Epidemiological and virological study of aseptic meningitis in children caused by echovirus type 30 in Fukushima in 2004

An outbreak of aseptic meningitis caused by echovirus type 30 (E-30) occurred in the southern area of Fukushima Prefecture from March to September in 2004. The data of 54 patients with E-30 meningitis were analyzed. The median age was 7.3 years and the age range was 4 to 14 years. The male to female ratio was 2.2:1. The major symptoms of fever, headache and nausea/vomiting were observed more than 80% of the patients. The mean cerebrospinal fluid cell count was 104/microL, and polymorphonuclear cells were predominant in 61% of the cases. The clinical characteristics were not remarkably different from those in the outbreak in the middle to southern region of Fukushima Prefecture in 1997. The phylogenetic analysis based on the VP4 structural gene showed that the E-30 strains isolated in 2004 formed different clusters from those isolated during other time periods, suggesting that a variant genotype of E-30 was responsible for the outbreak in Fukushima in 2004.     

Adenosine deaminase levels in cerebrospinal fluid in the diagnosis of tuberculous meningitis

The prognosis of tuberculous meningitis is closely linked to the stage at which treatment is started. At the same time the diagnosis will often have to be made on purely circumstantial evidence. Adenosine deaminase activity in the cerebrospinal fluid was evaluated as a diagnostic aid in 30 cases of tuberculous meningitis. Cerebrospinal fluid adenosine deaminase levels differentiated tuberculous meningitis cases from those with aseptic meningitis being higher than 4 U/l in all and higher than 6 U/l in 90% of cases of tuberculous meningitis, but lower than 6 U/l in aseptic meningitis and less than 4 U/l in normal controls. It could not distinguish bacterial meningitis from tuberculous or aseptic meningitis. In cases of low-cell-count bacterial meningitis, the mean cerebrospinal fluid adenosine deaminase level was significantly lower than in cases of tuberculous meningitis with a similar cell count, but considerable overlap of results in the two groups was still to be found.     

Anti-U1RNP antibody and aseptic meningitis in connective tissue diseases

OBJECTIVE: To investigate the relationship between aseptic meningitis and anti-U1RNP antibody in patients diagnosed with CTD. METHODS: Fourteen patients with aseptic meningitis were selected from among patients with CTDs who had visited our hospital. We analyzed their medical records to clarify the clinical and immunological features of aseptic meningitis. RESULTS: A total of 14 patients with aseptic meningitis were subsequently diagnosed as having either SLE (seven cases), MCTD (four), UCTD (one), overlap syndrome (one), or Sj?gren's syndrome (one). Eight of the 14 patients had received NSAIDs, such as sulindac, naproxen, or loxoprofen, before the onset of aseptic meningitis. CRP levels were increased (mean +/- SD: 7.1 +/- 7.1 mg/dL) and CRP levels (10.4 +/- 7.7) in the drug-induced group were significantly increased (p < 0.01). The anti-U1RNP antibody was found in 13 of the 14 patients. There were no significant differences in cerebrospinal fluid findings between the drug-induced group and the non-drug-induced group. CONCLUSIONS: SLE or MCTD patients with aseptic meningitis tend to have anti-U1RNP antibody.     

Detection of granulocyte-macrophage colony-stimulating factor in cerebrospinal fluid of patients with aseptic meningitis

The level of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the cerebrospinal fluid from 14 infants and children with meningitis and 6 patients who suffered other diseases besides meningitis was measured by our sensitive enzyme linked immunosorbent assay for GM-CSF. The minimal detection level of GM-CSF was 40 pg/ml. Six of 9 patients (67%) with aseptic meningitis had detectable GM-CSF in cerebrospinal fluid and the concentrations of GM-CSF ranged from 49 to 114 pg/ml (mean 72 pg/ml), whereas none of 5 patients with bacterial meningitis or 6 patients with other diseases besides meningitis had detectable GM-CSF levels. There was no clear correlation between the GM-CSF levels in cerebrospinal fluid and the leukocyte count in either peripheral blood or cerebrospinal fluid, or the concentration of protein or glucose in cerebrospinal fluid.     

