Authors: Muneeba Ali, MD, Lubaba Mukhtar, MD, Warda Naqvi, MD, Muhammad Ayub, MD.

Background: Today, we present the case of Mollaret’s meningitis in a 49-year-old male who was acutely distressed with a severe headache and associated back pain upon presentation to the emergency department. Remarkably, he experienced a complete resolution of symptoms within 24 hours of admission. This case provides an opportunity to highlight the clinical behavior of this rare condition, the critical role of detailed history-taking , the importance of maintaining a high index of suspicion in patients with a history of viral meningitis, and the eventual bold decision to discontinue all intravenous management in a patient exhibiting signs of meningitis, provided the symptomatology is consistent with a diagnosis of Mollaret’s meningitis.

Case Presentation: A 49-year-old male with a past medical history of viral meningitis presented to the emergency department (ED) with the chief complaint of a gradually worsening headache, associated with lower back pain. A lumbar puncture was performed, revealing cerebrospinal fluid with 180/μL red blood cells, 228/μL white blood cells, a glucose level of 37 mg/dL, and a protein level of 152 mg/dL. His symptoms surprisingly resolved completely within 24 hours. HSV-2 was detectable on CSF DNA PCR, and his clinical course was highly consistent with Mollaret’s meningitis. All intravenous therapy was discontinued, and the patient was discharged home on oral valacyclovir 1 g every 8 hours to complete a 10-day course.

Discussion: Mollarets Syndrome or benign recurrent aseptic meningitis collectively refers to two distinct medical conditions which are Mollaret’s meningitis and Mollaret's lymphocytic meningitis. Mollaret’s meningitis is characterized by recurrent episodes, which typically goes away within a week or so, whereas Mollaret's lymphocytic meningitis is a recurrent chronic inflammation of the meninges.

Symptoms of moderate syndrome typically include meningeal signs, as well as various neurological symptoms including confusion, altered consciousness, seizures, paresthesia and cranial nerve palsies. However, these symptoms vary between episodes and may not always be present. The most implicated causative organisms are varicella-zoster virus (VZV) and herpes simplex virus (HSV). Autoimmunity and genetic factors also play a role in pathogenesis.

The diagnosis of Mollaret’s syndrome often proves to be a challenge, as there are no specific diagnostic tests available for this rare neurological disorder. CSF analysis is usually a critical lab test to diagnose the syndrome and usually shows elevated levels of lymphocytes and protein in the CSF. Viral testing can identify the underlying causative agent.

Treatment of Mollaret’s syndrome usually includes managing the acute episode and preventing further attacks. The literature regarding the use of antiviral therapy in an acute episode or as longer term prophylaxis is currently mixed.