International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
The main aim of Corona is transmission of disease from person to person, and it had also been declared as a global pandemic which has caused disaster in the respiratory system of more than five million people and killed more than half a billion people across the world. Patients surviving from Covid-19 have lower immunosuppressive CD4+ T and CD8+ T Cells. And most of the patients are in severe need of mechanical ventilation. This is the reason for a longer stay in hospital for a particular patient. Gradually, these patients have been discovered to develop fungal co-infection. This infection is deadly leading to loss of hearing, loss of sight and eventually death. The fungal infection is referred to as Mucormycosis, the black fungus. The causative agent for this infection is Mucormycotina which is a member of Mucorales. Mucormycotina usually habitats in soil and decaying organic matter. The infection of Mucormycotina is associated with a wide range of human diseases including arthritis, gastritis, renal disorders and pulmonary diseases. This infection is closely associated with the mucous layer of skin, precisely cutaneous layer. This infection is present in the nasal and upper respiratory tract. In the lower respiratory tract these infections are difficult to diagnose and treat due to the lack of precise methods. It was found those neutroponia patients are more
prone to this infection. This is caused by extensive use of chemotherapy resulting in impaired immunity. In recent times, in the case of pulmonary Mucormycosis, necrotizing pneumonia is a major symptom. A combination of antifungal and antimicrobial
agents is being used for a higher clinical recovery in the Mucormycosis case.
Multisystem Inflammatory Syndrome in Children MIS C and Covid 19ijtsrd
Multisystem inflammatory syndrome in children MIS C may be a serious condition that appears to be linked to corona virus disease 2019 COVID 19 . MIS C is taken into account a syndrome - a gaggle of signs and symptoms, not a disease — because much is unknown about it, including its cause and risk factors. Most of the young children who become infected with the COVID 19 virus have only a light illness. The matter with MIS C caused by Covid 19 is that it develops into severe inflammation during a few hours requiring admission of the patient into a medical care unit. The signs and symptoms depend upon which areas of the body are affected. The precise explanation for MIS C isnt known yet. Many specialists consider MIS C to be a complication of COVID 19. Without early diagnosis and appropriate management and treatment, MIS C can cause severe problems with vital organs, like the heart, lungs or kidneys. In rare cases, MIS C could end in permanent damage or may be death. Mrs. Minu. S. R "Multisystem Inflammatory Syndrome in Children (MIS-C) and Covid -19" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-2 , February 2021, URL: https://www.ijtsrd.com/papers/ijtsrd38412.pdf Paper Url: https://www.ijtsrd.com/medicine/nursing/38412/multisystem-inflammatory-syndrome-in-children-misc-and-covid-19/mrs-minu-s-r
This presentation on Adenovirus was prepared and presented by me and my classmate.This topic generally comes under subject of virology. Hope you will find it helpful. Thank you.
Meningitis is always cerebrospinal infection. Meningitis is a rare infection that affects the delicate membranes -- called meninges -- that cover the brain and spinal cord.There are several types of this disease, including bacterial, viral, and fungal.
The main aim of Corona is transmission of disease from person to person, and it had also been declared as a global pandemic which has caused disaster in the respiratory system of more than five million people and killed more than half a billion people across the world. Patients surviving from Covid-19 have lower immunosuppressive CD4+ T and CD8+ T Cells. And most of the patients are in severe need of mechanical ventilation. This is the reason for a longer stay in hospital for a particular patient. Gradually, these patients have been discovered to develop fungal co-infection. This infection is deadly leading to loss of hearing, loss of sight and eventually death. The fungal infection is referred to as Mucormycosis, the black fungus. The causative agent for this infection is Mucormycotina which is a member of Mucorales. Mucormycotina usually habitats in soil and decaying organic matter. The infection of Mucormycotina is associated with a wide range of human diseases including arthritis, gastritis, renal disorders and pulmonary diseases. This infection is closely associated with the mucous layer of skin, precisely cutaneous layer. This infection is present in the nasal and upper respiratory tract. In the lower respiratory tract these infections are difficult to diagnose and treat due to the lack of precise methods. It was found those neutroponia patients are more
prone to this infection. This is caused by extensive use of chemotherapy resulting in impaired immunity. In recent times, in the case of pulmonary Mucormycosis, necrotizing pneumonia is a major symptom. A combination of antifungal and antimicrobial
agents is being used for a higher clinical recovery in the Mucormycosis case.
