Chronic Meningitis Dr. Shatdal Chaudhary

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Approach to a case of Chronic Meningitis

Approach to a case of Chronic Meningitis

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  • 1. Dr. Shatdal Chaudhary Associate Professor Department of Internal Medicine Universal College of Medical Sciences, Bhairahawa, Nepal
  • 2. Definition Chronic 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
  • 3. Five Categories of disease Meningeal infection Malignancy Noninfectious inflammatory disorders Chemical meningitis Parameningeal infections
  • 4. Infectious Causes Bacterial Brucella Francisella tularensis Actinomyces Listeria-unpastuerized Nocardia Rarely partially treated N. Meningitis, Streptococcus or H. Flu
  • 5. 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 of illness
  • 6. Mycobacterium Tuberculosis Bacilli seed to the meninges creating tubercles called “Rich foci” Tubercles that rupture into subarachnoid space causing meningitis Cranial nerve palsies can occur CN VI most frequently affected Up to 40% in children
  • 7. Viral Enterovirus HSV Mollaret’s syndrome- “Benign Recurrent Meningitis” HIV Lymphocytic Choriomeningitis CMV EBV VZV Mumps
  • 8. Other Infectious Etiologies Fungal Cryptococcus, Coccidioides, Sporithrix, Histoplasma Parasitic – Eosinophilic Meningitis Angiostrongylus, Taenia solium, Schistosomiasis, Toxoplasmosis
  • 9. Noninfectious Causes Malignancy Metastastic Ca of Breast, Lung, Pancreas, Lymphoma, Leukaemia, Meningeal gliomatosis Medications/ Chemical: Subarachnoid injection NSAIDS, trimethoprim-sulfamethoxazole Epidermoid tumor, Craniopharyngioma,
  • 10. Rheumatologic/ Noninfectious inflammatory conditions: Sarcoidosis SLE Bechet Syndrome Wegners Disease Vogt-Koyanagi-Harada Syndrome Idiopathic
  • 11. Symptoms Nonspecific and similar to acute meningitis Are determined by anatomical location of inflammation and its consequence.
  • 12. Symptoms  Double vision/visual loss  Hearing loss  Limb weakness  Sphincter dysfunction
  • 13. symptoms Hydrocephalus Cranial neuropathies Radiculopathy Cognitive disturbance Personality changes Presence of underlying systemic illness According to causative agent
  • 14. Historical Clues Travel to endemic areas – eg fungal, parasitic, lyme TB exposure or previous positive skin test Sexual history Tick exposure
  • 15. Historical Clues Medications-specifically NSAIDs Contact with rabbits, cats, wild game or meat processing Recurrent genital or oral ulcers Weight loss, night sweats Rash
  • 16. CSF Analysis Test 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
  • 17. CSF Analysis PMN predominate/ Lymph Low Glucose predominate/ Normal Glucose Bacteria -Actinomyces, Listeria, Brucellosis Mumps LCM NSAIDS Sulfa Behcet’s Early Viral Viral CNS Malignancy Endocarditis Early Mycobacterium Early Fungal Lymph predominate/ Low Glucose Mycobacterium Fungi
  • 18. Specific CSF Analysis Antigen 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 CSF Aerobic Mycobacterial Fungal Cytology
  • 19. Serum Tests HIV with ELISA VDRL/RPR Serologies LCM, leptospirosis, Lyme, Ehrlichia, Brucella Blood cultures x3
  • 20. Further Examinations  PPD  CXR  Retinal Exam  Echocardiogram  MRI  Rarely lead to specific diagnosis  Focal abnormalities may be useful if brain biopsy considered  Meningeal/Brain Biopsy  Particularly useful if focal on imaging  Progressive disease despite empiric therapy
  • 21. Treatment according to Etiological Agent Empiric Therapy Antituberculous therapy Antiviral Therapy Steroids Persistent negative cultures  Infectious etiology though unlikely  Trial of combination of ATT+Antifungal+Steroids