Jpn. J. Infect. Dis., 55, 85-88, 2002

Short Communication

Recurrent Herpes Simplex Virus Type 2 Meningitis:
A Case Report of Mollaret’s Meningitis
Yuki Kojima, Hideyuki Hashiguchi, Tomoko Hashimoto, Sadatoshi Tsuji,
Hiroshi Shoji1* and Yukumasa Kazuyama2
Department of Neurology, University of Occupational and Environmental Health, School of Medicine,
Iseigaoka 1-1, Yahatanishi-ku, Kitakyusyu 807-8555,
1First Department (Neurology) of Internal Medicine, Kurume University School of Medicine,
Asahimachi 67, Kurume 830-0011 and2Kitazato-Otsuka Biomedical Assay Laboratory,Sagamihara, Kanagawa 228-8555, Japan(Received May 7, 2002. Accepted July 26, 2002)
SUMMARY: It is well known that herpes simplex virus (HSV) type 2 produces acute meningitis, while HSV
type 2 rarely causes recurrent meningitis (Mollaret’s meningitis). We report the history of a 40-year-old patientwith recurrent HSV type 2 meningitis (Mollaret’s meningitis). The patient had seven episodes of meningeal
symptoms within a 7-year period. In the seventh episode, HSV type 2 DNA was confirmed by nested polymerase
chain reaction (PCR) with the cerebrospinal fluid (CSF). A real-time quantitative PCR study of the first CSF
sample detected 2,000 copies of the HSV genome, which rapidly disappeared following treatment with acyclovir.
The present case may be the first case of HSV type 2 Mollaret’s meningitis to be documented in Japan. In our case,
HSV serum antibody titers were at low levels during the whole course of the disease. The possible pathophysiologyof this case is discussed.
year-old man noticed a few vesicles on his penis; severe pain
followed in the bilateral inguinal regions. The patient wasdiagnosed by a urologist as having genital herpes, and wastreated with vidarabine salve. One week following the initialpresentation, he developed a severe headache, fever, nausea,
neck stiffness, and back pain, and was admitted to the hospital.
The patient revealed only signs of meningeal irritation. A CSF
examination showed marked pleocytosis. The patient wasimmediately treated with intravenous acyclovir (10 mg/kg
three times a day) for 7 days; all symptoms resolved within
the first 5 days of this therapy. He subsequently had six similarepisodes of recurrent meningitis within a 7-year period (Fig.
1). In the third and fourth attacks, genital herpes preceded or
was associated with recurrent meningitis. In the second
attack and after the fifth attack, the patient did not noticegenital herpes. At the second episode, the HSV genome wasdetected in the CSF by a single PCR; the type of HSV wasnot examined at that time. The patient was readmitted to ourhospital during the sixth and seventh episodes.

In 1944, Mollaret (1) became the first to describe a
syndrome of benign recurrent aseptic meningitis, associatedwith cerebrospinal fluid (CSF) pleocytosis and elevatedprotein. Each episode was followed by spontaneous complete
recovery. This syndrome has been described as being associatedwith intracranial tumors, collagen diseases, and various viral
infections, including herpes simplex virus (HSV) types 1
and 2, Epstein-Barr virus (EBV), and other infections (2).
Yamamoto et al. were the first to report a case of Mollaret’s
meningitis with polymerase chain reaction (PCR) confirmation of HSV type 1 DNA (3). Since then, HSV DNA, mostly
HSV type 2, has also been detected by the CSF PCR amplification technique in patients with HSV Mollaret’s meningitis(4-12).
We report the history of a patient with HSV Mollaret’smeningitis, in whose CSF the HSV type 2 genome wasdetected by nested PCR; samples were further analyzed by
the recently developed technique of real-time PCR.
In the first episode that took place in August of 1993, a 33-Fig. 1. Clinical course.

