TABLE I
SOME DATA ON 11 CAS OF RECURRENT
ASEPTIC MENINGITIS
Case
Number Sex
Age al
Attack
1 F 2 8/l2yr
2 9/12 yr
2 M 110/l2yr
2 8/12 yr
3 M 1 1/l2yr
2 4/12 yr
4 F 2 6/l2yr
3 4/12 yr
5 M 1 6/l2yr
210/12 yr
6 F 310/l2yr
6 yr
7 M 2 8/l2yr
211/12 yr
8 M lOmo
1 9/12 yr
9 1,f 2 9/l2yr
3 7/12 yr
10 ii: 3 1/12 yr
4 5/12 yr
11 M 3 3/l2yr
3 5/12 yr
EXPERIENCE AND REASON-BRIEFLY RECORDED 773
11. Court Brown, W. M., Jacobs, P. A., Maclean, N., and Mantle, D. J.: Abnormalities of the
sex chromosome complement in man. Mcdi-cal Research Council Special Report. Lon-don: Her Majesty’s Stationary Office, 1964. 12. Lamy, M., Josso, N., de Grouchy, J., and
Bi-tan, A. : Anomalies des gonosomes. 20e
Con-gres des Pediatres de Lange Francaise, pp.
41, ed. L’Expansion Scientifique Francaise, Paris, 1965.
13. Baker, T. G. : A quantitative and cytological
study of germ cells in human ovaries. Proc.
Roy. Soc., 158:417, 1963.
Recurrent Virus Meningitis
There are few reports of instances of
re-current virus meningitis. Four cases were
re-ported by Klemola and Lapinleumu,1 and a
case was reported by Anderson.2 However, our experience indicates that recurrent virus
men-ingitis is not uncommon.
MATERIALS AND METHODS
During the 16-year period, 1953-1968,
1,956 patients with aseptic meningitis visited the Pediatric Clinic of Aomori Prefectural Cen-tral Hospital. All were under 15 years of age.
Among them 71 patients had aseptic meningitis two or three times. Before 1960 virological
in-vestigations were not done; since then virologic and serologic studies have been done in almost all cases. Cerebrospinal fluid (CSF) , feces, and
serum specimens were examined. Virologic and
serologic studies were made at the Department of Bacteriology, Tohoku University School of Medicine. Details of these studies were
pre-viously reported by Hinuma, et
RESULTS
Sixty-seven patients experienced attacks twice and four patients had three attacks. The
interval between attacks ranged from a month to 4 years; most were within 2 years. There were 31 patients in whom the etiological agent was identified in one of the two or three
attacks. There were 1 1 patients in whom virus
was isolated from CSF and/or feces or con-firmed serologically in both of two attacks. There
was nothing indicative of earlier cranial trauma or suppurative meningitis in the patients’ his-tory. Clinical and laboratory findings differed little from attack to attack.
Some clinical and laboratory data on 11
Dale of Attack
June Q1, 1961
July 31, 196 August 13, 1963
June 25, 1964
June 14, 1961
September 8, 1962
August 2, 1962
June 20, 1963
July 12, 1961
October 7, 1962
August 30, 1961
July 25, 1964
June 3, 1961
August 11, 1961
August 25, 1960
July 16, 1961
October 2, 1960 July 28, 1961
June 25, 1960
July 9, 1961
September 21, 1965
October 19, 1965
patients in whom virological data were avail-able from both attacks are shown in Tables I and II.
Virological data are shown in Table III.
Coxsackie B5 virus was isolated from feces in
Case 8, but there was no rise in neutralizing
antibody titer. The next year the same virus
was isolated from CSF and feces of that
pa-tient. In Case 9, Coxsackie B5 virus was
iso-lated from CSF in the first attack and in the
next year the same virus was isolated from
feces, but not from CSF.
DISCusSIoN
Aseptic meningitis is caused by many viruses; therefore, the syndrome might have a different etiology in different attacks. In Aomori
Pre-fecture, which is in the northern end of Honshu (Japan proper) , outbreaks of aseptic meningitis
take place every year. Outbreaks of aseptic meningitis have been caused by Coxsackie B5 and A9 viruses,3’6 by ECHO 4 virus,4 and by
ECHO 14 virus.
