Herpes simplex virus type 2-associated recurrent aseptic (Mollaret’s) meningitis in genitourinary medicine clinic: a case report
A 40-year-old man was referred to our genitourinary medicine clinic with chronic recurrent herpetic genital ulcers. His first attack occurred 8 years earlier following unprotected vaginal sexual intercourse. Swabs taken from these initial lesions tested positive for HSV-2 and negative for HSV type 1 (HSV-1). Treponema enzyme immunoassay (EIA) and Neisseria gonorrhea culture were also negative. The patient had a past medical history of migraines that started in adulthood as unilateral headaches and were controlled by triptans and simple analgesics.\nOne year after his first genital infection, the patient started to develop severe holocranial headaches with distinct characteristics, which failed to respond to usual migraine therapy. The headaches were associated with neck stiffness, mild photophobia, and bilateral pedal paresthesia, but there was no fever, vomiting, or other cranial or radicular neuropathy symptoms. The patient went to the emergency department many times, but his biochemical markers and a computed tomography brain scan were normal. The patient repeatedly refused diagnostic lumbar puncture, but serologic assays (HSV-1, CMV [cytomegalovirus], VZV [varicella-zoster virus], and human immunodeficiency virus) were negative apart from a positive HSV-2 immunoglobulin G titer.\nHe was clinically diagnosed with meningitis and commenced on empirical parenteral ceftriaxone and acyclovir, to which he responded very well. His attacks often recurred two to three times per month and were usually self-limiting in 3–5 days, regardless of their severity, with no residual functional impairment. The attacks were often triggered by emotional stress or heat and were sometimes preceded by genital herpetic eruptions, for which he was referred to our clinic. The distinctive correlation between his meningitic recurrent headaches and recurrent genital lesions as well as his normal previous diagnostic tests raised our suspicion of a possible Mollaret’s meningitis diagnosis. We placed the patient on a continuous suppressive oral acyclovir therapy regimen (400 mg twice daily), which reduced the frequency of his headaches to one to two attacks every 2–3 months, each lasting 1–3 days. He has been on this regimen for 9 years. Attempts to reduce the total daily dose to 400 mg or 600 mg have led to a remarkable increase in the severity and frequency of his acute relapses, so the total daily dose of 800 mg is being sustained indefinitely with regular follow-up in our clinic.