Chronic Meningitis Dr. Shatdal Chaudhary

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Approach to a case of Chronic Meningitis

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Chronic Meningitis Dr. Shatdal Chaudhary

  1. 1. Dr. Shatdal Chaudhary Associate Professor Department of Internal Medicine Universal College of Medical Sciences, Bhairahawa, Nepal
  2. 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. 3. Five Categories of disease Meningeal infection Malignancy Noninfectious inflammatory disorders Chemical meningitis Parameningeal infections
  4. 4. Infectious Causes Bacterial Brucella Francisella tularensis Actinomyces Listeria-unpastuerized Nocardia Rarely partially treated N. Meningitis, Streptococcus or H. Flu
  5. 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. 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. 7. Viral Enterovirus HSV Mollaret’s syndrome- “Benign Recurrent Meningitis” HIV Lymphocytic Choriomeningitis CMV EBV VZV Mumps
  8. 8. Other Infectious Etiologies Fungal Cryptococcus, Coccidioides, Sporithrix, Histoplasma Parasitic – Eosinophilic Meningitis Angiostrongylus, Taenia solium, Schistosomiasis, Toxoplasmosis
  9. 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. 10. Rheumatologic/ Noninfectious inflammatory conditions: Sarcoidosis SLE Bechet Syndrome Wegners Disease Vogt-Koyanagi-Harada Syndrome Idiopathic
  11. 11. Symptoms Nonspecific and similar to acute meningitis Are determined by anatomical location of inflammation and its consequence.
  12. 12. Symptoms  Double vision/visual loss  Hearing loss  Limb weakness  Sphincter dysfunction
  13. 13. symptoms Hydrocephalus Cranial neuropathies Radiculopathy Cognitive disturbance Personality changes Presence of underlying systemic illness According to causative agent
  14. 14. Historical Clues Travel to endemic areas – eg fungal, parasitic, lyme TB exposure or previous positive skin test Sexual history Tick exposure
  15. 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. 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. 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. 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. 19. Serum Tests HIV with ELISA VDRL/RPR Serologies LCM, leptospirosis, Lyme, Ehrlichia, Brucella Blood cultures x3
  20. 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. 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

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