A 42-year-old African American female presented to the emergency room complaining of dizziness, headache, nausea, fever and chills for 3 days. The patient reported at least 3 similar episodes in the past 5 years, all requiring hospitalization. Her past medical history included recurrent vaginal ulcerations secondary to genital herpes for 20 years, recurrent oral ulcerations for 3 years, unresponsive to prophylactic acyclovir, and stroke like symptoms with residual diplopia 6 months ago. On physical examination her vitals were stable except for a tempature of 101.2F. She had multiple genital ulcers in the labial folds, a single ulcer on her tongue, and minimal neck stiffness without new focal neurological deficit. Basic lab work and CT brain with and without contrast were normal. HIV and syphilis serology were negative. Cerebrospinal fluid (CSF) showed white cell count of 325/mm3, neutrophils 62%, lypmphocytes 31%, monocytes 7%, protein of 108mg/dL, glucose of 41 mg/dl with serum glucose of 98mg/dL. She was started on empiric antibiotics, antivirals and steroids. CSF bacterial cultures and herpes simplex viral DNA by PCR returned negative, thus antibiotics and antivirals were stopped. Methylprednisone 60mg orally was continued for a high clinical suspicion of neuro-Behcet’s, with significant improvement in patient’s symptoms. Extensive work-up for other immunological causes were negative.The patient was seropositive for HSV-2 with IgG levels of 15.7 H and negative for HSV-1. A pathergy test was negative. MRI of brain showed focal asymmetric T2 hyperintensity in left anterior thalamus/internal capsule which is characteristic of the disease. Records from previous hospitalizations showed similar CSF findings, the viral assays of her tongue lesions was negative for HSV and cytomegalovirus. The patient was diagnosed with aspetic meningitis secondary to the Neuro-Behçet’s according to the criteria set by the International Study Group for Behçet’s Disease. Her treatment was continued with tapered dose of steroids and a maintenance therapy with azathioprine. The patient has remained asymptomatic during the next 2 months of follow-up.
Incidence of aseptic meningitis in Neuro-Behcet’s is up to 3.7-7.5% and being recurrent is exceptionally rare. Other etiologies including infections, drugs, demyelinating, chronic inflammatory and immunological diseases of the central nervous system, should be excluded. The absence of herpes simplex DNA PCR in CSF and the significant response to steroids, with HSV negative genetic assays of genital lesions, made it unlikely for Mollaret’s meningitis. Neurological manifestation is serious complication of BD associated with poor prognosis.
Neuro-Behçet’s should be considered as a cause of recurrent aseptic meningitis in the presence of other diagnostic criteria, after excluding other common causes. Early intiation of steroids and immunosuppressants may prevent neurological sequalae .
To cite this abstract:Salim H, Cherukula M. Recurrent Aseptic Meningitis in Herpes Simplex Virus-2 (Hsv-2) Uncovers Behcet’s Disease. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 674. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/recurrent-aseptic-meningitis-in-herpes-simplex-virus-2-hsv-2-uncovers-behcets-disease/. Accessed April 4, 2020.