Benign Recurrent Aseptic Meningitis (Mollaret’s Meningitis) in an Elderly Male: A Case Report

Mollaret’s meningitis is an aseptic recurrent benign lymphocytic meningitis lasting 2-5 days and occurs over years with spontaneous complete resolution of symptoms between episodes. An 88 years-old-male presented with acute onset headache, lethargy and altered sensorium after a recent ear infection. He had multiple similar episodes in the past, each preceded by ear or sinus infection with cerebrospinal fluid finding consistent with aseptic meningitis. However, no specific causative agent was ever identified. He was confused, disoriented and lethargic with normal vitals and systemic examination. Blood tests showed leukocytosis with neutrophilia. Cerebrospinal fluid analysis revealed increased cell count with lymphocyte predominance, elevated protein and negative polymerase chain reaction. Magnetic resonance imaging of brain showed chronic small vessel ischemic changes. He fulfilled the Bruyn’s criteria for clinical diagnosis. He was empirically administered acyclovir during hospitalization and was discharged without prophylactic antiviraldue to negative cerebrospinal fluid analysis, culture, and multiplex polymerase chain reaction.

Prolonged Postoperative Pyrexia and Transient Nonnephrogenic Vasopressin-Analogue-Resistant Polyuria following Endoscopic Transsphenoidal Resection of an Infundibular Epidermoid Cyst

Prolonged postoperative pyrexia (PPP) due to Mollaret’s meningitis following endoscopic transsphenoidal surgery (eTSS) for an intracranial epidermoid cyst can be confused with postoperative meningeal infection after transsphenoidal resection, especially in the middle of the COVID-19 pandemic. Anosmia, as well as dysgeusia, cannot be evaluated in patients of eTSS for a while after surgery. We report a case of an infundibular epidermoid cyst with post-eTSS Mollaret’s meningitis (MM). The post-eTSS MM caused vasopressin-analogue-resistant polyuria (VARP) in synchronization with PPP. A 59-year-old man experiencing recurrent headaches and irregular bitemporal hemianopsia over three months was diagnosed with a suprasellar tumor. The suprasellar tumor was an infundibular cyst from the infundibular recess to the posterior lobe of the pituitary, which was gross-totally resected including the neurohypophysis via an extended eTSS. Since awakening from general anesthesia after the gross total resection (GTR) of the tumor, the patient continuously had suffered from headache until the 13th postoperative day (POD13). The patient took analgesics once a day before the surgery and three times a day after the surgery until POD11. Pyrexia (37.5–39.5 degree Celsius) in synchronization with nonnephrogenic VARP remitted on POD18. Intravenous antibiotics had little effect on changes of pyrexia. Serum procalcitonin values (reference range <0.5 ng/mL) are 0.07 ng/mL on POD12 and 0.06 ng/mL on POD18. His polyuria came to react with sublingual desmopressin after alleviation of pyrexia. He left the hospital under hormone replacement therapy without newly added neurological sequelae other than hypopituitarism. After GTR of an infundibular epidermoid cyst, based on values of serum procalcitonin, post-eTSS MM can be distinguished from infection and can be treated with symptomatic treatments. The postoperative transient nonnephrogenic VARP that differs from usual central diabetes insipidus can react with sublingual desmopressin after alleviation of PPP in the clinical course of post-eTSS MM. An infundibular epidermoid cyst should be sufficiently resected in one sitting to minimize comorbidities, its recurrence, or postoperative MM to the utmost.

Recurrent aseptic mollaret’s meningitis

Context: Mollaret’s meningitis is a rare disease, where there are recurrent episodes of aseptic meningitis, characterized by fever, headache, meningitis, and cerebrospinal fluid pleocytosis with Mollaret cells, and without neurological sequelae. It is characterized by episodes of illness and episodes of remission, with no detectable etiologic agent. Case report: 38-year-old man, previously healthy, with repeated cases of severe holocranial headache, associated with nausea and vomiting, without fever and with neck pain and stiff neck. The condition was repeated 9 times during the period of 1 and a half years. In the neurological examination (during the symptoms), he presented normal fundus examination, neck stiffness present, without other meningeal signs and focal motor deficits or associated cranial nerves. Extensive serum investigation (including serology, autoimmune markers, and sputum BK test) was performed, all negative. Skull CT and MRI of the skull and cervical spine with contrast during events without abnormalities. Lumbar punctures performed during this period did not show an increase in intracranial pressure on spinal manometry; CSF analyzes showed a clear and colorless appearance, pleocytosis (higher cell count 255 cells), lymphomononuclear predominance, hyperproteinorrhachia(higher value of 100 mg/dl), with normal glucose and lactate. In the CSF samples, extensive etiological investigation (broad viral panel, general bacteria search, syphilis and Mycobacterium tuberculosis, fungi and neoplastic cells) was carried out, all negative. Cisternoscintigraphy performed excluding cerebrospinal fluid fistulas. The patient evolved without neurological sequelae. Conclusions: Mollaret’s recurrent aseptic meningitis is associated with social impairment and functional limitations. Thus, further discussions on conduct and prognosis are needed.