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Enteroviral meningitis in children and adults

Medical expert of the article

Infectious disease
, medical expert
Last reviewed: 26.11.2021

When inflammation of the pia mater is caused by enteroviruses of the Picornaviridae family, enteroviral meningitis is diagnosed. The code of this disease according to ICD-10 is A87.0 in the section of infectious diseases (and G02.0 in the section of inflammatory diseases of the central nervous system). Enteroviruses include Coxsackie A and B viruses, echoviruses, polioviruses, and recently identified numbered viruses such as enterovirus 71. [1]

Epidemiology

Picornaviruses, in particular the enterovirus and rhinovirus groups, are responsible for most viral diseases in humans. Enteroviruses cause 10 to 15 million symptomatic infections in the United States each year. [2]

In general, the incidence of viral meningitis in the general population during the year is estimated at five cases per 100 thousand population.

The exact etiology of viral meningitis (that is, the specific serotype of the virus) is detected in no more than 70% of cases. [3]

Enteroviruses are considered the most common cause of viral meningitis in many countries around the world: in some high-income countries, 12 to 19 cases per 100,000 people are reported annually. [4]

Causes of the enteroviral meningitis

Studies have established that up to 85-90% of all cases of viral  meningitis ,  [5]which is also called  aseptic meningitis ,  [6]is associated with damage to the pia mater and arachnoid membrane and the subarachnoid space of the brain by  enterovirus infections , the spread of which is seasonal and significantly increases in summer. [7]

The reasons are infection  with Coxsackie viruses  or  ECHO  (Enteric Citopatthogenic Human Orphan) viruses, which can occur in two ways: fecal-oral (through water, food, hands or objects contaminated with these viruses) and airborne droplets (upon contact with sick or recovering people, in the respiratory aerosol of which there is a virus). [8]

Risk factors

Failure to comply with hygiene rules, children under three years of age and weakened immunity in adolescents and adults are considered risk factors for the development of enteroviral meningitis.

Enteroviruses, which cause most cases of viral meningitis, are contagious, but in many cases it is asymptomatic or non-meningitis febrile conditions. [9]

Pathogenesis

It is clear that the pathogenesis of enteroviral inflammation of the meninges is due to the action of viruses that have entered the body. The mechanism of the inflammatory process induced by these Coxsackie viruses and the ECHO virus is not completely clear. [10], [11]

It is known that proteins of their capsids - before the start of genome replication - interact with some receptors of cell (lysosomal) membranes in many tissues and types of human cells, including T-lymphocytes and neurons, which, in fact, is the first stage of the life cycle of the virus... [12]

First, the replication of viruses occurs in the lymphatic tissues of the upper respiratory tract and small intestine, and then they spread, entering the bloodstream (that is, after secondary viremia). [13]

More information in the material -  Enterovirus infections - Causes and pathogenesis

Symptoms of the enteroviral meningitis

The first signs of viral (aseptic) meningitis caused by enteroviruses are usually manifested by acute fever (above + 38.5 ° C),  [14]headache, photophobia, neck stiffness (stiff neck), nausea and vomiting. [15]

Symptoms also include signs of meningeal irritation: involuntary contraction of the hamstring tendon during knee extension in a supine patient (Kernig's sign); involuntary bending of the legs and pulling them to the stomach when trying to tilt the patient's head forward (Brudzinsky's sign). [16]

With this infection of the lining of the brain in infants, increased irritability and moodiness, a complete lack of appetite and refusal of breast, increased drowsiness, and vomiting are noted. Although enteroviral meningitis in young children can occur without pronounced meningeal signs.

The younger the child, the faster damage to the meninges can occur and a response inflammatory process can develop - fulminant enteroviral meningitis with the same manifestations or only with weakness and headache. In rare cases, clouding of consciousness and stupor are possible. [17]

Newborns with enteroviral meningitis may present in the same way as bacterial sepsis and may also have systemic lesions such as liver necrosis, myocarditis, necrotizing enterocolitis, seizures, or focal neurologic symptoms.