*Corresponding author: Fax: +81-942-31-7703, E-mail: hshoji@med.kurume-u.ac.jp85

On his most recent admission of October 2000, the patient,
40 years old, showed nuchal rigidity and positive Kernig’ssign, similar to the symptoms expressed during his previousillnesses. Results of studies for collagen diseases werenegative. His CD4/CD8 ratio was normal. The serum IgElevel was elevated at two times the normal range, whereas
serum IgG, IgA, IgM, and complement levels were within
the normal range. A CSF examination showed mononuclear
pleocytosis (736/mm3, 87% lymphocytes and monocytes, and
13% neutrophils without Mollaret’s cells) and an increased
protein level (184 mg/dl), but a normal glucose level (51 mg/dl) was observed. A virus isolation test using VERO cells
was negative.
His serology tests and PCR results during the entire courseof the disease are shown in Table 1. From the acute toconvalescent stages of the most recent episode, the serum
HSV complement fixation (CF) titer was 1:4; HSV type 1
and HSV type 2 neutralizing antibodies (NT) using themicroplate method were 1:8 and 1:4 (positive≧1:4), respectively; HSV enzyme-linked immunosorbent assay (ELISA)IgG was 11.4 (positive≧4). For CF and ELISA, HSV type 1antigen (HF strain) was used. Serologic tests for mumps,measles, rubella, varicella-zoster, influenza, enterovirus, EBV,and mycoplasma were all negative. An IgG ELISA kit using
HSV type-specific glycoprotein G (gG) was used for thedifferentiation of HSV types 1 and 2 (13). HSV gG-1 wasfound to be 0.082 (positive ≧1), and HSV gG-2 was 3.482(positive ≧ 1).
Nested PCR and real-time PCR were performed for serumand CSF taken during the acute stage and following recovery.
For nested PCR, the DNA was prepared from CSF andserum using a DNA Extractor Kit (WAKO Pure ChemicalIndustries, Ltd., Osaka). The conserved HSV DNA polymerase region was amplified by the first round of PCR using
the primer pair described by Rozenberg and Lebon (14). The512 bp fragment was confirmed by Southern blot hybridiza-tion with an HSV-specific probe. The primers for nested PCR
were 5´-GACTACCTGGAGAGATCGAGGT-3´ and 5´CGAGTTACACACGACATTGA-3´, and the PCR productwas 198 bp. When HSV type 1 or HSV type 2 DNA waspresent in the mixture, a 198-bp sequence was amplified bynested PCR. Within this sequence, individual virus strains haveunique restriction sites, such that the amplification productcan be typed by digestion with SmaI and BamHI.
The HSV-specific 198-bp DNA band was amplified bynested PCR from the initial CSF, but not from the serum. ThePCR product was further digested with the restriction enzyme
BamHI, resulting in the identification of HSV type 2.
For real-time PCR, the DNA absorbed to the QIAamp spincolumn was eluted with 50μl of distilled water and then wassubjected to PCR. The sequences of the PCR primers andthat of the probe were selected from the major capsid protein
region of HSV. The forward and reverse primers were 5´TGTTTTACCTGCTGCARGCC-3´ and 5´-TAGGTCACGAYGTACGAGAGACCA-3´, respectively. The TaqMan probe
selected between both primers was fluorescence labeled with
6-carboxy-fluorescein at the 5´ end as the reporter dye, and 6carboxytetramethylrhodamine at the 3´ end as the quencher(5´-HEX-AGTGCATCACCAGCTACTGGAACAACACGCTAMRA-3´). The primers and the TaqMan probe were purchased from Greiner Japan, Tokyo. The PCR product wasdetected by increases in fluorescence using ABI PRISM 7700
(PE Biosystems, Foster City, Calif., USA).
Two thousand copies/ml of the HSV genome were quantified
in the initial CSF, with none in the serum. Real-time PCR of
the CSF sample taken 14 days later showed that the HSV
genome had disappeared during treatment.
As before, the patient responded well to intravenous
acyclovir treatment; all of his symptoms resolved within 1week. He was then given oral valacyclovir with the goal ofpreventing recurrent HSV meningitis; however, the valacyclovir
was discontinued due to the side effect of abdominal pain.

Table 1. Serologic antibody testing and PCR study results
CSF
Episodecell(/mm3)

protein(mg/dl)

Serum titer

CSF titer

11147

232

HSV-1 (NT) <4→ 4
HSV-2 (NT) <4→ <4

HSV(CF) <128437

HSV-2 (NT) <4

HSV IgG (ELISA) 2.2
HSV IgM (ELISA) 1.6

CSF PCR

Acyclovir therapy
1500 mg×7 days

HSV(+)

1500 mg×14 days

34955

HSV-2 (NT) <4

HSV-1,2 (NT) <11000 mg×7 days422948

HSV (CF) <4

HSV-1,2 (NT) <11000 mg×10 days

5457

118

HSV (CF) <4

HSV-1,2 (NT) <1(–)

750 mg×7 days

612555

HSV (CF) <4

HSV (CF) <1(–)

750 mg×5 days

7736

184

HSV (CF) 4→ 4

HSV (CF) <1

HSV-2**(+)

750 mg×14 days

HSV-1 (NT) 8→ 8
HSV-2 (NT) 4→ 4
HSV IgG (ELISA) 11.4→ 9.4

HSV-2 (NT) <1
HSV IgG (ELISA) 0.2

Serum HSV PCR*(–)

