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Viral Meningitis


John E. Greenlee

, MD, University of Utah Health

Reviewed/Revised Nov 2022
Topic Resources

Viral meningitis is inflammation of the layers of tissue that cover the brain and spinal cord (meninges) and of the fluid-filled space between the meninges (subarachnoid space) when it is caused by viruses.

  • Viral meningitis usually begins with symptoms of a viral infection such as fever, a general feeling of illness, headache, and muscle aches.

  • Later, people develop a headache and a stiff neck that makes lowering the chin to the chest difficult or impossible.

  • Doctors suspect viral meningitis based on symptoms and do a spinal tap (lumbar puncture) to confirm the diagnosis.

  • If people appear very ill, they are treated for bacterial meningitis until that diagnosis is ruled out.

  • If the cause is human immunodeficiency virus (HIV) or a herpesvirus, drugs effective against those viruses are used.

  • For other viruses, no effective drugs are available, but most people recover on their own within weeks.

The brain and spinal cord are covered by three layers of tissue called meninges. The subarachnoid space is located between the middle layer and the inner layer of the meninges, which cover the brain and spinal cord. It contains the cerebrospinal fluid, which flows through the meninges, fills the spaces within the brain, and helps cushion the brain and spinal cord.

Viral meningitis is the most common cause of aseptic meningitis. Aseptic meningitis refers to meningitis that is caused by anything other than the bacteria that typically cause meningitis. Thus, aseptic meningitis can include meningitis caused by drugs, disorders that are not infections, or other organisms (such as the bacteria that cause Lyme disease Lyme Disease Lyme disease is a tick-transmitted infection caused by Borrelia species, primarily by Borrelia burgdorferi and sometimes by Borrelia mayonii in the United States. These... read more Lyme Disease or syphilis Tertiary (third, or late) syphilis Tertiary (third, or late) syphilis ).

Tissues Covering the Brain

Within the skull, the brain is covered by three layers of tissue called the meninges.

Tissues Covering the Brain

Causes of Viral Meningitis

The most common cause of viral meningitis is

Enteroviruses tend to reside in the digestive tract. Infections are very contagious.

Other common causes include

HSV-2 causes genital herpes Herpes Simplex Virus (HSV) Infections Herpes simplex virus infection causes recurring episodes of small, painful, fluid-filled blisters on the skin, mouth, lips (cold sores), eyes, or genitals. This very contagious viral infection... read more Herpes Simplex Virus (HSV) Infections , a sexually transmitted infection that causes painful blisters in the genital area. HSV-2 can also cause symptoms of meningitis. HSV-2 meningitis usually occurs when the virus first infects the body. Genital and meningitis symptoms can occur at the same time. Symptoms of meningitis may appear before the genital symptoms, and some people have meningitis but do not have any genital symptoms. After symptoms disappear, HSV-2 remains in the body in a nonactive (dormant) state. That is, it does not cause symptoms. However, it can become active again (reactivate) periodically and cause symptoms. Thus, meningitis due to HSV-2 Viruses Recurrent meningitis is meningitis that occurs more than once. Meningitis is inflammation of the layers of tissue that cover the brain and spinal cord (meninges) and of the fluid-filled space... read more can recur.

Occasionally, meningitis develops in people with COVID-19 COVID-19 COVID-19 is an acute respiratory illness that can be severe and is caused by the coronavirus named SARS-CoV-2. Symptoms of COVID-19 vary significantly. Two types of tests can be used to diagnose... read more . Rarely, this meningitis is caused by simultaneous infection with another virus (such as varicella-zoster virus).

Transmission of viral meningitis

Viral meningitis can be spread in several ways, depending on the virus:

  • Spread through the bloodstream from an infection in another part of the body (the most common way)

  • Contact with contaminated stool, which may occur when infected people do not wash their hands after a bowel movement or when they swim in a public swimming pool (for enteroviruses)

  • Sexual intercourse or other genital contact with an infected person (for HSV-2 and HIV)

  • A bite of an insect, such as a mosquito (for West Nile virus, St. Louis virus, Zika virus, or Chikungunya virus)

  • Spread through the air by inhaling the virus (for varicella-zoster virus)

  • Contact with dust or food contaminated by the urine or stool of infected mice or pet hamsters (for lymphocytic choriomeningitis virus)

  • Use of infected needles to inject drugs (for HIV)

Because of the way they are spread, some viruses (such as those spread by mosquitoes) cause meningitis only during certain seasons.

Symptoms of Viral Meningitis

Viral meningitis usually begins with symptoms of a viral infection, such as fever, a general feeling of illness (malaise), cough, muscle aches, vomiting, loss of appetite, and headache. However, occasionally, people have no symptoms at first.

Later, people have symptoms that suggest meningitis. That is, they typically have fever, headache, and a stiff neck. Trying to lower the chin to the chest causes pain and may be impossible. Moving the head in other directions is not as difficult.

Symptoms may resemble those of bacterial meningitis but are usually less severe and develop and progress more slowly.

Diagnosis of Viral Meningitis

  • Spinal tap and analysis of cerebrospinal fluid

  • Sometimes culture and testing of blood, other body fluids, or stool

Doctors suspect meningitis when people have a headache, fever, and stiff neck. They then try to determine whether meningitis is present and whether it is caused by bacteria (requiring immediate treatment) or a virus. Viral meningitis is more likely when the symptoms are less severe.