Multisystem Inflammatory Syndrome in Children MIS C and Covid 19ijtsrd
Multisystem inflammatory syndrome in children MIS C may be a serious condition that appears to be linked to corona virus disease 2019 COVID 19 . MIS C is taken into account a syndrome - a gaggle of signs and symptoms, not a disease — because much is unknown about it, including its cause and risk factors. Most of the young children who become infected with the COVID 19 virus have only a light illness. The matter with MIS C caused by Covid 19 is that it develops into severe inflammation during a few hours requiring admission of the patient into a medical care unit. The signs and symptoms depend upon which areas of the body are affected. The precise explanation for MIS C isnt known yet. Many specialists consider MIS C to be a complication of COVID 19. Without early diagnosis and appropriate management and treatment, MIS C can cause severe problems with vital organs, like the heart, lungs or kidneys. In rare cases, MIS C could end in permanent damage or may be death. Mrs. Minu. S. R "Multisystem Inflammatory Syndrome in Children (MIS-C) and Covid -19" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-5 | Issue-2 , February 2021, URL: https://www.ijtsrd.com/papers/ijtsrd38412.pdf Paper Url: https://www.ijtsrd.com/medicine/nursing/38412/multisystem-inflammatory-syndrome-in-children-misc-and-covid-19/mrs-minu-s-r
This presentation on Adenovirus was prepared and presented by me and my classmate.This topic generally comes under subject of virology. Hope you will find it helpful. Thank you.
Meningitis is always cerebrospinal infection. Meningitis is a rare infection that affects the delicate membranes -- called meninges -- that cover the brain and spinal cord.There are several types of this disease, including bacterial, viral, and fungal.
Splenic Abscess: Etiology, clinical spectrum and Therapyiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
Chronic Pneumonia: Update on Clinical Manifestations, Diagnosis and Therapyiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
AIDS stands for: Acquired Immune Deficiency Syndrome
AIDS is a medical condition. A person is diagnosed with AIDS when their immune system is too weak to fight off infections.
Since AIDS was first identified in the early 1980s, an unprecedented number of people have been affected by the global AIDS epidemic. Today, there are an estimated 33.3 million people living with HIV and AIDS worldwide.
http://www.pediatricdentists.blogspot.com
This week, cerebrospinal meningitis is on the news. This disease, which is majorly prevalent during the dry season has been reported to be ravaging five states in the North-West region of Nigeria including- Zamfara, Sokoto, Kebbi, Katsina and Niger States.
ABSTRACT
Background: With the advances in medical care, invasive fungal
infections possess a significant health problem especially in
immunocompromised patients. These infections have varied aetiological
agents which are commonly found in soil, water, plant debris and organic
substrates. Aim: The overview of different fungal aetiological agents,
newer and rapid diagnostic modalities and overall treatment and
prevention options available is presented in this article. Methods:
Literature search was performed in PubMed by using MeSH terms
‘mycoses’ and ‘immunocompromised host’. Only relevant review articles
published within the last five years were considered. Google Scholar
search engine was also used. Results: Common invasive fungi include
Candida spp., Cryptococcus spp., Aspergillus spp., Trichosporon spp.,
Rhodotorula spp., Fusarium spp., Mucormycotina, Pheohyphomycosis
spp., Pneumocystis jirovecii, Scedosporium spp., and endemic mycoses
such as Penicillium, Histoplasma and Blastomyces. A high degree of
suspicion is required for early diagnosis and optimal management of these
infections. Conclusion: Early and rapid diagnosis of causative fungal
agents is required so that appropriate treatment can be initiated. Adequate
preventive measures must be applied in an immunocompromised host that
can prevent development of drug resistant super-infections.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Are There Any Natural Remedies To Treat Syphilis.pdf
Diagnostic Approaches to Chronic Fungal and Tuberculous Meningitis
1. International Journal of Pharmaceutical Science Invention
ISSN (Online): 2319 – 6718, ISSN (Print): 2319 – 670X
www.ijpsi.org || Volume 4 Issue 1|| January 2015 || PP.06-12
www.ijpsi.org 6 | Page
Diagnostic Approaches to Chronic Fungal and Tuberculous
Meningitis
Murtaza Mustafa1
, MS.Rahman2
, SS.Husain3
, MTH.Parash4
, SC.Shimmi5
Faculty of Medicine and Health Sciences, University Malaysia, Sabah, Kota Kinabalu,
Sabah, Malaysia.