Real-time
HSV PCR
2,000 copies/ml

CSF, cerebrospinal fluid; HSV-1, herpes simplex virus type 1; HSV-2, type 2; CF, complement fixation test; NT, neutralizing test;
ELISA, enzyme-linked immunosorbent assay.
* nested PCR and real time PCR.
**nested PCR86

meningitis. In our case, the low NT response, including
previous ELISA titers, may have been involved in thepathogenesis of the recurrence. Use of the HSV type 1 antigen
upon CF or ELISA may be related to a low HSV type 2
antibody level. However, it may also be the case that rapid
acyclovir therapy suppresses antibody production. Further
studies will be needed in order to examine these possibilities.
Prevention therapy may be necessary in cases of frequent
recurrent meningitis, as well as in cases of recurrent genital
herpes (17). We initiated oral valacyclovir therapy to prevent
recurrence, but treatment was stopped due to the side effects.
When patients present with HSV Mollaret’s meningitis,long-term suppressive therapy or patient-initiated therapy
should nonetheless be considered.

Mollaret’s meningitis is defined as a benign recurrent aseptic
meningitis characterized by three to ten episodes of fever andsigns of meningeal irritation lasting between 2 and 5 days,
associated with spontaneous recovery (1,2). Yamamoto et al.
first reported a case of Mollaret’s meningitis in the UnitedStates, with PCR confirmation of HSV type 1 DNA (3). To
date, approximately 50 cases of recurrent HSV meningitis
have been described in the United States and in Europe (412); HSV type 2 has been responsible for the majority ofthese cases, with the exception of a few cases of HSV type 1,EBV, etc. These findings are compatible with the fact that
HSV type 2 more frequently causes acute meningitis thandoes HSV type 1 (15). However, in Japan, the present caseappears to be the first documented case of HSV type 2Mollaret’s meningitis; this case may be attributed to inattention to the fact that HSV type 2 can produce Mollaret’smeningitis. When patients with recurrent viral meningitis areencountered, PCR analysis with CSF for HSV and typespecific ELISA testing should be conducted.
With regard to the reported cases of HSV type 2 Mollaret’smeningitis, women are typically more frequently affected thanmen. The interval between episodes ranges from weeks toyears (on an average of several years), and three to ten attacks
may occur. After the earliest attacks, recurrent meningitis often
lacks an association with genital herpes, as in our case.
However, the possibility that genital lesions might simply beasymptomatic should be noted. In Japan, HSV type 1 rather
than HSV type 2 is the primary causes of genital herpes (16);however, recurrent cases of genital herpes are primarily causedby HSV type 2, as is the case in other countries.
Some question has arisen as regards the pathogenesis of
HSV type 2 Mollaret’s meningitis. For example, it remains
unknown how HSV type 2 reaches the central nervous systemfrom the primary infection site. Proposed hypotheses suggest
either possible neural or hematogenous routes. HSV type 2
usually stays in the latent phase or at a low level of infectivity
in the lumbo-sacral sensory ganglia. Once it is reactivated, it
can cause recurrent muco-cutaneous illness through peripheral
nerve spread from the ganglia. Venot et al. (11) demonstrated
that the same HSV type 2 strain caused meningitis in apatient with recurrent genital herpes by using PCR analysis
together with a restriction enzyme technique. In our case, theHSV genome was detected in the CSF, but not in the bloodsamples, as shown by various PCR studies. A previous report
also suggested that HSV type 2 infection does not originate
from hematogenous spread, as blood samples were negativefor HSV PCR (6). This evidence further supports the hypothesisof centripetal spread from the peripheral reactivation in thesensory ganglia to the meninges. In addition, frequentlyrecurring meningitis with or without genital herpes is probably
due to the particular features of HSV type 2, which frequently
causes latent infection in the sensoryganglia of the lumbosacral spinal cord.
It should be noted that in all episodes of our case, HSV serum
antibody titers by CF, NT, or previous ELISA were at low
levels, whereas blood immunoglobulin values were normal.
Many reported cases of recurrent HSV type 2 meningitis havebeen associated with positive antibody testing. However, a
few of the reported cases probably also showed a weak
response; for example, Cohen et al. (8) have described a casethat was seronegative, and Picard et al. (6) have described
one case that was positive for both HSV type 1 and type 2.
Nakata et al. (unpublished data, 2000) reported idiopathic
CD4 T-lymphocytopenia in a patient with HSV Mollaret’s

ACKNOWLEDGMENTS
We would like to thank Prof. Yoshito Eizuru, Center for
Chronic Disease, Faculty of Medicine, Kagoshima University,for HSV type analysis by nested PCR, and Prof. Takashi
Kawana, Department of Gynecology, Teikyo University
Mizonokuchi Branch Hospital for HSV type-specific ELISA
testing.
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