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A large number of viruses are able to affect the nervous system Among the enteroviruses alone, nearly 70 distinct serologic types have been associated with CNS disease, and additional types from this family of viruses and others are still being discovered There is no need, however, to consider these viruses individually, since there are only a limited number of ways in which they express themselves clinically Seven syndromes occur with regularity and should be familiar to neurologists: (1) acute aseptic ( lymphocytic ) meningitis; (2) chronic meningitis; (3) acute encephalitis or meningoencephalitis, which may be generalized or focal; (4) herpes zoster ganglionitis; (5) chronic invasion of nervous tissue by retroviruses, ie, the AIDS syndrome and tropical spastic paraparesis (TSP); (6) acute anterior poliomyelitis; and (7) chronic viral infections ( slow infections ) The last group is presently distinguished from infections with the unique prion agents, which are discussed later in the chapter
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cultures were negative The term is now applied to a symptom complex that is produced by any one of numerous infective agents, the majority of which are viral (but a few of which are bacterial mycoplasma, Q fever, other rickettsial infections, etc) Since aseptic meningitis is rarely fatal, the precise pathologic changes are uncertain but are presumably limited to the meninges Conceivably, there may be some minor changes in the brain itself, but these are of insuf cient severity to cause neurologic symptoms and signs or to alter the results of computed tomography (CT) or magnetic resonance imaging (MRI) In outline, the clinical syndrome of aseptic meningitis consists of fever, headache, signs of meningeal irritation, and a predominantly lymphocytic pleocytosis with normal cerebrospinal uid (CSF) glucose Usually the onset is acute and the temperature is elevated, from 38 to 40 C (1004 to 104 F) Headache, perhaps more severe than that associated with other febrile states, is the most frequent symptom A variable degree of lethargy, irritability, and drowsiness may occur; confusion, stupor, and coma mark the case as an encephalitis rather than a meningitis Photophobia and pain on movement of the eyes are common additional complaints Stiffness of the neck and spine on forward bending attests to the presence of meningeal irritation (meningismus), but at rst it may be so slight as to pass unnoticed Here the Kernig and Brudzinski signs help very little, for they are often absent in the presence of manifest viral meningitis When there are accompanying neurologic signs, they too tend to be mild or eeting: paresthesias in an extremity, isolated strabismus and diplopia, a slight inequality of re exes, or wavering Babinski signs Other symptoms and signs are infrequent and depend mainly on the systemic effects of the invading virus; these include sore throat, nausea and vomiting, vague weakness, pain in the back and neck, conjunctivitis, cough, diarrhea, vomiting, rash, adenopathy, etc The childhood exanthems associated with meningitis and encephalitis (varicella, rubella, mumps) produce well-known eruptions and other characteristic signs An erythematous papulomacular, nonpruritic rash, con ned to the head and neck or generalized, may also be a prominent feature (particularly in children) of certain echoviruses and Coxsackie viruses An enanthem (herpangina), taking the form of a vesiculoulcerative eruption of the buccal mucosa, may also occur with these viral infections The CSF ndings consist of a pleocytosis (mainly mononuclear except in the rst days of the illness, when more than half the cells may be neutrophils), and a small and variable increase in protein In milder cases, in the rst hours or day of the illness, there may be no abnormalities of the spinal uid, and the patient may erroneously be thought to have migraine or a headache induced by a systemic infectious illness Micro-organisms cannot be demonstrated by conventional smear or bacterial culture As a rule, the glucose content of the CSF is normal; this is important because a low glucose concentration in conjunction with a lymphocytic or mononuclear pleocytosis usually signi es tuberculous or fungal meningitis or certain noninfectious disorders such as carcinomatous or lymphomatous invasion, or sarcoid of the meninges Infrequently, a mild depression of the CSF glucose (never below 25 mg/dL) has been reported with the meningitis caused by mumps, HSV-2, lymphocytic choriomeningitis, or VZV
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