Viral Meningitis: Symptoms, Types, Causes and Treatment

Viral meningitis, often referred to as "aseptic meningitis," is a significant neurological condition that affects people of all ages. Unlike its bacterial counterpart, viral meningitis is generally less severe, but it can still lead to considerable discomfort, hospitalization, and—in rare cases—serious complications. Understanding its symptoms, types, causes, and treatment options is crucial for patients, caregivers, and healthcare professionals alike. This comprehensive guide synthesizes up-to-date research to offer a clear and engaging overview of viral meningitis.

Symptoms of Viral Meningitis

Recognizing the symptoms of viral meningitis is the first step toward timely medical care. While symptoms can mimic those of bacterial meningitis, viral meningitis typically presents with a specific constellation of signs that can vary by age and immune status.

Symptom	Description	Frequency/Severity	Source(s)
Headache	Severe, persistent headache	Very common, prominent	2 3 6 7 13
Fever	Elevated body temperature	Common	2 3 6 7 13
Neck stiffness	Difficulty bending the neck, nuchal rigidity	Common	2 3 6 7 13
Photophobia	Sensitivity to light	Frequently reported	2 3 7 13
Nausea/Vomiting	Feeling sick or actual vomiting	Often present	2 3 7 13
Rash	Skin rash, especially with VZV or enteroviruses	Occasional	1 2 7
Myalgia	Muscle pain and aches	Sometimes present	3 6
Fatigue	General tiredness or malaise	Common	3 6
Diarrhea/URTI	Gastrointestinal or upper respiratory symptoms	Sometimes, especially EV	2 3

Table 1: Key Symptoms of Viral Meningitis

The Classic Symptom Triad

Viral meningitis most commonly presents with a triad of headache, fever, and neck stiffness. Photophobia (light sensitivity) and nausea or vomiting are also frequent. In one large study, the combination of headache, neck stiffness, and photophobia/hyperacusis was present in about 28% of adult cases, highlighting that not all patients have the full triad at presentation 7.

Age-Dependent Presentations

• Infants and young children may exhibit more severe symptoms, including high fever, irritability, and poor feeding. In pediatric viral meningitis, signs like Kernig's and Brudzinski's can be evaluated, though their reliability varies 3.
• Adults and older children typically report severe headache, fever, neck stiffness, and photophobia. Myalgia, fatigue, and malaise are common but less specific 2 3 6 7.

Additional and Atypical Symptoms

• Rash: Can occur, especially in cases of varicella zoster virus (VZV) or enterovirus infections. For VZV, the rash may appear days after the onset of meningitis symptoms 1.
• Gastrointestinal and Respiratory Symptoms: Diarrhea and respiratory tract symptoms may accompany enteroviral meningitis, particularly in younger patients 2.
• Recurrence: Certain viruses, such as herpes simplex virus type 2 (HSV-2), can cause recurrent episodes of meningitis 13.

Severity and Course

The severity of symptoms can range from mild, self-limited illness to more critical presentations. While most cases resolve without long-term consequences, some patients—especially young children—may develop complications or prolonged symptoms 3 7.

Types of Viral Meningitis

Viral meningitis is not a single disease but a syndrome caused by a variety of viral pathogens. Understanding these types is important for epidemiology, diagnosis, and sometimes for management.

Type/Agent	Common Viruses/Examples	Age/Population Pattern	Source(s)
Enteroviral	Coxsackievirus, echovirus, enterovirus	All ages; peak in children	1 2 3 4 5 6 8 10
Herpesvirus	HSV-1, HSV-2, VZV, HHV-6	HSV-2 (adults); VZV (older adults/immunosuppressed)	1 3 6 7 8 12 13
Arboviral	West Nile, Toscana, Japanese encephalitis	Seasonal, regional	6 8 10 12
Mumps/Other	Mumps, LCMV, adenovirus, influenza	Rare, sometimes outbreaks	5 6 8 10 12

Table 2: Main Types of Viral Meningitis by Causative Agent

Enteroviral Meningitis

• Prevalence: By far the most common cause, accounting for up to 85–95% of viral meningitis cases worldwide 1 2 3 4 5 6 8 10.
• Seasonality: Peaks in late summer and fall.
• Manifestation: Can affect all ages but is especially prevalent in children and young adults. Outbreaks may occur in communities or institutions 2 3.

Herpesvirus-Related Meningitis

• Herpes Simplex Virus (HSV): HSV-2 is a frequent cause in adults, particularly women; may cause recurrent meningitis (Mollaret's meningitis) 1 7 13.
• Varicella Zoster Virus (VZV): More common in older adults and immunosuppressed individuals; often associated with shingles rash that may appear after neurological symptoms 1 7 8.
• Others: Human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV) are rare but possible, especially in immunocompromised patients 8 12.

Arboviral Meningitis

• Examples: Includes West Nile virus, Japanese encephalitis, and Toscana virus.
• Epidemiology: Occurs in regions and seasons where the vectors (mosquitoes, ticks) are active 6 8 10 12.

Other Viral Causes

• Mumps: Now rare in countries with vaccination but still reported in some outbreaks 5 8 10 12.
• Lymphocytic Choriomeningitis Virus (LCMV): Rare, can be seen in rodent exposure.
• Influenza and Adenovirus: Occasional causes, more common in children 5 8 12.

Overlap and Diagnostic Challenges

Many cases remain undiagnosed even after extensive testing, and distinguishing between types based solely on clinical presentation is difficult 6 8 9 11. Laboratory testing, especially PCR, is crucial for identifying the causative agent 1 3 11.

Causes of Viral Meningitis

Viral meningitis is triggered by a diverse group of viruses, each with its own mode of transmission and epidemiological pattern. Understanding these causes helps inform prevention and public health strategies.

