Recurrent herpes simplex virus type 2 Mollaret meningitis in a man living with HIV: a case report and patient-initiated episodic valacyclovir strategy.

Recurrent benign lymphocytic meningitis (RBLM) or Mollaret meningitis is an uncommon manifestation of herpes simplex virus type 2 (HSV-2) infection, characterized by self-limiting aseptic meningitis with complete recovery between episodes. Despite high background prevalence of HSV-2 in people living with HIV (PLWH), RBLM remains extremely rare in this population. Only two cases, both involving female patients, have been reported. We report the case of a man with HIV who experienced recurrent HSV-2 meningitis despite sustained virological suppression for HIV, preserved CD4 cell count at the time of the current episode, and several recent recurrences. A 55-year-old Japanese man with virologically suppressed HIV infection presented with fever, headache, and photophobia, consistent with nine prior episodes of HSV-2 meningitis. HSV-2 polymerase chain reaction testing of cerebrospinal fluid was negative likely because of early lumbar puncture and prior antiviral initiation. The episode rapidly resolved after intravenous administration of 10 mg/kg acyclovir every 8 h, followed by oral valacyclovir. He adopted a self-initiated episodic oral antiviral strategy at symptom onset, which may have attenuated clinical severity. This case shows that RBLM can occur in immunologically preserved PLWH and suggests that early patient-initiated antiviral therapy may be a feasible approach to mitigate recurrence-associated morbidity.