A Case Series on Enteroviral Meningitis in Pakistan

Enteroviruses (EVs) are the most common cause of viral meningitis with a peak incidence between late summer and fall. The onset of symptoms is characteristically abrupt and typically includes headache, fever, nausea or vomiting, malaise, photophobia, and meningismus. In addition, diarrhea, upper respiratory symptoms, and a rash may also be present. The clinical presentation and epidemiologic features help in the diagnosis and it is confirmed by the detection of RNA in the cerebrospinal fluid (CSF) by polymerase chain reaction (PCR). We present the clinical description, diagnosis, and management of five consecutive cases of viral meningitis secondary to enterovirus that presented to the emergency department at a tertiary care center in Karachi, Pakistan, over a span of five weeks during the monsoon season. These cases or outbreaks have not been reported previously in Pakistan and, hence, this case series is the first of its kind. All of our patients were young males, with ages between 18-35 years, did not have any prior co-morbidities, and resided in different localities of Karachi, Pakistan. The presenting complaints were severe headache in all five patients (100%), fever in all five patients (100%), and diarrhea in two out of five patients (40%). On examination, neck stiffness was present in all patients (100%). After the required workup and detection of RNA in the CSF by PCR, diagnosis of enteroviral meningitis was confirmed. The patients were given symptomatic treatment and discharged home with no neurologic complications. Aseptic meningitis occurring during the summer or fall is most likely to be caused by non-polio EVs (eg. coxsackievirus, echovirus, etc.). It is self-limiting and only requires supportive treatment. However, clinically it cannot be differentiated from other central nervous system infections and significant morbidity has been reported, including hospitalization and impairment of routine activities.