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Approach to a case of Chronic Meningitis
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Dr. Shatdal ChaudharyAssociate Professor
Department of Internal MedicineUniversal College of Medical Sciences, Bhairahawa, Nepal
DefinitionChronic inflammation of meninges where
Symptoms lasting for four weeks or more duration
Symptoms can be constant, fluctuate or slowly worsen
Clinical course can vary widely between patients
Five Categories of diseaseMeningeal infectionMalignancyNoninfectious inflammatory disordersChemical meningitisParameningeal infections
Infectious Causes
BacterialBrucellaFrancisella tularensisActinomycesListeria-unpastuerizedNocardiaRarely partially treated N. Meningitis,
Streptococcus or H. Flu
SpirochetesTreponema pallidum
Disseminates during early infectionSerum and CSF VDRL typically positive
Lyme MeningitisTypically late summer and early fallTravel to endemic areaHistory consistent with erythema
migransLeptospirosis
Meningeal symptoms develop in 50% of patients during anicteric second stage of illness
Mycobacterium TuberculosisBacilli seed to the meninges creating
tubercles called “Rich foci”Tubercles that rupture into subarachnoid
space causing meningitisCranial nerve palsies can occur
CN VI most frequently affected Up to 40% in children
ViralEnterovirusHSV
Mollaret’s syndrome- “Benign Recurrent Meningitis”
HIVLymphocytic ChoriomeningitisCMVEBVVZVMumps
Other Infectious EtiologiesFungal
Cryptococcus, Coccidioides, Sporithrix, Histoplasma
Parasitic – Eosinophilic MeningitisAngiostrongylus, Taenia solium,
Schistosomiasis, Toxoplasmosis
Noninfectious CausesMalignancy
Metastastic Ca of Breast, Lung, Pancreas, Lymphoma, Leukaemia, Meningeal gliomatosis
Medications/ Chemical: Subarachnoid injectionNSAIDS, trimethoprim-sulfamethoxazoleEpidermoid tumor, Craniopharyngioma,
Rheumatologic/ Noninfectious inflammatory conditions:SarcoidosisSLEBechet SyndromeWegners DiseaseVogt-Koyanagi-Harada Syndrome
Idiopathic
SymptomsNonspecific and similar to acute
meningitisAre determined by anatomical
location of inflammation and its consequence.
Symptoms
Double vision/visual loss Hearing loss Limb weakness Sphincter dysfunction
symptomsHydrocephalusCranial neuropathiesRadiculopathyCognitive disturbancePersonality changesPresence of underlying systemic illnessAccording to causative agent
Historical CluesTravel to endemic areas – eg fungal,
parasitic, lymeTB exposure or previous positive skin testSexual historyTick exposure
Historical CluesMedications-specifically NSAIDsContact with rabbits, cats, wild game or meat
processingRecurrent genital or oral ulcersWeight loss, night sweatsRash
CSF AnalysisTest Bacterial Viral Fungal Parasitic
Opening
Pressure
Elevated Usually normal
Variable Variable
White blood cell count
>1000 <100 Variable Variable
Cell differential
PMN Lymphs Lymphs Eosinophilia
Protein Mild to Marked Elevation
Normal to Elevated
Elevated Elevated
Glucose Normal to Low
Normal Low Low
CSF AnalysisPMN predominate/
Low Glucose
Lymph predominate/
Normal Glucose
Lymph predominate/
Low Glucose
Bacteria
-Actinomyces,
Listeria, Brucellosis
Mumps
LCM
NSAIDS
Sulfa
Behcet’s
Early Viral
Viral
CNS Malignancy
Endocarditis
Early Mycobacterium
Early Fungal
Mycobacterium
Fungi
Specific CSF AnalysisAntigen testing
Cryptococcus neoformans, HSV, VZV, EBV, CMV, VDRL
Significant inter- and intralab variability with PCRs
Cultures – if routine cultures negative may need 10-20 ml of CSFAerobicMycobacterialFungal
Cytology
Serum TestsHIV with ELISA
VDRL/RPR
SerologiesLCM, leptospirosis, Lyme, Ehrlichia, Brucella
Blood cultures x3
Further ExaminationsPPDCXRRetinal ExamEchocardiogramMRI
Rarely lead to specific diagnosisFocal abnormalities may be useful if brain biopsy
consideredMeningeal/Brain Biopsy
Particularly useful if focal on imagingProgressive disease despite empiric therapy
Treatment according to Etiological Agent
Empiric TherapyAntituberculous therapy
Antiviral TherapySteroids
Persistent negative cultures Infectious etiology though unlikely
Trial of combination of ATT+Antifungal+Steroids