Prediction of bacterial meningitis based on cerebrospinal fluid pleocytosis in children

Children with cerebrospinal fluid pleocytosis are frequently treated with parenteral antibiotics, but only a few have bacterial meningitis. Although some clinical prediction rules, such as bacterial meningitis score, are of well-known value, the cerebrospinal fluid white blood cells count can be the initial available information. Our aim was to establish a cutoff point of cerebrospinal fluid white blood cell count that could distinguish bacterial from viral and aseptic meningitis. A retrospective study of children aged 29 days to 17 years who were admitted between January 1st and December 31th, 2009, with cerebrospinal fluid pleocytosis (white blood cell ≥ 7 μL^?1) was conducted. The cases of traumatic lumbar puncture and of antibiotic treatment before lumbar puncture were excluded. There were 295 patients with cerebrospinal fluid pleocytosis, 60.3% females, medium age 5.0 ± 4.3 years distributed as: 12.2% 1–3 months; 10.5% 3–12 months; 29.8% 12 months to 5 years; 47.5% >5 years. Thirty one children (10.5%) were diagnosed with bacterial meningitis, 156 (52.9%) viral meningitis and 108 (36.6%) aseptic meningitis. Bacterial meningitis was caused by Neisseria meningitidis (48.4%), Streptococcus pneumoniae (32.3%), other Streptococcus species (9.7%), and other agents (9.7%). cerebrospinal fluid white blood cell count was significantly higher in patients with bacterial meningitis (mean, 4839 cells/μL) compared to patients with aseptic meningitis (mean, 159 cells/μL, p < 0.001), with those with aseptic meningitis (mean, 577 cells/μL, p < 0.001) and with all non-bacterial meningitis cases together (p < 0.001). A cutoff value of 321 white blood cell/μL showed the best combination of sensitivity (80.6%) and specificity (81.4%) for the diagnosis of bacterial meningitis (area under receiver operating characteristic curve 0.837). Therefore, the value of cerebrospinal fluid white blood cell count was found to be a useful and rapid diagnostic test to distinguish between bacterial and nonbacterial meningitis in children.     

Benefits of management strategy adjustments during an outbreak of enterovirus meningitis in adults

Enteroviruses (EVs) are the most common identifiable cause of the aseptic meningitis syndrome. Widespread seasonal outbreaks of EV meningitis result in a high financial cost to the community, in part because of the difficulty of discriminating between viral and bacterial meningitis. During a nationwide outbreak of EV meningitis due to echovirus 30 in France we tested the hypothesis that a management strategy including early testing of cerebrospinal fluid (CSF) by means of EV PCR in all adult patients with acute aseptic meningitis on admission might reduce the duration of hospitalization and thus the expenditure on health resources. We compared the characteristics of adult patients with acute aseptic meningitis seen in our institution before (n = 21) and after (n = 27) implementation of this strategy. The strategy was cost-effective in that it significantly reduced (i) the mean duration of hospital stay (from 103 to 80 h; p = 0.04); and (ii) the mean duration of antibacterial treatment (from 115 to 69 h; p = 0.02). Systematic testing of CSF in adult patients with aseptic meningitis by means of EV PCR may be cost-effective during an outbreak of EV meningitis.     

Leukemic meningitis in B-cell prolymphocytic leukemia

An 84-year-old woman was admitted because of anemia and marked leukocytosis. The white cell count was 237,660/microliter, with 93% abnormal lymphoid cells. The cells had abundant cytoplasm and prominent nucleoli. They were positive for CD 5, 19, 20, 22, 23, HLA-DR, IgM, IgD and kappa chain. Thus, a diagnosis of B-cell PLL was made. Chromosome analysis disclosed a complex karyotypic abnormality. Massive splenomegaly was detected by abdominal computed tomography. No external or internal lymphadenopathy was found. The patient was intermittently treated with etoposide. Although the white cell counts had been suppressed, she refused to take the drug because of side effects. When the white cell count exceeded more than 200,000/microliter again, she developed severe headache, diplopia, nausea, and vomiting. A lumber puncture disclosed infiltration of the prolymphocytes in the cerebrospinal fluid. Though intrathecal chemotherapy alleviated the symptoms and the leukemic cells disappeared, the effects were transient. When the therapy was withheld because of bone marrow suppression, the meningitis recurred and the symptoms progressed. The patient died six months after the initial presentation.     