ABSTRACT: Bacterial meningitis is common in Brazil and in endemic region of Sub-SaharanAfrica.
Chronicmeningitis (CM) is defined as meningitis lasting for four weeks or more and have signs of chronic
inflammation in the cerebrospinal fluid.CM is a diagnostic dilemma, with limited literature on the subject.CM is
common in immunocompromised, immunocompetent and in patients infected with immunodeficiency virus
(AIDS).Less common Mollaret’s meningitis and Bachet’sdisease, a chronic multisystem disorder. Common
pathogens isolated include enteroviruses,Mycobacterium tuberculosis,Cryptococcus neoformans, Treponema
pallidum,Coccidioides immitis,rare pathogens include Angiostrongylus cantonennesis, Naegleriafowleri.
Treatment of choice in tuberculous meningitiswith four-drug regimen,and amphotericin B with flucocytosine or
fluconazole for 4 to 6 weeks for cryptococcal meningitis. Prompt diagnosis and antibiotic therapy with long-
term follow up have a better outcome.
KEYWORDS: Chronic meningitis,Cryptococcal meningitis,Tuberculous meningitis,Diagnosis,
I. INTRODUCTION
Meningitis is a notifiable disease in many countries, the exact incidence rate is unknown [1].As of 2010
it is estimated that meningitis resulted in 420,000 deaths excluding cryptococcal meningitis [2,3].Bacterial
meningitis occurs in 3 people per 100,000 annually in Western countries. In Brazil, the rate of bacterial
meningitis is higher, at 45.8 per 100,000 annually[4].Sub-Saharan Africa has been plagued by large epidemics
of meningococcal meningitis for over century, leading it being labelled the “meningitis belt” [5].Meningococcal
disease occurs in epidemics in areas where many people live together for first time, such as army barracks
during mobilization, college campuses and the annual Hajj pilgrimage(visit to Holy Land in Saudi
Arabia)[6,7].There are local differences in the local distribution of causes for bacterial meningitis.For instance,
while N.meningitidis group B and C cause most disease episodes in Europe, group A is found in Asia and
continues to dominate in Africa, with 80 to 85 % of documented meningococcal meningitis cases [8].Chronic
meningitis(CM) is defined as patients with chronic central nervous system infection for at least four weeks and
have signs of chronic inflammation in the cerebrospinal fluid[9]CM is common in immunocompromised,
immunocompetent and in patients infected with immunodeficiency virus (AIDS).CM is characterized by a
progressive,sub- acute onset of lepomeningeal disease and persisting cerebrospinal(CSF) abnormalities such as
elevated protein level and pleocytosis for at least one month[10].Frequently isolated pathogens in chronic
meningitis include viruses(enteroviruses,herpesvirus,type 2,varicella zoster virus,Mollaret’s meningitis a
chronic recurrent form of herpes meningitis),bacterial(Mycobacterium tuberculosis,N.meningitidis,group B
streptococci, Treponema pallidum Borrelia burgdoerferi(lymediseases), fungal (Cryptococcus neofomans,
Coccidioides immitis, Histoplasma capsulatum, Blastomycesdermatitidis, Candidaalbican)and parasitic
(Angiostrongylus cantonnensis and Naegleria fowleri).Noninfectious include Becher’s disease, a chronic
multisystem disorder [11].Differential diagnosis include tests for inflammatory markers(e.g.C-reactive
protein)FBC,CSF examination, computedtomography(CT),or magnetic resonance imaging(MRI)[12].Empiric
treatment with broad –spectrum antibiotics and mechanical ventilation as required. The paper reviews the
current literature, etiologies, clinical presentation and therapy of chronic meningitis.
