Recurrent Benign Lymphocytic Meningitis RBLM

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Recurrent Benign Lymphocytic Meningitis (RBLM)

• Eric Edwards, MD
• AM Report
• 1/11/08

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Objectives

• Review the principles of the evaluation of
  cerebrospinal fluid
• List the common etiologies of aseptic meningitis
• Discuss the etiology, presentation, diagnosis,
  and treatment of RBLM

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CSF evaluation

• Cell count (nl0-5 WBC)
• WBCgt1000 87 sensitive for bacterial meningitis
• Viral meningitis WBC usually lt100
• Differential
• Can have PMN predominance in early stages of
  viral/fungal/TB meningitis
• gt10 of cases of bacterial meningitis will have
  lymphocyte predominance

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CSF evaluation (continued)

• Gram stain
• 60-80 sensitive in untreated bacterial
  meningitis
• Lab experience important
• Protein (nl 15-45 mg/dl)
• Bacterial Avg. 400 (20-2000)
• Viral 75 (10-400)
• Will be elevated in traumatic tap
• Correction Subtract 1 mg per 1000 RBCs
• Glucose (nl 2/3 of serum glucose)
• Up to 50 of cases of bacterial meningitis will
  have normal glucose

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Aseptic Meningitis

• Definition Evidence for meningeal inflammation
  with negative routine bacterial cultures
• 1 cause Enteroviruses (Echovirus,
  coxsackievirus, etc.)
• Summer-fall months
• HIV
• HSV (2gt1)
• Other viruses
• Spirochetes (syphilis, lyme)
• Tick-borne (RMSF, erlichiosis)
• Fungal (Cryptococcus Coccidioides)
• TB

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Pierre Mollaret (1898-1987)
In French, the letters D, G, M, N, P, S, T, X,
and Z are usually silent at the end of a word.
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RBLM Etiology and Pathogenesis

• HSV-2
• Dormant in sacral dorsal root ganglia
• Retrograde seeding of CSF
• HSV-1 (less frequently)
• Other viruses have been implicated

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RBLM Presentation

• Recurrent episodes of fever and meningism
• Acute onset
• Maximum intensity within hours of onset
• 1-3 day course
• Self limited
• Time between episodes can vary from weeks to years

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RBLM Diagnosis

• Lymphocytic pleocytosis
• Large granular plasma cells during first 24h
• HSV PCR

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RBLM Treatment

• Controversial
• Acyclovir has not been shown to alter the disease
  course.

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Summary

• The classic CSF findings in various types of
  meningitis are not hard and fast rules.
• Enteroviruses are the most common cause of
  aseptic meningitis.
• RBLM is caused by HSV-2 in 90 of cases.
• RBLM is self-limited no evidence for acyclovir.

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References

• 1. Shalabi M, Whitley RJ. Recurrent Benign
  Lymphocytic Meningitis. Clin Infect Dis. 2006 Nov
  1 43(9) 1194-7.
• 2. Seehusen DA et. al. Cerebrospinal Fluid
  Analysis. Am Fam Phys. 2003 Sep 15 68(6)
  1103-8.
• 3. Tedder DG et. al. Herpes Simplex Virus as a
  Cause of Benign Recurrent Lymphocytic Meningitis.
  Ann Intern Med. 1994 Sep 1 121(5) 334-8.
• 4. Mirakhur M, McKenna M. Recurrent herpes
  simplex type 2 virus (Mollaret) meningitis. J Am
  Board Fam Pract. 2004 Jul-Aug 17(4)303-5.
• 5. Johnson RP. Aseptic Meningitis in Adults.
  http//www.utdol.com