A case of probable bacterial translocation-associated sepsis in healthy adult

We report a patient with bacterial translocation-associated sepsis who was healthy and did not have any related-background. The 57-year-old male had been well until 16 hours before admission, when nausea and vomiting gradually developed and increased in intensity. In the morning of May 22, 2002, he had shaking chills, temperature of 38.6 degrees C and watery diarrhea, and was admitted to Kawasaki Municipal Hospital. On admission, temperature was 40.7 degrees C but otherwise physical examination revealed no particular abnormality. Laboratory data showed total white blood cells of 28,400/microliter, platelet count of 130,000/microliter, creatinine of 2.0 mg/dl and C-reactive protein of 7.5 mg/dl. 1 g of cefmetazole was administered every eight hours. In the early morning of May 23, he suddenly went into shock. At that time, laboratory findings revealed total white blood cells of 33,700/microliter, platelet count of 65,000/microliter, C-reactive protein of 24.9 mg/dl, creatinine of 5.6 mg/dl and serum potassium concentration of 5.7 mEq/l. Gram positive cocci and gram negative rods were isolated from blood culture obtained on admission. Cefmetazole was changed to 1.5 g/day of imipenem/cilastatin sodium and 600 mg/day of clindamycin. In addition, hemodialysis and endotoxin removal with an adsorbent column using polymyxin B were performed. Bacteria detected in the blood on admission were identified as Klebsiela oxytoca and Enterococcus faecium. Imipenem/cilastatin sodium and clindamycin were continued for 13 days. The patient recovered fully and was discharged on June 11. This case suggests that bacterial translocation-associated sepsis might occur even in a hitherto healthy adult.     

A case of ventriculitis with bacterial meningitis occurred during the treatment of liver abscess

A 47-case-year old male was admitted to our hospital because of high fever and general fatigue. He had no immune deficiency, and had no other disease in his past history. On admission, the white blood cell count and C-reacted protein were severely elevated (18,700/microliter, 27.7 mg/dl, respectively) and abdominal CT revealed multiple low density, From these results, he was diagnosed as liver abscess. Intravenous MINO and SBT/CPZ injection were started. On the fifth hospital day, he suffered from headache and nuchal rigidity. The clinical data revealed the cerebro-spinal fluid (CSF) counting 8,336 cells/mm3 (mononuclear 8,000,) protein at 119 mg/dl, and sugar 42 mg/dl. CSF cultures were negative, but Klebsiella was recognized in the blood culture and drainage fluid in liver abscess. This condition was diagnosed as bacterial meningitis and antibiotics were changed to intravenous CTRX and MEPM. Furthermore we administered oral PSL and intravenous steroid-pulse therapy. After these combination therapies his condition improved gradually. After 40 hospital day, however, he suddenly had double vision, Axial FLAIR (SE6,000/120) image revealed with high signal intensity at 4th ventricle. Intravenous MEPM was administered again. On the 60th hospital day, double vision was gradually improved and abnormal intensity at 4th ventricle was almost disappeared. This case may provide us a considerable suggestion on the treatment of bacterial meningitis.     

Aseptic meningitis in a large MMR vaccine campaign (590,609 people) in Curitiba, Paraná, Brazil, 1998.

The aseptic meningitis after Measles-Mumps-Rubella vaccine (MMR) is a well recognized complication, and different incidences have been observed in several studies. We retrospectively analyzed forty cases of aseptic meningitis, during a large public immunization campaign (1998) in Curitiba, Southern Brazil (590,609 people), admitted in our Service. The vaccine utilized was Leningrad-3-Zagreb mumps strain, Edmonston-Zagreb measles strain, and RA 27#3 rubella strain. In all county, a total number of 87 cases were reported, resulting in a incidence of 1.7 cases per 10,000 given doses. The mean age was 23.7 +/- 12.8 years. The female:male ratio was 1.35:1. Severe headache with meningismus (92.5%), fever (87.5%), nausea/vomiting (82.5%) were the most common clinical findings. Three cases (7.5%) developed mild mumps. All patients underwent cerebrospinal fluid (CSF) tap with the following findings: mononuclear pleocytosis from 100 to 500 cells/mm(3) in 17 cases (42.5%; 257.5 +/- 260.6 cells/mm3); increased protein 28 cases (67.5%; 92.1 +/- 76.9 mg/dL); glucose was normal in all cases (56.8 +/- 11.2 mg/dL) except in 4 (10%) cases, which presented less than 44 mg/dL. All serological tests (latex to bacterial meningitis, Cryptococcus, cysticercosis, VDRL) and bacteriological cultures were negative. Virus identification were also negative in 8 samples. None of the patients had neurological deficits or related symptoms after one year of onset. We believe the benefit of vaccination clearly outweighs the incidence of benign vaccine-associated meningitis.     