Cause	Transmission Route	Key Epidemiological Notes	Source(s)
Enteroviruses	Fecal-oral, respiratory	Most frequent; seasonal outbreaks	2 3 4 5 6 8 10 12
Herpesviruses	Direct contact (saliva, genital, skin)	HSV-2 often via sexual contact; VZV reactivation	1 7 8 12 13
Arboviruses	Vector-borne (mosquito/tick)	Regional, seasonal, travel-related	8 10 12
Mumps, Others	Respiratory droplets, etc.	Reduced incidence with vaccination	5 8 10 12

Table 3: Causative Agents and Transmission of Viral Meningitis

Enteroviruses

• Pathway: Spread primarily via the fecal-oral route and, less commonly, through respiratory secretions.
• Epidemiology: Responsible for the majority of viral meningitis cases globally. Outbreaks are common in summer and early fall, especially in children 2 3 4 6 10 12.

Herpesviruses

• Herpes Simplex Virus (HSV): HSV-2 is usually sexually transmitted and is linked to meningitis in young and middle-aged adults, particularly women 1 7 13.
• Varicella Zoster Virus (VZV): Reactivation (shingles) can cause meningitis, especially in older adults and immunosuppressed patients. Rash may lag behind neurological symptoms 1 7.
• Other Herpesviruses: CMV and HHV-6 are less common, typically in immunocompromised individuals 8 12.

Arboviruses

• Transmission: Through bites from infected mosquitoes or ticks.
• Examples: West Nile virus, Japanese encephalitis, Toscana virus. Risk increases during vector seasons and with travel to endemic areas 8 10 12.

Other Viral Causes

• Mumps: Once a common cause, now rare in vaccinated populations. Outbreaks can still occur where vaccination rates are low 5 8 10 12.
• Lymphocytic Choriomeningitis Virus (LCMV): Rodent exposure is the main risk; seen rarely 8 12.
• Other respiratory viruses: Influenza, adenovirus, and others can occasionally cause meningitis, mostly in children 5 8.

Pathogenesis

Viruses typically enter the body through mucosal surfaces, replicate, and travel to the central nervous system via the bloodstream (hematogenous spread) or, less frequently, by retrograde nerve transport (e.g., HSV, VZV) 5 6.

Treatment of Viral Meningitis

Treatment approaches for viral meningitis emphasize supportive care, as most cases are self-limiting. However, antiviral therapies are indicated in specific situations, and accurate diagnosis can help minimize unnecessary interventions.

Treatment	Application/Agent	Indication/Evidence	Source(s)
Supportive care	Fluids, pain/fever control	Mainstay for all cases	2 3 5 6 11
Antivirals	Acyclovir, Valacyclovir	HSV & VZV meningitis; role unclear	1 7 11 12 13
Antibiotics	Empiric, until bacterial ruled out	Often started, then stopped	2 9 13
Hospitalization	Monitoring, severe cases	As needed	2 7 11
Prevention	Vaccination, hygiene, vector control	Varies by virus	5 8 12

Table 4: Treatment and Management Approaches

Supportive Care

• Mainstay: Most viral meningitis cases resolve without specific antiviral therapy. Treatment focuses on:
  • Adequate hydration
  • Pain and fever management
  • Rest and monitoring for complications 2 3 5 6 11

Antiviral Therapy

• HSV and VZV: Antivirals like acyclovir or valacyclovir may be used for HSV or VZV meningitis. However, evidence for a clear benefit in HSV-2 or VZV meningitis is limited; early antiviral treatment does not always result in improved outcomes 7 12 13.
• Other Viruses: No specific antiviral therapy is available for enteroviral or most other viral meningitis types. Research into new treatments is ongoing 11 12.

Use of Antibiotics

• Empirical Therapy: Because viral and bacterial meningitis cannot be reliably distinguished on clinical grounds alone, antibiotics are often started until bacterial infection is ruled out by cerebrospinal fluid (CSF) analysis 2 9 13.
• Discontinuation: Once a viral cause is confirmed, antibiotics are stopped, reducing unnecessary medication 2 9 13.

Hospitalization and Monitoring

• Indications: Hospital admission may be necessary for severe cases, immunocompromised patients, infants, or those with complications. Most adults with mild cases can be managed as outpatients once bacterial infection is excluded 2 7 11.

Prevention

• Vaccination: Effective for some viral agents (e.g., mumps, VZV, influenza, Japanese encephalitis). Maintaining high community vaccination rates is key 5 8 12.
• Hygiene: Good handwashing practices reduce the spread of enteroviruses.
• Vector Control: Reduces risk of arboviral meningitis in endemic areas 5 8 12.

Conclusion

Viral meningitis remains an important and often under-recognized cause of central nervous system infection worldwide. While the majority of cases resolve with supportive care, understanding the diversity of causative agents and their clinical presentations is crucial for prompt diagnosis and management.

Key Points Covered:

• Symptoms: Headache, fever, neck stiffness, photophobia, and sometimes rash are hallmark features, but presentations can vary by age and virus.
• Types: Enteroviruses are the leading cause, but herpesviruses, arboviruses, and others also contribute.
• Causes: Transmission routes include fecal-oral, direct contact, and vectors; prevention strategies differ by agent.
• Treatment: Supportive care is the mainstay; antivirals are reserved for certain herpesvirus infections, but their benefit is not always clear. Accurate diagnosis minimizes unnecessary antibiotic use.
• Prevention: Vaccination and good hygiene are effective strategies for reducing the burden of viral meningitis.

By staying informed about the evolving landscape of viral meningitis, both healthcare providers and the public can contribute to better outcomes, faster diagnoses, and improved prevention for this important neurological condition.