II. HISTORICAL PERSPECTIVE
Some authorities suggest that Hippocrates may have realized the existence of meningitis, and it seems
that meningsm was known to pre-Renaissance physicians such as Avicenna(Ibnu-senna)[4,13].The description
of tuberculous meningitis, then called “dropsy in the brain”, is often attributed to Edinburgh physician Sir
Robert Whytt in a postmothous report that appeared in 1768,although the link with tuberculosis and its pathogen
was not made until next century[13].It appears that epidemic meningitis is a relatively recent
phenomenon[14].The first recorded major outbreak occurred in Geneva in 1805[14].Several other epidemics in
Europe and the United States were described shortly afterward, and first report of an epidemic in Africa
appeared in 1840.Africal epidemics became much more common in the 20th
century,strating with a major
2. Diagnostics approaches to chronic…
www.ijpsi.org 7 | Page
epidemic sweeping Nigeria and Ghana in 1905-1908[14]. The first report of bacterial infection underlying
meningitis was by the Austrian bacteriologist Anton Weichselbaum,who in 1887 described the
meningococcus[15].Mortality from meningitis was very high(over 90%) in early reports. In 1906,antiserum was
produced in the horses, this was developed further by the American scientist Simon Flexner and markedly
decreased mortality from meningococcal disease[16].In 1944,pencillin was reported to be effective in
meningitis[17].The introduction in the late 20th
century of Haemophilus vaccines let to a marked fall in cases
associated with this pathogen[18],and in 2002 evidence emerged that treatment with steroids could improve the
prognosis of bacterial meningitis[16].
III. ETIOLOGIC AGENTS
Fungal agents of meningitis. Cryptococcalmeningitis. Cryptococcus neoformans and Cryptococcus gattii are
the most common causes of fungal meningitis [19].The majority of patients are immunosuppressed, but the
previously healthy patients with cryptococcosis has fewer organisms in CSF and present more of a diagnostic
dilemma. In the latter group, symptoms can be indolent, with headaches present for weeks or months
[19].Dementia may attract attention only after automobile accident or inattention to business or personal matters
create a crisis. Skinlesions precede meningeal symptoms in about 10% of patients and are useful for diagnosis.
MRI is most often normal unless hydroenchalitis has supervened.CSF cultures of AIDS patients with
cryptococcal meningitis became positive in few days, but CSF cultures from indolently ill patients may require
2- weeks incubation and culture of more than 1 ml.of CSF.CSF antigen being more often positive than serum
antigen, with the CSF antigen being negative only in most indolent patients, those being the patients with
profound hypoglycorrhachia,high protein level and high cell count[19].
HistoplasmaMeningitis. Chronic meningitis can be the presenting sign of Histoplasma meningitis in previously
healthy patients or may be part of more systemic illness, particularly in the immunocompromised patients.
Patients at risk of dissemination to brain and other organs include patients with AIDS, solid organ transplant
recipients, or those taking adrenal corticosteroids or tumor necrosis factor-α(TNFα) inhibitors[20].Signs of
dissemination outside the neuraxis, if present, are extremely variable, including Addison’s disease, chronic
granulomatous hepatitis,endocarditis, orpancytopenia. Patients do not give a historysuggesting acute pulmonary
histoplasmosis before the diagnosis of meningitis. Accompanying pulmonary symptoms are minimal or absent.
