CHRONIC MENINGITIS Dr. Dino Sgarabotto Malattie Infettive e Tropicali Azienda Ospedaliera di Padova
DEFINITION <ul><li>Meningeal Symptoms lasting four weeks or more </li></ul><ul><li>Symptoms can be constant, fluctuate or ...
ETIOLOGY <ul><li>Infectious </li></ul><ul><ul><li>Bacterial, Mycobacterial, Spirochete, Viral, Fungal, Parasitic </li></ul...
BACTERIAL <ul><li>Brucella </li></ul><ul><li>Francisella tularensis </li></ul><ul><li>Actinomyces </li></ul><ul><li>Lister...
SPIROCHETES <ul><li>Treponema pallidum </li></ul><ul><ul><li>Disseminates during early infection </li></ul></ul><ul><ul><l...
MYCOBACTERIUM TUBERCULOSIS <ul><li>Bacilli seed to the meninges creating tubercles called “Rich foci” </li></ul><ul><li>Tu...
VIRAL <ul><li>Enterovirus </li></ul><ul><li>HSV </li></ul><ul><ul><li>Mollaret’s syndrome- “Benign Recurrent Meningitis” <...
OTHER INFECTIOUS ETIOLOGIES <ul><li>Fungal </li></ul><ul><ul><li>Cryptococcus, Coccidioides, Sporithrix, Histoplasma </li>...
NONINFECTIOUS <ul><li>Malignant </li></ul><ul><li>Medications – NSAIDS, trimethoprim-sulfamethoxazole </li></ul><ul><li>Sa...
SYMPTOMS <ul><li>Nonspecific and similar to acute meningitis </li></ul>
HISTORICAL CLUES <ul><li>Travel to endemic areas – eg fungal, parasitic, lyme </li></ul><ul><li>TB exposure or previous po...
HISTORICAL CLUES <ul><li>Medications-specifically NSAIDs </li></ul><ul><li>Contact with rabbits, cats, wild game or meat p...
CSF ANALYSIS Test Bacterial Viral Fungal Parasitic Opening Pressure Elevated Usually normal Variable Variable White blood ...
CSF ANALYSIS PMN predominate/ Low Glucose  Lymph predominate/ Normal Glucose Lymph predominate/ Low Glucose Bacteria -Acti...
SPECIFIC CSF ANALYSIS <ul><li>Antigen testing  </li></ul><ul><ul><li>Cryptococcus neoformans, HSV, VZV, EBV, CMV, VDRL </l...
SERUM TESTS <ul><li>HIV with ELISA </li></ul><ul><li>VDRL/RPR </li></ul><ul><li>Serologies </li></ul><ul><ul><li>LCM, lept...
FURTHER EXAMINATIONS <ul><li>PPD </li></ul><ul><li>CXR </li></ul><ul><li>Retinal Exam </li></ul><ul><li>Echocardiogram </l...
EMPIRIC THERAPY <ul><li>Antituberculous therapy 1 </li></ul><ul><ul><li>In face of negative tuberculin skin test </li></ul...
EMPIRIC STEROIDS <ul><li>Persistent negative cultures </li></ul><ul><li>Infectious etiology though unlikely </li></ul><ul>...
REFERENCES <ul><li>Coyle, PK. Overview of acute and chronic meningitis. Neurol Clin 1999; 17:691. </li></ul><ul><li>Sexton...
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Chronic meningitis

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Chronic meningitis

  1. 1. CHRONIC MENINGITIS Dr. Dino Sgarabotto Malattie Infettive e Tropicali Azienda Ospedaliera di Padova
  2. 2. DEFINITION <ul><li>Meningeal Symptoms lasting four weeks or more </li></ul><ul><li>Symptoms can be constant, fluctuate or slowly worsen </li></ul><ul><li>Clinical course can vary widely between patients </li></ul>
  3. 3. ETIOLOGY <ul><li>Infectious </li></ul><ul><ul><li>Bacterial, Mycobacterial, Spirochete, Viral, Fungal, Parasitic </li></ul></ul><ul><li>Malignancy </li></ul><ul><li>Medications </li></ul><ul><li>Rheumatologic </li></ul><ul><li>Idiopathic </li></ul>
  4. 4. BACTERIAL <ul><li>Brucella </li></ul><ul><li>Francisella tularensis </li></ul><ul><li>Actinomyces </li></ul><ul><li>Listeria-unpastuerized </li></ul><ul><li>Ehrlichia chaffeensis </li></ul><ul><li>Nocardia </li></ul><ul><li>Rarely partially treated N. Meningitis, Streptococcus or H. Flu </li></ul>
  5. 5. SPIROCHETES <ul><li>Treponema pallidum </li></ul><ul><ul><li>Disseminates during early infection </li></ul></ul><ul><ul><li>Serum and CSF VDRL typically positive </li></ul></ul><ul><li>Lyme Meningitis </li></ul><ul><ul><li>Typically late summer and early fall </li></ul></ul><ul><ul><li>Travel to endemic area </li></ul></ul><ul><ul><li>History consistent with erythema migrans </li></ul></ul><ul><li>Leptospirosis </li></ul><ul><ul><li>Meningeal symptoms develop in 50% of patients during anicteric second stage of illness </li></ul></ul>
  6. 6. MYCOBACTERIUM TUBERCULOSIS <ul><li>Bacilli seed to the meninges creating tubercles called “Rich foci” </li></ul><ul><li>Tubercles that rupture into subarachnoid space causing meningitis </li></ul><ul><li>Cranial nerve palsies can occur </li></ul><ul><ul><li>CN VI most frequently affected </li></ul></ul><ul><ul><li>Up to 40% in children </li></ul></ul>
