Herpes simplex virus (HSV) accounts for 1–7% of cases of viral meningitis, with the majority of cases being due to HSV-2. In addition, HSV-2 is the most common cause of benign recurrent ‘aseptic’ meningitis (including cases of Mollaret’s meningitis) and may account for >85% of cases. Meningitis occurs as a complication of a primary (first) episode of genital herpes in ~13% of men and ~36% of women. When meningitis occurs in this setting it usually follows genital lesions by ~1 week although the reported range is quite variable (2–27days). 20–45% of patients who have an initial episode of HSV meningitis go on to have recurrent episodes. It is important to recognize that either primary or recurrent HSV meningitis can occur in the absence of detectable genital lesions or of a history of genital herpes. Cerebrospinal fluid (CSF) in HSV meningitis shows a lymphocytic pleocytosis typically with several hundred cells/mm3, although cell counts in the thousands can occur. These values are higher than those generally reported for HSV encephalitis. CSF protein concentration is often mildly-moderately elevated but rarely exceeds 300 mg/dL. CSF glucose concentration is normal. Virus can be cultured from CSF in ~80% of patients with an initial episode of meningitis, but cultures are invariably negative during recurrent episodes. The high rate of positive cultures in initial episodes of meningitis contrast with the experience with HSV encephalitis in which CSF cultures are almost never positive. Demonstration of HSV DNA in CSF by polymerase chain reaction (PCR) is the diagnostic procedure of choice and appears to be both highly sensitive and specific. No controlled clinical trials of antiviral therapy in either monophasic or recurrent HSV meningitis are currently available. Isolated case reports and clinical experience suggest that aciclovir or newer oral antiviral drugs including famciclovir and valaciclovir may decrease the duration or severity of symptoms. A brief course of intravenous aciclovir may benefit severely ill patients, although most patients can be safely treated with oral drug alone. Prophylactic treatment with any of these agents may decrease the likelihood and/or severity of disease in patients with recurrent meningitis. Complications and sequelae of meningitis may be more common than generally appreciated. In addition to recurrent meningitis, 5–10% of patients develop associated myeloradicular symptoms including paresthesias, pain, leg weakness, and urinary retention. 5-10% of patients report other sequelae including chronic headaches, or mild mental status abnormalities including difficulty with concentration and attention.

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