MRI may show an intracerebral granuloma in some patients. Histoplasma antigen or antibody may be detected
in the CSF.CSF cultures are usually negative, though a high -volume of culture is occasionally successful.
Serum or urine test is negative unless dissemination is suggested by nonneural findings [19].
Candida Meningitis. Candida is commonly found in multiple small brain abscesses in patients dying of
disseminated candidiasis, but presentation as chronic meningitis is rare. Most such patients are very low birth
weight newborns or post neurosurgery or immunosuppressed patients [21].Newborns with Candida meningitis
have typically had long stays in the neonatal intensive care unit and required prolonged use of intravascular
catheters. Others are infants with severe congenital abnormalities of the intestine or urinary tract required
complicated surgical repair. Candida enters the bloodstream through intravascular catheters from complications
of intestinal surgery or from an obstructed urinary tract. Difficulty assessing the neurologic status of these
newborns and the absence of fever cause delay in diagnosis. Hydrocephalus may already be present when the
diagnosis of Candida meningitis is made.CSF is markedly abnormal, but culture has such few organisms that
contamination of the CSF culture may be suspected [22].CSF shunts infected with Candida may present as
partial or complete blockage of the shunt, usually in children with multiple shunt revisions or skin ulcers over
the shunt valve or tubing. Patients with hematologic malignancies may develop meningitis as a part of
disseminated candidiasis. Meningitis may only be recognized after antifungal therapy and return od marrow
function has allowed control of the other manifestations of disseminations of disseminated candidiasis [22].
CoccidioidalMeningitis.Principal areas of exposure for coccidioidal meningitis are central and southern
Arizona and Central Valley of California, though the endemic area is much broader. Spotty endemic areas exist
in contiguous parts of the Southwest. Winds can carry the spores’ long distances outside the endemic area.
Extremely briefexposure of visitors from outside the endemic area is sufficient to cause infection.The initial
illness may be diagnosed as a community acquired pneumonia and seem to improve temporarily with
antibiotics.0r the initial respiratory phase may not even prompt medical attention. Previously healthy people
with meningitis may present with indolent onset of headache, present for weeks or months at time of diagnosis.
The pulmonaryportal, prominent earlier, at the time symptoms of meningitis appear may be only visible as hilar
adenopathy or a small pulmonary infiltrate.The patient may recall the pneumonia as a period of fever and cough
occurring 2 to 4 weeks following exposure [23].Immunosuppressed patients, including those with AIDS are
more likely to present with systemic illness, including fever, headache, profound malaise, and lesions in bone or
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skin. The chest x-rays of immunosuppressed patients may show single or diffuse infiltrates.Low grade
eosinophilia in the blood and more commonly the CSF is a valuable sign; through Wright-Giemsa staining of
CSF may be needed to detect eosinophilia. The single best test is not culture or smear of CSF,which are
uncommonly positive, but positive complement fixation test done in a reliable reference laboratory [24].The
complement fixation test on CSF is specific and sensitive.CSF antibody detected by an immunodiffusion test
with a band of identity is useful screen because it is sensitive, but it is less specific than the complement fixation
test.None of the commercially available enzyme-linked immunosorbent assays (ELISAs) have sufficient
sensitivity or sensitivity to be useful and may be misleading.Serum complement fixation tests are usually
positive but remain positive after remote infection, a so- called serologic scar[23].
BlastomycosisMeningitis. Patients with blastomycosis present with one or more brain abscesses in the central
nervous system. When a brain abscess ruptures into the ventricular system, a rapidly progressive purulent
meningitis results with a strong tendency to obstruct the aqueduct of sylvius, accelerating the progression to
coma.Skin, bone, or lung lesions of blastomycosis are present in most patients and permit diagnosis [19].
SporotrichosisMeningitis. The published cases of sporotrichosis meningitis due to Sporotrichum schenckii
have presented formidable diagnostic difficulties because the organism has proven very difficult to recover in
CSF cultures. A few cases have had disseminated skin lesions that provided a site for biopsy diagnosis.