Acute urinary retention as an unusual manifestation of aseptic meningitis

A formerly healthy 32-year-old woman was hospitalized for a closer examination of undiagnosed fever with mild headache. Despite lack of distinct findings on physical and laboratory examinations at admission, she suddenly developed anuresis due to acontractile neurogenic bladder. On the basis of her symptoms and the faint nuchal rigidity revealed later, as well as the results of cerebrospinal fluid analyses, a diagnosis of aseptic meningitis was eventually reached. While aseptic meningitis subsided within 3 weeks, about 10 weeks, including a 26-day period of anuria, was necessary for complete restoration of normal voiding function, necessitating intermittent self-catheterization. Acute urinary retention should be considered an uncommon but critical manifestation of aseptic meningitis.     

A case of pituitary apoplexy approving as severe headache and nausea

The causes of pituitary apoplexy are unclear. We report a case of pituitary apoplexy presenting with headache and nausea. On June 17th, 1997 a 74-year-old woman had complained of retro-orbital headache, fever and vomiting. A cold was diagnosed for which she recurred medication. In addition to the previous symptoms she was getting to lose appetite. She was admitted to our hospital for further examination and treatment on June 21. On admission neurological examination showed left pupil mydriasis, the left eye had no light reflex and the right eye had only a slight response to the light. She could hardly move both eyeballs up. Laboratory data showed a normal white blood cell count and the CRP was 16.2 mg/dl. Lumbar puncture showed 97 mg/dl total protein and 82 cells per microliter, most of which were lymphocytes. We diagnosed viral infection based on the evidence of clinical symptoms and lumbar puncture data. The patient was treated with gamma-globulin and improved. From the 16th day of sickness we recognized symptoms of oculomotor paralysis and the syndrome of inappropriate antidiuretic hormone. On the 23rd day of sickness we strongly suspected pituitary apoplexy based on transaxial MR images. After absorption of intra-tumor hemorrhage, the oculomotor symptoms recurred. We finally reached a diagnosis of pituitary apoplexy based on pathological material, MR images, symptoms and laboratory data. We must think of pituitary apoplexy when we see an aged out-patient with severe headache, nausea, vomiting and oculomotor paralysis. It was difficult to diagnose this disease in the early time course of the disease.     

Clinical,Laboratory, and Molecular Epidemiology of an Outbreak of Aseptic Meningitis Due to a Triple-Recombinant Echovirus in Ashburton,New Zealand

Here, we describe a small enterovirus outbreak including nine cases of aseptic meningitis in a New Zealand hospital in 2017. Most patients had a lymphocytic predominance in the CSF, their length of stay was short, and there were no paediatric cases or ICU admissions. VP1 genotyping revealed that the outbreak was caused by an echovirus E30 strain closely related to strains reported from the US, UK, Brazil, and Denmark. They all form a separate cluster within lineage “h”, which leads to the proposal of establishing a new lineage tentatively named “j” for this group of echovirus E30 strains. However, whole genome sequencing and reference mapping to echovirus E30 sequences showed very poor mapping of reads to the 3′ half of the genome. Further bioinformatic analysis indicated that the causative agent of this outbreak might be a mosaic triple-recombinant enterovirus composed of echovirus E6, echovirus E11, and echovirus E30 genome segments.     

结核性脑膜炎96例临床分析

目的 分析结核性脑膜炎的临床表现、诊断和治疗特点,以提高对该病的诊治水平.方法 对2006年6月至2010年10月我院收治的96例结核性脑膜炎患者的临床资料、实验室检查结果、诊断及预后情况进行总结分析.结果 本组96例结核性脑膜炎多呈慢性或亚急性起病,临床表现以发热、头痛、呕吐为主,脑脊液改变以压力、白细胞、蛋白升高、葡萄糖、氯化物降低为主.87.5％合并颅外结核.头颅CT或MRI检查异常51例,表现为脑积水、结核瘤、脑室扩张、多发病灶等.经正规抗结核治疗,临床治愈52例,好转25例,14例未见好转,自动出院或转院治疗,5例死亡.结论 患者的临床表现、脑脊液、头颅CT或MRI检查、是否合并颅外结核感染及正规抗结核治疗是否有效,是诊断结核性脑膜炎的重要依据;早期诊断及合理治疗可提高结核性脑膜炎的治愈率.     

