chronic meningitis hummert

7/28/2019 Chronic Meningitis Hummert

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Chronic Meningitis

Erin Hummert

July 9, 2007


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Definition

Meningeal Symptoms lasting fourweeks or more

Symptoms can be constant, fluctuateor slowly worsen

Clinical course can vary widelybetween patients


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Etiology

Infectious

Bacterial, Mycobacterial, Spirochete,

Viral, Fungal, Parasitic Malignancy

Medications

Rheumatologic Idiopathic


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Bacterial

Brucella

Francisella tularensis

Actinomyces Listeria-unpastuerized

Ehrlichia chaffeensis

Nocardia Rarely partially treated N. Meningitis,

Streptococcus or H. Flu


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Spirochetes

Treponema pallidum Disseminates during early infection

Serum and CSF VDRL typically positive

Lyme Meningitis Typically late summer and early fall

Travel to endemic area

History consistent with erythema migrans

Leptospirosis Meningeal symptoms develop in 50% of

patients during anicteric second stage ofillness


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Mycobacterium Tuberculosis

Bacilli seed to the meninges creating

tubercles called Rich foci

Tubercles that rupture intosubarachnoid space causing

meningitis

Cranial nerve palsies can occur CN VI most frequently affected

Up to 40% in children


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Viral

Enterovirus

HSV Mollarets syndrome- Benign Recurrent

Meningitis HIV

Lymphocytic Choriomeningitis

CMV

EBV VZV

Mumps


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Other Infectious Etiologies

Fungal

Cryptococcus, Coccidioides,

Sporithrix, Histoplasma

Parasitic Eosinophilic Meningitis

Angiostrongylus, Taenia solium,Schistosomiasis, Toxoplasmosis
http://images.google.com/imgres?imgurl=http://microbewiki.kenyon.edu/images/4/4b/23231D.jpg&imgrefurl=http://microbewiki.kenyon.edu/index.php/Cryptococcus&h=343&w=275&sz=121&hl=en&start=5&um=1&tbnid=qLYluC8DAIOhjM:&tbnh=120&tbnw=96&prev=/images%3Fq%3Dcryptococcus%26svnum%3D10%26um%3D1%26hl%3Den


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Noninfectious

Malignant

Medications NSAIDS, trimethoprim-

sulfamethoxazole Sarcoidosis

Behcets syndrome

Systemic Lupus Erythematous Endocarditis


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Symptoms

Nonspecific and similar to acute

meningitis


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Historical Clues

Travel to endemic areas eg fungal,

parasitic, lyme

TB exposure or previous positive skintest

Sexual history

Tick exposure


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Historical Clues

Medications-specifically NSAIDs

Contact with rabbits, cats, wild game

or meat processing Recurrent genital or oral ulcers

Weight loss, night sweats

Rash


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CSF Analysis

Test Bacterial Viral Fungal Parasitic

Opening

Pressure

Elevated Usually

normal

Variable Variable

White blood

cell count

>1000


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CSF Analysis

PMN predominate/

Low Glucose

Lymph

predominate/

Normal Glucose

Lymph

predominate/

Low Glucose

Bacteria

-Actinomyces,

Listeria, Brucellosis

Mumps

LCM

NSAIDSSulfa

Behcets

Early Viral

Viral

CNS Malignancy

Endocarditis

Early Mycobacterium

Early Fungal

Mycobacterium

Fungi


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Specific CSF Analysis

Antigen testing Cryptococcus neoformans, HSV, VZV, EBV,

CMV, VDRL

Significant inter- and intralab variability withPCRs

Cultures if routine cultures negative mayneed 10-20 ml of CSF Aerobic

Mycobacterial Fungal

Cytology


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Serum Tests

HIV with ELISA

VDRL/RPR

Serologies

LCM, leptospirosis, Lyme, Ehrlichia, Brucella

Blood cultures x3


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Further Examinations

PPD

CXR

Retinal Exam

Echocardiogram MRI

Rarely lead to specific diagnosis

Focal abnormalities may be useful if brain biopsyconsidered

Meningeal/Brain Biopsy Particularly useful if focal on imaging

Progressive disease despite empiric therapy


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Empiric Therapy

Antituberculous therapy1

In face of negative tuberculin skin test

One study of 28 patients with chronic

meningitis without etiology empiricallytreated

Close to half with responsed to treatment withadditional 11 with improvement in symptoms whileon therapy

Study performed in endemic TB area

Antiviral Therapy

Case reports


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Empiric Steroids

Persistent negative cultures

Infectious etiology though unlikely

Smith et al3

at Mayo Clinic studied 39patients with chronic meningitis of unknown

etiology

Mean duration of symptom was 19 months

Symptoms resolved in 19 of 39 patients 14 of 19 had continued symptoms and 4 had

worsening symptoms


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References

Coyle, PK. Overview of acute and chronic meningitis. Neurol Clin 1999;

17:691.

Sexton, Daniel (Ed). Chronic Meningitis. UpToDate.

Smith, JE, Aksamit, AJ Jr. Outcome of chronic idiopathic meningitis.

Mayo Clin Proc 1994; 69:548.

chronic meningitis hummert

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