Infection has occurred in previously healthy and in immunosuppressed patients [25]
PhaeohyphomycosisMeningitis.Dark-walled molds have a predisposition for spread to the brain, causing a
brain abscess,phaeohyphomycosis meningitis or both,CSF cultures are sterile and brain biopsy is required for
diagnosis Most patients are previously healthy and have no visible pulmonary portal or other disease outside the
central nervous system. Because these molds can be air contaminants in a culture, the rare positive CSF culture
may bedisregarded as a contaminants [26,27]
Miscellaneous fungal Meningitis.Several less significant fungal agents has been involved in CNS infection.
Scedosporium prolificans, and scedosporium apiospermum infections have a predisposition for hematogenous
spread to CNS,usually presenting a brain abscess but occasionally as chronic meningitis. Immunosuppression is
present in majority of patients, though intravenous drug users may also develop the infection. Patients with
aspergillosis and mucromycosis in the CNS and commonly present with angioinvasion with hemorrhagic
infection, not chronic meningitis [19].
IV. BACTERIAL MENINGITIS.
Tuberculous meningitis is probably the most common cause of chronic meningitis, and because diagnosis can
be difficult, Mycobacterium tuberculosis is the agent that may be treated empirically when all other diagnostic
measures fail. Children with hematogenously disseminated tuberculosis are prone to a more rapid course than is
typical for adults, with as little as 2 to 4 weeks of symptoms before diagnosis. Fever, miliary lesions in the lung,
andretina, marrowsuppression, and hepatosplenomegaly may herald the systemic disease, whereas headache
followed by confusion and coma portend a poor prognosis from CNS disease[19].Disease in previously healthy
adults tends to be more indolent with fewer signs of disseminated tuberculosis other than fever, weight loss,
night sweats, and malaise. Chest x-rays is normal in only about half of patients. Diagnosis is suspected from
country of origin or household exposure to tuberculosis, both occurring years before symptoms are evident.
Tuberculin skin test and interferon-ɣ(IFN-ɣ) test may be negative, and neither support or exclude the diagnosis.
MRI may be normal or show small lesions in the cortical sulci or may show hydrocephalus. Hypoglycorrachia is
usual, as are pleocytosis of up to a few hundred cells and an elevated protein level. Adenosine deaminase may
be elevated in the CSF but is not more helpful than low CSF glucose. Smear rarely demonstrate acid- fast
bacilli. Culture in automated broth culture techniques is positive in half the cases but requires about 2 weeks of
incubation, often two slow to assist early therapeutic diagnosis [19].The old literature spoke of taking the clot
that forms in CSF from tuberculosis patient as it stands the so-called pellicle and using those clumped strands of
cells and clot from several milliliters of CSF for smear and culture. Although no modern laboratory would
consider using such a time-consuming technique, the popularity of the technique speaks to small inoculum of
organisms in the CSF and need for culturing more than minimal volumes of CSF.The Gen-Probe MTB Direct
test is not approved for use on CSF, but the problem is lack of sensitivity not false-positive results, making this
test important for early diagnosis. Although many referral laboratories are offering PCR diagnosis, the lack of
standardization makes interpretation difficult [19].