Case Attack
Cerebrospinal Fluid Findings Durali
Duration of
of Fever Days Leucocyte Sugar Protein Chior Pleocijtosis
(days) after counts (/1) (mg/mi) (mg/mi) in CSF
Ofl8a (per mm3)
,5 3 17 65.9 11.0 423 2 weeks
1
4
1 86 58.7 9 .0 422 2 weeks
2 261 56.7 10.0 451 2 weeks
3 35 36.5 14.5 445 2 weeks
3 2 57 N.T. NT. NT. 2weeks
4 7 64 51.7 12.0 413 2 weeks
2 2 58 61.9 17.5 370 1 week
8 8 19 58.9 NT. 461 3 weeks
4 2 408 43.2 15.0 463 5 weeks
5 4 150 42.8 17.8 465 5 weeks
9 2 520 76 .4 23.0 443 2 weeks
4 3 19 40.3 7.0 448 2weeks
3 3 150 48.1 5.5 437 2 weeks
4 3 7 52.7 4.0 460 2 weeks
10 7 19 53.0 7.5 97 3 weeks
5 3 14 96.4 8.7 469 3 weeks
4 4 32 N.T. N.T. NT. 2weeks
5 1 15 77.0 4.0 427 3 weeks
774 RECURRENT VIRUS MENINGITIS
TABLE II
(‘IINIcAL AND LABORATORY DATA ON 11 CAS OF RECURRENT Aspric MENINGiTIS
Nuni- Num- Clinical Symptoms
ber ber
1 Fever, vomiting and
diarrhea
2 Fever, headache and
volniting
1 Fever and vomiting
2 Fever, headache aiid
abdominal pain
1 Fever, vomiting and diarrhea
2 Fever, headache and vomiting
1 Fever, headache and
vomiting
2 Fever and vomiting
1 Fever, vomiting and
limb pain
‘2 Fever, headache, coughs
and abdominal pain
1 Fever, headache and
vomiting
2 Fever, headache and vomiting
1 Fever, headache, vomiting
7 ttiicl coflStipatioll
2 Fever and vomiting
1 Fever, vomiting 1111(1 (liarrhea
8
2 FCv(l, VoillitilIg an(1
limb paiii
1 Fever, headache and
() liiiihpails
2 Fever and headache
1
C)
3
4
5
Duration
of Fever
(days)
(‘erebrospinal Fiuid Findings
Days after
Onset
Leucocyte
counts
(per mm3)
Sugar Protein
(mg/mi) (ingmi)
i)uralion
of
C) 1
C)
3
ii
ECho 4
EChO 14
EChO 4
Coxsaekie B5 NT.
NT.
EChO 6
NT.
ECHO 6
I (‘oxsackie B5
5 2 Coxsackie A9
N.’l’. = not tested.
1: 64(34)
1: 32(2.5)
EXPERIENCE AND REASON-BRIEFLY RECORDED 775
* Nuniher in l)m1r(lltlLeses indicates (hi4S after onset of illness. ‘rABLE II (Continued)
(‘a.8e Alt Wk
.V,iin- .Vu,u- (‘linical Symptoms
ber ber (‘hior Pleocyloxis
(ing/mii in (‘SF
10
1 Fever, hea(lache 5411(1
Voillit iug
2 Fever, IleIldachie, vonsiting 5415(1 aI)dOlflinal pain
Ii
1 Fever, headache and vomiting
‘2 Fever, Ileadachle and
vomiting
6 7 52 46.5 14.0 465 4 weeks
2 34 93 .7 7 .0 508 3 weeks
9 2 83 62.3 9.0 437 2 weeks
1 2 32 42.3 ‘35.0 442 2 weeks
meningitis, therefore it may be no wonder that
there were multiple attacks of aseptic meningi-tis in the same individual. Whereas 4.6% of the
siblings of patients with one attack also had
similar aseptic meningitis, the incidence of
attacks in the six siblings of recurrent cases
was one in six, or 16.6%. The history of the
patients indicated that those patients with
multiple attacks had no predisposition to
in-fectious diseases and no abnormalities in lab-oratory findings, even though one might sur-misc that patients with repeated attacks of aseptic meningitis might have a unique
sus-ceptibility to infection or disease. It is
note-worthy that of eleven cases, eight were males,
and that in only one instance was a virus re-covered from the CSF in both of two attacks that occurred.