  7. 7. VIRAL <ul><li>Enterovirus </li></ul><ul><li>HSV </li></ul><ul><ul><li>Mollaret’s syndrome- “Benign Recurrent Meningitis” </li></ul></ul><ul><li>HIV </li></ul><ul><li>Lymphocytic Choriomeningitis </li></ul><ul><li>CMV </li></ul><ul><li>EBV </li></ul><ul><li>VZV </li></ul><ul><li>Mumps </li></ul>
  8. 8. OTHER INFECTIOUS ETIOLOGIES <ul><li>Fungal </li></ul><ul><ul><li>Cryptococcus, Coccidioides, Sporithrix, Histoplasma </li></ul></ul><ul><li>Parasitic – Eosinophilic Meningitis </li></ul><ul><ul><li>Angiostrongylus, Taenia solium, Schistosomiasis, Toxoplasmosis </li></ul></ul>
  9. 9. NONINFECTIOUS <ul><li>Malignant </li></ul><ul><li>Medications – NSAIDS, trimethoprim-sulfamethoxazole </li></ul><ul><li>Sarcoidosis </li></ul><ul><li>Behcet’s syndrome </li></ul><ul><li>Systemic Lupus Erythematous </li></ul><ul><li>Endocarditis </li></ul>
  10. 10. SYMPTOMS <ul><li>Nonspecific and similar to acute meningitis </li></ul>
  11. 11. HISTORICAL CLUES <ul><li>Travel to endemic areas – eg fungal, parasitic, lyme </li></ul><ul><li>TB exposure or previous positive skin test </li></ul><ul><li>Sexual history </li></ul><ul><li>Tick exposure </li></ul>
  12. 12. HISTORICAL CLUES <ul><li>Medications-specifically NSAIDs </li></ul><ul><li>Contact with rabbits, cats, wild game or meat processing </li></ul><ul><li>Recurrent genital or oral ulcers </li></ul><ul><li>Weight loss, night sweats </li></ul><ul><li>Rash </li></ul>
  13. 13. 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
  14. 14. CSF ANALYSIS PMN 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
  15. 15. SPECIFIC CSF ANALYSIS <ul><li>Antigen testing </li></ul><ul><ul><li>Cryptococcus neoformans, HSV, VZV, EBV, CMV, VDRL </li></ul></ul><ul><ul><li>Significant inter- and intralab variability with PCRs </li></ul></ul><ul><li>Cultures – if routine cultures negative may need 10-20 ml of CSF </li></ul><ul><ul><li>Aerobic </li></ul></ul><ul><ul><li>Mycobacterial </li></ul></ul><ul><ul><li>Fungal </li></ul></ul><ul><li>Cytology </li></ul>
  16. 16. SERUM TESTS <ul><li>HIV with ELISA </li></ul><ul><li>VDRL/RPR </li></ul><ul><li>Serologies </li></ul><ul><ul><li>LCM, leptospirosis, Lyme, Ehrlichia, Brucella </li></ul></ul><ul><li>Blood cultures x3 </li></ul>
  17. 17. FURTHER EXAMINATIONS <ul><li>PPD </li></ul><ul><li>CXR </li></ul><ul><li>Retinal Exam </li></ul><ul><li>Echocardiogram </li></ul><ul><li>MRI </li></ul><ul><ul><li>Rarely lead to specific diagnosis </li></ul></ul><ul><ul><li>Focal abnormalities may be useful if brain biopsy considered </li></ul></ul><ul><li>Meningeal/Brain Biopsy </li></ul><ul><ul><li>Particularly useful if focal on imaging </li></ul></ul><ul><ul><li>Progressive disease despite empiric therapy </li></ul></ul>
  18. 18. EMPIRIC THERAPY <ul><li>Antituberculous therapy 1 </li></ul><ul><ul><li>In face of negative tuberculin skin test </li></ul></ul><ul><ul><li>One study of 28 patients with chronic meningitis without etiology empirically treated </li></ul></ul><ul><ul><ul><li>Close to half with responsed to treatment with additional 11 with improvement in symptoms while on therapy </li></ul></ul></ul><ul><ul><ul><li>Study performed in endemic TB area </li></ul></ul></ul><ul><li>Antiviral Therapy </li></ul><ul><ul><li>Case reports </li></ul></ul>
  19. 19. EMPIRIC STEROIDS <ul><li>Persistent negative cultures </li></ul><ul><li>Infectious etiology though unlikely </li></ul><ul><li>Smith et al 3 at Mayo Clinic studied 39 patients with chronic meningitis of unknown etiology </li></ul><ul><ul><li>Mean duration of symptom was 19 months </li></ul></ul><ul><ul><li>Symptoms resolved in 19 of 39 patients </li></ul></ul><ul><ul><li>14 of 19 had continued symptoms and 4 had worsening symptoms </li></ul></ul>
  20. 20. REFERENCES <ul><li>Coyle, PK. Overview of acute and chronic meningitis. Neurol Clin 1999; 17:691. </li></ul><ul><li>Sexton, Daniel (Ed). “Chronic Meningitis”. UpToDate. </li></ul><ul><li>Smith, JE, Aksamit, AJ Jr. Outcome of chronic idiopathic meningitis. Mayo Clin Proc 1994; 69:548. </li></ul>
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