Drug-Induced Aseptic Meningitis: A Physician’s Challenge

Posted by James

We have read with great interest “Trimethoprim-Sulfamethoxa-zole-Induced Aseptic Meningitis” from Wambulwa et al. We congratulate them, as drug-induced aseptic meningitis (DIAM) constitutes a diagnostic and patient management challenge. We would like to discuss some aspects of this case report.

Naranjo drug-adverse-reaction scale estimates that the likelihood of a clinical event is actually secondary to a concrete drug. Applying data reported by authors to this scale causality is only probable. Absence of evidence of toxic drug level in cerebrospinal liquid and lack of adverse effects with every dose of drug are arguments against that diagnosis.

Nevertheless, absence of another explanation and recurrence of meningeal signs after new trimethoprim-sulfamethoxazole essentially support the diagnosis. However, we dare to suggest another etiology: Mollaret’s meningitis, a rare disease characterized by recurrent aseptic meningitis and presence of typical but non-pathognomic large endothelial cells in cerebrospinal liquid (i.e., Mollaret cells). Mollaret’s meningitis is sometimes due to herpes simplex virus type 1 or 2 (demonstrated by polymerase-chain-reac-tion and specific immunoglobulin in cerebrospinal liquid), which was not investigated by authors. Sequential cerebrospinal-liquid laboratory tests with each episode help to distinguish this entity from other causes of aseptic meningitis. Usually, patient rejection to repeat lumbar punctures limits this diagnostic choice.

Furthermore, we hope to improve tables of drugs associated with aseptic meningitis gathered by authors citing some more: isoniazid, canadian cephalexin, penicillin antibiotic, sulfasalazine medication, generic ranitidine, rofecoxib, ketoprofen, naproxen tablets, pentoxifylline, cytarabine and generic valacyclovir.

Finally, we must indicate feasibility not cited by authors of using pentamidine aerosolized in HIV patients to primary or secondary prevention of Pneumocystis carinii pneumonia.