SyphliticMeningitis. Treponema pallidum is the agent of syphilitic meningitis.CNS manifestations of syphilis
are not as easily divided into categories as might be desired. Secondary syphilis causes aseptic meningitis, but
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illness resolves either spontaneously or with therapy so that chronicity at this stage of infection is
uncommon.Meningovascular syphilis is a later complication that occurs 2 to 10 years after infection as an
ischemic stroke in a young person. Presenting symptoms of parenchymal disease are gumma formation or
general paresis,15 to 20 years after infection, or tabes dorsalis even later. General paresis has prominent
encephalopathy signs and may have ocular signs as well [19].Tabes dorsalis has prominent spinal cord signs and
symptoms with radicular pain (“Lightning pains”)that sets it symptoms apart from usual patient with chronic
meningitis in whom spinal cord symptoms are uncommon.Patients with neurosyphlis, although uncommon
present simply with chronic meningitis with a CSF pleocytosis and elevated protein level but normal glucose
level. Some of these patients will have a waxing and waning course, perhaps beginning when they had
secondary syphilis .A significant minority have a negative nontreponemaltests, such as VDRL or RPR on serum
and CSF. These can be falsely positive in the presence of an otherwise unexplained abnormal CSF ,a history of
multiple sexual partners or sexually transmitted diseases, and clinical signs compatible with chronic meningitis,
a serum treponemal test should be performed[19].There is no no “gold standard test”.The FTA-abs (flurorescent
treponemal antibody-absorbed),TPPA(Treponema pallidum particle agglutination),MHA-TP(microaggultination
antibody-Treponema pallidum),TPHa(Treponema pallidum hemaggultination),and EIA(enzyme immunoassay)
are all useful test varying in specificity and sensitivity.Westren blot test are now rarely performed.Referral
laboratories prefer automated EIA tests, which use one or more cloned antigens or protein from Treponema
pallidum subsp. pallidum. Sensitivity and specificity vary so widely that clinical decision is difficult to make
without knowing performance characteristics of the test.In the presence of negative RPR or VDR, a positive
EIA-IgG should be confirmed with another treponemal test[28].
Norcardiosis and Actinomycoses.Nocardiosis has a strong tendency for hematogenous spread from lungs to
brain. An acute or sub-acute meningitis can result from rupture of an abscess into CSF, Actinomycosis can cross
the dura from a contiguous infection in the paranasal sinus or middle ear and can cause an indolent meningitis.
The organism are rarely isolated from the CSF .Infection is predominantly parameningeal[19].
Lyme Borreliosis.Central nervous system disease can occur weeks to months after infection with
Borelliaburgdoferi.Cranial nerve palsies are common, unlike syphilitic meningitis. Cognitive decline and ataxia
may occur because of encephalitis .Seizures, ataxia, painful radiculopathy, or rarely meningitis may also
occur.CSF shows a modest pleocytosis, slight elevation of protein levels, and normal glucose level. HA and
Westren blot for IgG antibody in CSF are helpful but probable insensitive.PCR detection in CSF is under
evaluation but appears promising [19].
Brucellosis.Now rare in the United States, brucellosisremains a common disease in many countries. Ingestion
of unpasteurized dairy products from other countries, such as soft cheese is a common source of infection in the
United States. Illness is usually acute but may be relapsing or occasionally chronic. A few patients with chronic
meningitis have been reported, but positive CSF cultures have been unusual. Serum Brucella agglutinins and an
exposure history are helpful to screen patients .Serologies for brucellosis other than agglutinin are not
recommended [19].
Parasitic agents of Maningitis. Unlike Naegleria (Naegleriafowleri, meningitis contracted from freshwater
sources[30])which causes acute meningitis cerebral manifestation of Acanthamoeba infections evolve over few
weeks, with decreased mental status,seizures, fever, headache, meningitis, visua ldisturbance, and ataxia, with
hemiparesis as a later manifestation.Most reported patients have suppressed immune function such as patients
with AIDS or stem cell transplant recipients.Other have been chronically ill and debilitated [19].Angiostrongylus
cantonensis is a common cause of meningitis in the United States have been in the travelers recently returned
from the pacific,Hawaii, or the Caribbean, who acquired infection from eating uncooked produce. Patients
present with an acute eosinophilic meningitis ,though symptoms can linger for several weeks[30].Other parasites
implicated are Gnathostoma spinigerum, Schistosoma, as well as the conditions cysticcercosis ,toxocariasis,
baylisascariasis, paragonimiasis, and a number of rare infections and noninfectious conditions[31].
