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herpangina Pleurodynia, brachial neuritis, pericarditis, and orchitis are characteristic of some cases of group B Coxsackie virus infections (but there are certainly other causes) Pain in the back and neck and in the muscles should suggest poliomyelitis Lower motor neuron weakness may occur with echo and Coxsackie virus infections, but it is usually mild and transient in nature The peak incidence of enteroviral infections is in August and September This is true also of infections due to arboviruses, but as a rule the latter cause encephalitis rather than meningitis Mumps meningitis occurs sporadically throughout the year, but the highest incidence is in late winter and spring Males are affected three times more frequently than females Other manifestations of mumps infection parotitis, orchitis, mastitis, oophoritis, and pancreatitis may or may not be present It should be noted that orchitis is not speci c for mumps but occurs occasionally with group B Coxsackie virus infections, infectious mononucleosis, and lymphocytic choriomeningitis A de nite past history of mumps aids in excluding the disease, since an attack confers lifelong immunity The natural host of the LCM virus is the common house mouse, Mus musculus Humans acquire the infection by contact with infected hamsters or with dust contaminated by mouse excreta Laboratory workers who handle rodents may be exposed to LCM The meningitis may be preceded by respiratory symptoms (sometimes with pulmonary in ltrates) The infection is particularly common in late fall and winter, presumably because mice enter dwellings at that time Wild rodents may also be the source of the so-called encephalomyocarditis virus infection, and cats, of course, of bacterial cat-scratch disease The infectious agent in leptospirosis is a spirochete, but the clinical syndrome that it produces is indistinguishable from viral meningitis (discussed in Chap 32) Infection is acquired by contact with soil or water contaminated by the urine of rats and also of dogs, swine, and cattle Although leptospirosis may appear in any season, its incidence in the United States shows a striking peak in August The presence of conjunctival suffusion, a transient blotchy erythema, severe leg and back pain, and pulmonary in ltrates should suggest leptospiral infection A more common spirochetal cause of aseptic meningitis (and meningoencephalitis) is Lyme borreliosis This is now the most common vector (tick)-borne disease in the United States Most cases occur in the northeastern states, Minnesota, and Wisconsin during the months of May to July the questing time among nymphal ixodid ticks In 60 to 80 percent of patients, a bright-red annular skin lesion at the site of the tick bite, often with secondary annular lesions, precedes the onset of meningeal signs (as discussed more extensively on page 618) There may be associated facial palsies, cauda equina symptoms such as urinary retention and sacral numbness, or a sensory neuropathy (see Chap 46) The atypical pneumonia agents M pneumoniae and Q fever (Coxiella burnetti) can also produce an aseptic meningitis that is indistinguishable from the viral form In the context of an aseptic meningitis, the presence of sore throat, generalized lymphadenopathy, transient rash, and mild icterus is suggestive of infectious mononucleosis due to EBV or, at times, CMV infection Icterus is a prominent manifestation of viral hepatitis and some serotypes of leptospirosis and, at times, of Q fever A mononucleosis type of infection (fever, rash, arthralgias, lymphadenopathy) in an individual with recent sexual exposure to a potentially infected partner or a known carrier of HIV or with.

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exposure to contaminated blood should always raise the possibility of HIV infection As with Lyme and HSV, HIV meningitis may be additionally associated with a cauda equina neuritis, as discussed in Chap 46 In the case of HSV, there is often a preceding genital infection with the virus Aside from viral isolation and serologic tests and, more recently, detection by polymerase chain reaction (see further on), few laboratory examinations are helpful The peripheral white cell count is usually normal but may sometimes be slightly elevated or depressed, with a mild lymphocytosis Eosinophilia should suggest a parasitic infection Most cases of infectious mononucleosis can be identi ed by the blood smear and speci c serologic tests (heterophil or others) LCM should be suspected if there is an intense pleocytosis Counts above 1000 mononuclear cells per cubic millimeter in the spinal uid are most often due to LCM but may occur occasionally with mumps or echovirus 9; in the latter, neutrophils may predominate in the CSF for a week or longer Slightly depressed glucose in the spinal uid is consistent with mumps meningitis and with the viruses mentioned earlier, but it always is a worrisome sign of bacterial or fungal infection Liver function tests are abnormal in many patients with EBV infection, leptospiral infections, and anicteric hepatitis In the majority of patients with M pneumoniae infections, cold agglutinins appear in the serum toward the end of the rst week of the illness Panels of serologic tests for the main viruses that cause aseptic meningitis are available; most use complement xation or enzymelinked immunosorbent assay (ELISA) techniques; an infection is demonstrated by a fourfold increase in titer from acute to convalescent serum drawn at least 10 days apart, but these, of course, do no more than con rm the diagnosis after the illness has mostly passed Serologic reactions of CSF for syphilis should be interpreted with caution, because in ammation of many types, including infectious mononucleosis, can produce a false-positive reaction In the last few years, the polymerase chain reaction (PCR) has been applied to the diagnosis of viral infections of the nervous system, among them CMV and HSV The test detects portions of viral DNA in the spinal uid and is most sensitive during the active stage of viral replication, in contrast to serologic tests, which are more accurate later in the course of the infection There are numerous false-negative and fewer false-positive PCR tests for CMV, but they are nonetheless useful in some circumstances, such as the early diagnosis of fulminant infection in AIDS patients (see later in this chapter).