Clinical study of an outbreak of aseptic meningitis due to echovirus type 30 in Munakata City in 1997-1998

From October, 1997 through July, 1998, an outbreak of aseptic meningitis due to echovirus type 30 occurred in the northern part of Kyushu area in Japan. In this outbreak, clinical and virologic observations were carried out on 157 in-patients with aseptic meningitis at our hospital. The age of the patients ranged from 1 year and 9 months to 57-year old. One hundred and twenty out of 157 cases were the children under 15 years of age, and in this age group, male/female ratio was 2:1. The largest proportion of cases occurred in the 5- to 9-year age group. The number of cases reached a peak in December, 1997, but the epidemic extended to the next summer. In 12 families, more than one person became ill (total 22 cases). Virus isolation from cerebrospinal fluid (CSF) was tried on 130 out of 157 cases. Echovirus 30 was isolated in 74 cases (58 children, 16 adults), and echovirus 18 in 9 cases from June, 1998 until the end of the study. Paired acute and convalescent sera were available from the 25 patients with negative virus isolation, and 7 out of 25 patients had a fourfold or greater rise in neutralizing antibodies. Headache, fever, vomiting, nuchal rigidity were detectable in most cases, but in this outbreak, continued severe headache was characteristic. Eye pain was experienced by 2% of the total cases. In children, gastrointestinal symptoms were noted in 12% of the cases, but were not in adult patients. The CSF cell counts ranged from 2 to 3,478 cells per cubic millimeter. Fifty-eight percent were predominantly lymphocytic, while 42% were polymorphonuclear predominant. Virus was highly isolated from the CSF when the specimens were obtained within three days after the onset of the acute illness, but in one case, virus was isolated on day 7. In a few cases, virus was isolated without pleocytosis in CSF.     

Epidemic of aseptic meningitis with echovirus type 18 in Gifu Prefecture in 1988

On one hundred thirty seven cases with aseptic meningitis and 36 cases except aseptic meningitis in 1988, virological and serological investigations were performed. Cases with aseptic meningitis ranged from 0 to 15 years old age, and 90.5% of them were under 8 years of age. Seven types of enteroviruses and one unidentified strain were isolated from 58 of the 137 cases (42.3%), and echovirus type 18 was recovered from 46 cases (79.3%). Echovirus type 18 was isolated also from 16 cases with acute febrile illness and exanthem etc. With the cross neutralizing test between the prototype and isolated strains in 1988 of echovirus type 18, a slight antigenic variation could be found. In the serological studies in 1989, the positive rate of neutralizing antibody to echovirus type 18, was raised remarkably in children under 8 years old.     

An epidemic of aseptic meningitis caused by echoviruses in Fukuoka Prefecture during April 1997 to August 1998

An epidemic of aseptic meningitis in Fukuoka Prefecture during April 1997 to August 1998 was studied to determine the serotype of viruses isolated in Fukuoka Prefecture. In Fukuoka Prefecture, bimodal peaks were seen in July and December 1997. Monthly changes of reported aseptic meningitis patients and period of virus isolation revealed that epidemics of the earlier part in 1997 was caused by echovirus 9 (E 9) and the latter part due to echovirus 30 (E 30). E 9 was isolated mainly in Chikugo Area from June to October 1997 but, E 30 was isolated all in areas of Fukuoka Prefecture. Isolation of E 30 continued after January 1998 in Fukuoka Prefecture. Isolation of echovirus 18 started in June 1998. The main serotypes of isolates are changing. The E 30 isolates are serotyped by neutralization with the aid of antiserum pools for enterovirus type differentiation, but serotyping was difficult with commercially available antiserum. The result of neutralization tests with standard serum and an immune albino rabbit serum prepared in our laboratory with the E 30 isolates indicated that the isolates in Fukuoka Prefecture was an antigenic variant.     

