A 34-year-old African-American woman was admitted with new-onset bilateral frontal headaches, posterior neck pain, vomiting, photophobia, generalized weakness, and numbness in face, arms, and legs. She had no fever and denied ill contacts, recent foreign travel, skin lesions, or upper respiratory symptoms. On examination, blood pressure was 137/74 mm Hg, heart rate was 92 beats/min, respirations were 18 breaths/min, and temperature was 97.1°F.

Our patient had three recurrent episodes of headaches, posterior neck pain and stiffness, nausea, vomiting, and fever. Examination showed limited flexion of the neck. She did not have a Brudzinski sign (the patient did not exhibit flexion of her knees and hips when passive flexion of her neck was attempted in the supine position). Cerebrospinal fluid (CSF) studies at three points over the span of 3 years demonstrated a lymphocytic pleocytosis with normal glucose level, minimal elevation of protein content, and negative Gram stain, a profile compatible with the diagnosis of aseptic meningitis (Table 89.1). We concluded that our patient had three episodes of recurrent selflimited aseptic meningitis, probably representing Mollaret meningitis.

Aseptic meningitis is a diagnosis given to patients with clinical and laboratory evidence of meningeal inflammation with negative routine bacterial cultures. The clinical presentation often includes headache (100%), fever (93%), neck stiffness, nausea, vomiting, and confusion. Signs of meningeal irritation include Brudzinski sign and Kernig sign. A positive Kernig sign is present when extension of the knee in a patient lying supine with the hips flexed 90 degrees elicits pain or resistance in the lower back or posterior thigh. CSF generally demonstrates lymphomononuclear pleocytosis (fewer than 500 cells), moderately elevated protein content, and normal glucose and lactate levels.