findings, antiviral therapy should be continued. Because false-negative PCR is possible during the first 72 hours of herpes simplex encephalitis, PCR testing should be repeated after 3 to 7 days.

Varicella zoster infection causes a disproportionate number of cases of viral encephalitis in immunocompromised patients. If VZV is identified as the cause of viral encephalitis, guidelines recommend continuing empiric acyclovir therapy despite less robust supporting evidence for this medication than in HSV-1 infection.

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References
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