Enterovirus Infections in Germany: Comparative Evaluation of Different Laboratory Diagnostic Methods

Background: The diagnosis of an enterovirus infection may be achieved through direct virus detection from fecal or cerebrospinal fluid (CSF) samples by virus isolation or PCR. Serologically, a significant rise in antibody titer may be detected and different enteroviral types can be differentiated using the neutralization assay. Patients and Methods: We investigated the contribution of these different laboratory parameters to the diagnosis of enterovirus infections occurring in the Frankfurt am Main area during the years 1997 to 1999, including an echovirus 30 outbreak in a group of children with aseptic meningitis in 1997. Samples were referred from 1,013 patients; virus isolation was attempted from 579 CSF specimens and from 400 stool samples. 208 CSF samples were tested by PCR. Results: During the echorivus 30 outbreak we identified 22.3% of samples as positive, almost exclusively echovirus 30. In 1998 only 7.1% of samples were positive and a rather broad range of agents was isolated. In 1999 10.4% were positive, predominantly coxsackie B5 and echovirus 11. We could show that in acute enterovirus infections, virus detection by cell culture and PCR is superior to serological methods (neutralization assay and IgM assay). For virus isolation, there was a higher rate of positives from stool compared to CSF (1997: 27.8% versus 25%; 1998: 14.4% versus 3%; 1999: 17.9% versus 8.5%). When comparing PCR and virus isolation from the CSF, the former yielded a higher rate of positive results but was not clearly superior to virus isolation from CSF. Conclusion: The recommended method for the diagnosis of acute enterovirus infections is virus isolation from feces. In cases of suspected aseptic meningitis virus isolation and PCR are valuable for the direct detection of virus in CSF. Received: March 31, 2000 · Revision accepted: March 5, 2001     

Early diagnosis of enteroviral meningitis by a solid-phase reverse immunosorbent test and virus isolation

45 cases of aseptic meningitis/meningoencephalitis were studied with regard to enteroviral etiology by virus isolation and solid-phase reverse immunosorbent test (SPRIST), a cross-reacting test for enterovirus IgM. An etiological diagnosis was reached in 37/45 (82%) patients. Etiological diagnoses other than enteroviruses were found in 8 patients: Borrelia burgdorferi in 4, varicella-zoster virus in 2, herpes simplex virus in 1 and mumps virus in 1 patient. Enteroviruses (echovirus 6, 21 and 30) were isolated from cerebrospinal fluid (CSF) in 26/37 (70%) and from stool samples of 20/21 (95%) of patients with no other etiology. Altogether enteroviruses were isolated from CSF and/or faecal samples in 29 patients. Echovirus 30 dominated as etiologic agent. In 34/40 (85%) of the samples with an enterovirus, a cytopathogenic effect was observed in cell culture within 4 days. In patients with an enterovirus isolate a SPRIST IgM response to echovirus 3, 5, 7 and/or coxsackievirus B3 was detected in 6/13 (46%) sera sampled 3-4 days after the onset of meningeal symptoms and in altogether 17/25 patients (68%). In 4 out of these virus isolation positive and SPRIST negative patients a single serum for SPRIST was available less than 4 days after onset of meningeal symptoms. Antigen from echovirus 5 gave the highest diagnostic yield. The SPRIST IgM test was positive in 2 cases where virus isolation, complement fixation and neutralization tests were negative. Epidemiological data however supported an enteroviral diagnosis in both of them. In conclusion, both SPRIST and virus isolation seem to be valuable for the early diagnosis of enteroviral meningitis.     

Aseptic meningitis

PURPOSE OF REVIEW: To highlight some of the recent key epidemiologic and clinical diagnostic dilemmas of aseptic meningitis and to evaluate some tests that may help distinguish aseptic compared with bacterial meningitis. RECENT FINDINGS: Enteroviruses remain the most common cause of aseptic meningitis. Certain enteroviruses (e.g. coxsackie B5, echovirus 6, 9 and 30) are more likely to cause meningitis outbreaks, while others (coxsackie A9, B3 and B4) are mostly endemic. Nucleic acid tests are more sensitive than cultures in diagnosing enteroviral infections. In centers where the turnaround time for these tests is less than 24 h, there can be substantial cost savings and avoidance of unnecessary treatment of aseptic meningitis with antibiotics. Serum and stool specimens are important adjunct samples for diagnosing enteroviral infections in children. Cerebrospinal fluid protein (> or = 0.5 g/l) and serum procalcitonin (> or = 0.5 ng/ml) appear to be useful laboratory markers for distinguishing between bacterial and aseptic meningitis in children aged 28 days to 16 years, but they have relatively low sensitivity and specificity. SUMMARY: Enteroviruses are the major causes of aseptic meningitis. The major focus of diagnosis remains ruling out bacterial infection or confirming enteroviral etiology of infection. Properly implemented nucleic acid tests have the potential to reduce cost and unnecessary treatment.