‘I’ABLE III
\IROLOGICAL I)ATA ON 11 CASES 0’ AsEenc MENINGITIS
Case il/tack
i’suinber Number
Virus Isoiaiion
From (‘SF From feces Virus
Neutralizing Antibody Tiler
Acute (‘onvalescent
1 Coxsackie A9 NT. Coxsackie B5 1 : <4 (4)* 1 : 64 (97)
Coxsackie A9 1 : <4 (4) 1 : 32 (8)
ECho 14 1 : 4 (2) 1 : 128 (14)
NT.
1:<4 (3) 1: 4(21)
4 1 Coxsackie A9 Coxsackie A9 Coxsackie A9 1 :256 (2) 1 :256 (9)
2 N.’1’. Coxsackie B2 Coxsackie B2 1 : 128 (8) 1 : 256 (19)
N.’r. CoxsackieB5 1: 16 (2)
776 HEMOLYTIC-UREMIC SYNDROME
TABLE III (Continued)
Case
‘%umber
Attack
Number
1irus isolation Need ralizing Antibod y Titer
, ‘
I rom tl SF From feces Virus. Acute Convalescent
6 ? Coxsackie B5 -NT. ECHO25 Coxsackie B5 NT.
1 : 4 (12) 1 : 16 (19)
7 1 ‘2 Coxsackie B5 Ni’. -Polio III Coxsackie B5 Polio III
1 : 16 (2)
1 : 64 (3)
1 : 64 (5)
1 : 64 (12)
8 2 NT. Coxsackie B5 Coxsackie B5 Coxsackie B5 Coxsackie B5 Coxsackie B5
1 : <4 (7)
1 : 4 (3)
1 : <4 (32)
1 : 16 (10)
4) . 2 Coxsackie B5 -NT. Coxsackie B5 N.T.
Coxsackie B5 1 : 16 (1) 1 : 16 (34)
10 2 NT. -Coxsackie A9 CoxsackieB5 Coxsackie A9 CoxsackieB5
1 : 64 (5)
1:<4 (1)
1 : 64 (18)
1:<4 (8) 1 1 2 N.’!’. ECIIO6 Coxsackie B3 NT. N.T. NT.
NT. =not tested.
S Nummiber II) 1)slrellthleses iIl(hiCiItes (lays after Oliset of illness.
SUMMARY
Seventy-one patients with two or three
at-tacks of aseptic meningitis were seen during the 16-year period, 1953-1968, when a total of 1,956 patients with that disease were observed.
All were under 15 years of age. The interval between attacks ranged from a month to 4
years. Clinical and laboratory findings of
sequential attacks did not differ. Virological data were available from both of two attacks in 1 1 patients. These data indicate that a per-son may be attacked with aseptic meningitis more than once; usually the causative virus is
different in subsequent attacks.
TOORU NAKAO, M.D.
Roicm Miun, M.D.
Department of Pediatrics
Sapporo Medical College
s.1 W.16, Sapporo, Japan
REFERENCES
1. Klemola, E., and Lapinleumu, K. : Multiple
at-tacks of aseptic meningitis in the same
mdi-vidual. Brit. Med. J., 1: 1087, 1964.
2. Anderson, J. P. : Recurrent virus meningitis.
Brit. Med. J., 4:786, 1969.
3. Hinuma, Y., Murai, Y., Fukuda, M., Numazaki, Y., Ishida, N., and Nakao, T. : An outbreak of
aseptic meningitis associated with Coxsackie
B5 and A9 viruses in northern Japan, 1961. Virological and serological studies. J. Hyg., 62:159, 1964.
4. Hinuma, Y., Uruno, K., Morita, M., Ishida, N., and Nakao, T. : Virological and
epiderniologi-cal studies on an outbreak of aseptic meningi-tis caused by echovirus 4 in northern Japan in
1964. J. Hyg., 64:53, 1966.
5. Hinuma, Y., Murai, Y., and Nakao, T. : Two
outbreaks of echovirus 14 infection : A
possi-ble interference with oral poliovirus vaccine
and a possible association with aseptic
menin-gitis. J. Hyg., 63:277, 1965.
6. Nakao, T., Nitta, T., Miura, R., Ogata, K.,
Kume, T., Nobuta, K., and Hinuma, Y. : Clini-cal and epidemiological studies on an out-break of aseptic meningitis caused by
Cox-sackie B5 and A9 viruses in Aomori in 1961. Tohoku J. Exp. Med., 83:94, 1964.