Also read -  Symptoms of Coxsackie and ECHO infections

Complications and consequences

The main complications of enteroviral inflammation of the meninges are the development of meningoencephalitis and cerebral edema. Although most types of aseptic meningitis are not serious, long-term effects can include neuromuscular disorders, headache attacks, and short-term memory impairment.

Some subtypes of enteroviruses, such as EV71 and EV68, are associated with more severe neurological disease and worse outcomes. The most common severe complications of enteroviral meningitis are meningoencephalitis, myocarditis, and pericarditis. In children, neurological complications of enterovirus infection may include acute flaccid paralysis and rhombencephalitis. Neuropsychological disorders after viral meningitis are measurable, but generally not as severe as those after bacterial meningitis. [18]Some studies have noted sleep disturbance as a long-term consequence of meningitis. [19]

Diagnostics of the enteroviral meningitis

To provide adequate treatment, patients with suspected meningitis require accurate and rapid diagnosis, which begins with a physical examination and an assessment of the symptoms present.

To determine the causative agent of the disease (and the differentiation of viral and bacterial meningitis), tests are necessary: a swab from the nasopharynx, blood and feces tests,  analysis of cerebrospinal fluid  (by lumbar puncture). [20]

CSF or cerebrospinal fluid in enteroviral meningitis is examined by multiplex PCR - polymerase chain reaction, which allows detecting the presence of viral RNA in it. [21]

Instrumental diagnostics most often consists of  computed tomography of the brain

More information in the article -  Enterovirus infections - Diagnostics

Differential diagnosis

And differential diagnosis is carried out with bacterial, tuberculous and fungal meningitis, Lyme disease, as well as other viral infections (arbovirus, herpes simplex virus, paramyxovirus, etc.). Other infectious etiologies to consider include mycoplasmas, spirochetes, mycobacteria, brucella, and fungal meningitis or encephalitis. [22]  Noninfectious etiology includes drugs (NSAIDs, trimethoprim-sulfamethoxazole, intravenous immune globulin), heavy metals, neoplasms, neurosarcoidosis, systemic lupus erythematosus, Behcet's syndrome, and vasculitis. In children, Kawasaki disease can manifest itself in the same way as bacterial or viral meningitis.[23]

Treatment of the enteroviral meningitis

Most viruses, including enteroviruses that cause meningitis, have no specific treatment other than supportive therapy. Fluid and electrolyte administration and pain relief are the mainstays of treatment for viral meningitis. Patients should be monitored for neurologic and neuroendocrine complications, including seizures, cerebral edema, and SIADH.

As experts note, viral is usually a benign disease that goes away on its own. 

Treatment for symptom relief includes NSAIDs (Ibuprofen et al.) For fever and headache, and for severe vomiting, maintenance of fluid and electrolyte levels in the body is required (you need to drink more water). In more severe cases, Dexamethasone is given parenterally  .

Pleconaril is a first-of-its-kind active orally active antiviral agent that selectively inhibits picornavirus replication by blocking viral attachment and de-enveloping. This placebo-controlled, double-blind study tested the efficacy of oral pleconaril in the treatment of viral enteroviral meningitis. Pleconaril significantly reduces the duration and severity of symptoms of enteroviral meningitis in children and is well tolerated. [24]

Antibiotics are not effective against viruses, but upon admission to a hospital - the exact cause of the inflammation is not yet known - they can be prescribed empirically, and after the detection of a viral pathogen, the use of antibiotics is discontinued.

For details see:

Prevention

There is no special prevention of this disease, but adherence to the rules of personal hygiene can prevent infection.

Forecast

Compared to meningitis caused by bacterial and fungal infections, as well as inflammation of the lining of the brain of hepreviral origin, enteroviral meningitis has a better prognosis,  [25]and most patients recover completely.


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