A spinal tap Spinal Tap Diagnostic procedures may be needed to confirm a diagnosis suggested by the medical history and neurologic examination. Imaging tests commonly used to diagnose nervous system (neurologic) disorders... read more Spinal Tap (lumbar puncture) is done to obtain a sample of cerebrospinal fluid. However, if doctors suspect that pressure within the skull is increased, computed tomography (CT) or magnetic resonance imaging (MRI) may be done first to check for causes of the increased pressure (such as a tumor or another mass in the brain). Doing a spinal tap when pressure within the skull is increased may cause a life-threatening disorder called brain herniation Herniation: The Brain Under Pressure Herniation: The Brain Under Pressure . After pressure within the skull is lowered or if no mass is detected, the spinal tap is done.

The sample of cerebrospinal fluid is sent to a laboratory to be examined and analyzed. Sugar and protein levels and the number and type of white blood cells in the fluid are determined. The fluid is cultured to check for bacteria and thus rule out or confirm bacterial meningitis. The fluid is not usually cultured for viruses because doing so is technically difficult.

The polymerase chain reaction (PCR) technique, which produces many copies of a gene, is used to identify enteroviruses, herpesviruses (such as HSV and varicella-zoster virus), and some other viruses. Doctors also test cerebrospinal fluid for the presence of antibodies to certain viruses. For example, detecting antibodies to West Nile virus in cerebrospinal fluid indicates infection with that virus.

Doctors sometimes also take a sample of blood, nasal or throat secretions, or stool for culture, examination, and/or, if available, PCR testing. HIV can be diagnosed based on the results of antibody tests and PCR. Levels of antibodies to other viruses are measured and sometimes remeasured a few weeks later. An increase in the level of antibodies to a particular virus indicates that the virus caused a recent infection and so probably was the cause of recent meningitis.

Prognosis for Viral Meningitis

Most people who have viral meningitis recover within a few weeks. Occasionally, recovery can take months, as sometimes occurs when meningitis is caused by West Nile virus or lymphocytic choriomeningitis virus.

Treatment of Viral Meningitis

  • Acyclovir (an antiviral drug) for herpes simplex virus (HSV) or varicella-zoster infection

  • Antiretroviral drugs for HIV infection

  • Treatment of symptoms

If people appear very ill, doctors start treatment right away without waiting for test results to identify the cause. These people are given antibiotics until doctors are sure that they do not have bacterial meningitis Acute Bacterial Meningitis Acute bacterial meningitis is rapidly developing inflammation of the layers of tissue that cover the brain and spinal cord (meninges) and of the fluid-filled space between the meninges (subarachnoid... read more , which, if untreated, can rapidly cause permanent brain or nerve damage or death. They are also given acyclovir (an antiviral drug) in case the meningitis is due to HSV or varicella-zoster infection.

After the cause is identified, doctors change drugs as needed.

HIV infection is treated with antiretroviral drugs Antiretroviral Treatment of Human Immunodeficiency Virus (HIV) Infection Antiretroviral medications used to treat human immunodeficiency virus (HIV) infection aim to do the following: Reduce the amount of HIV RNA (viral load) in the blood to an undetectable amount... read more . These drugs prevent HIV (a retrovirus) from reproducing and multiplying inside human cells. Almost always, people need to take a combination of several antiretroviral drugs. People must take these drugs for the rest of their life.

If the cause is HSV or varicella-zoster infection, acyclovir is continued.

For most of the other viruses that commonly cause meningitis, there are no effective drugs. However, if people have a normal immune system, they almost always recover from these infections on their own.

Symptoms are also treated. For example, acetaminophen, taken by mouth or suppository (inserted into the rectum), can reduce fever. Pain relievers (analgesics), taken as needed, can help control headache.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Sitavig, Zovirax, Zovirax Cream, Zovirax Ointment, Zovirax Powder, Zovirax Suspension
7T Gummy ES, Acephen, Aceta, Actamin, Adult Pain Relief, Anacin Aspirin Free, Aphen, Apra, Children's Acetaminophen, Children's Pain & Fever , Children's Pain Relief, Comtrex Sore Throat Relief, ED-APAP, ElixSure Fever/Pain, Feverall, Genapap, Genebs, Goody's Back & Body Pain, Infantaire, Infants' Acetaminophen, LIQUID PAIN RELIEF, Little Fevers, Little Remedies Infant Fever + Pain Reliever, Mapap, Mapap Arthritis Pain, Mapap Infants, Mapap Junior, M-PAP, Nortemp, Ofirmev, Pain & Fever , Pain and Fever , PAIN RELIEF , PAIN RELIEF Extra Strength, Panadol, PediaCare Children's Fever Reducer/Pain Reliever, PediaCare Children's Smooth Metls Fever Reducer/Pain Reliever, PediaCare Infant's Fever Reducer/Pain Reliever, Pediaphen, PHARBETOL, Plus PHARMA, Q-Pap, Q-Pap Extra Strength, Silapap, Triaminic Fever Reducer and Pain Reliever, Triaminic Infant Fever Reducer and Pain Reliever, Tylenol, Tylenol 8 Hour, Tylenol 8 Hour Arthritis Pain, Tylenol 8 Hour Muscle Aches & Pain, Tylenol Arthritis Pain, Tylenol Children's, Tylenol Children's Pain+Fever, Tylenol CrushableTablet, Tylenol Extra Strength, Tylenol Infants', Tylenol Infants Pain + Fever, Tylenol Junior Strength, Tylenol Pain + Fever, Tylenol Regular Strength, Tylenol Sore Throat, XS No Aspirin, XS Pain Reliever
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