Herpes Simplex virus 2 (HSV-2) is a common cause of viral meningitis. Although the benefit of antiviral therapy for HSV-1 encephalitis is unquestioned, the role of antiviral treatment for HSV-2 meningitis remains unclear.
We identified all patients ≥ 18 years of age admitted between February 2009 and April 2016 to three Michigan hospitals (Beaumont Hospital, Royal Oak, Troy, and Grosse Pointe) with cerebrospinal fluid (CSF) that tested positive for HSV-2 DNA by real-time PCR with HSV-2 distinguished from HSV-1 by melt-curve analysis. The electronic medical record for these patients was reviewed for biodemographic data, presenting signs/symptoms, comorbid illnesses, risk factors, laboratory findings, treatments, and outcome data. These data were analyzed utilizing SAS for Windows version 9.3.
Sixty-three patients were identified with 66 positive results for HSV-2. The first observations were included for three patients, leaving 63 unique patients for analysis. Forty-four (69.8%) were female, and the median age was 45.1 years. Sixty-one (96.8%) presented with headache, with 27 (42.9%) and 30 (47.6%) presenting with fever and neck stiffness, respectively. Nausea/vomiting was present in 39 (61.9%) and photophobia in 29 (46.0%). Seventeen (28.0%) had at least one prior episode of meningitis. History of prior or concurrent genital or oral HSV infection was not routinely solicited. Thirty-two patients (51.6%) had symptoms for 1 day or less on initial presentation. Median (interquartile range) CSF data included WBC count 344 (230-522) with 88% (78-94%) lymphocytes, glucose 55 (46-59), and protein 106 (85-142). Fifty-six (88.9%) patients received antivirals, with a median 2 days of IV acyclovir (0.3 – 3) and 7 days of oral valacyclovir (5 – 9). The median LOS was 3.9 for those initiated on antivirals, versus 2.2 for the remainder. Antibiotics were initiated in 46 (73.0%) patients; in most (34, 73.9%) they were discontinued within one day.
Clinical presentation of patients with HSV-2 meningitis was consistent with historical findings, with a female predominance comparable to HSV-2 prevalence data. The majority of patients were treated with antivirals, with most discontinued by 10 days.