V. CLINICAL MANIFESTATION AND DIAGNOSIS
Patients with chronic meningitis have the indolent onset symptoms compatible with chronic central
nervous system infection for at least four weeks and have signs of chronic inflammation in the cerebrospinal
fluid[9].This entity must be distinguished in the history from recurrent aseptic meningitis or persistent sequelae
of encephalitis. A careful history from patient or family member may be needed to date the onset of symptoms
and distinguish chronic from recurrent meningitis. What may have seemed like a sudden onset may on further
questioning, have been the culmination of a longer process, Symptoms of chronic meningitis can wax and wane
over weeks and months. An abnormal CSF may not have been repeated to see if improved symptoms were
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accompanied by improved CSF abnormalities. Early symptoms of chronic meningitis include headache, nausea,
and decreased memory and comprehension. When hydrocephalus complicates indolent meningitis, dementia can
be prominent finding, better related by family members than the patient. Later symptoms of chronic meningitis
include decreased vision, double vision or other cranial nerve palsies, unsteady gait, emesis, and confusion
[32,25].Patients with chronic meningitis may have a normal physical examination. Including absence of fever.
Neurologic examination is most frequent abnormality, with decreased recent and remote memory, confusion,
and apathy, papilledema, and cranial nerve palsies, particularly sixth nerve palsy. As cerebral edema causes
brain stem compression, upper motor neuron signs, increased deep tendon reflexes, ankle clonus, a positive
Babinski sign and finally Chekyne-Stokes respiration may be noted. Other than cranial nerve palsies, neurologic
signs are decidedly symmetrical. Resting tremor, rigidity, and decreased mental acuity occasionally suggest
Parkinson’s disease [19].Skin lesions may be important source of biopsy material in sarcoidosis, cryptococcosis,
cocidioidomycosis, blastomycosis ,or sporotrichisis, Vitiligo and poliosis may suggest Vogt-Koyanagi-Harada
syndrome.Lymphadenopathy may point toward sarcoidosis, lymphoma, or hematogenously disseminated
tuberculosis or histoplasmosis.A dilated fundoscopic examination may reveal retinal lesions of
Bechet’ssyndrome. Vogt-Koyanagi Haradasyndrome ,sarcoidosis, tuberculosis ,coccidioidomycosis, or
cryptpcoccosis .Arygyll Robertson pupil sign is highly suggestive of neurosyphlis[19].
For accurate diagnosis past history can be helpful, in that coccidioidomycosis is rare in patients who have never
been in the southwestern United States or northern Mexico. The endemic area for histoplasmosis is broad in the
United States it is uncommon in the Pacific Northwest and Rock Mountain states. Immigrants from countries
where tuberculosis is prevalent are at increased risk of reactivation, as are patients who have lived in a
household where someone had tuberculosis [19]. Neurocysticercosis occurs in residents of endemic countries,
rarely in travelers. Lymeborreliosis in northeastern United States. A history of typical lesion of erythema
migrants may suggest the diagnosis of Lyme disease. Travelers outside the United States may have been
exposed to Angiostrongylus or brucellosis [19].Occupation is rarely helpful diagnostically. Age is important, in
that cryptococcosis is uncommon in the first decade of life. A history of multiple sexual partners, men having
sex with men, injection drug use or previous sexually transmitted disease should suggest the possibility of
neurosyphilis or HIV-associated infections. Underlying disease is important in that AIDS and corticosteroids
therapy are majorpredisposing factors to cryptococcal and Acanthameobameningitis [19].
Diagnosis. A contrast-enhanced MRI is the preferred test for imaging the brain and may show intracranial mass
lesions, hydrocephalus or parameningeal foci such as mold infection; and actinomycosis of the paranasal sinuses
or middle ear [19].Blood tests are performed for markers of inflammation (e.g.C-reactive protein, complete
blood count),as well as blood cultures[33].The most important to in identifying or ruling out meningitis is
analysis of cerebrospinal fluid(CSF) through lumbar puncture(LP,spinal tap[34].However lumbar puncture is
contraindicated if there is a mass in the brain(tumor or abscess) or intracranial pressure(ICP) is elevated, as it
may lead to brain herniation. If someone is at risk for either a mass or raised ICP(recent head injury, a known
immune system problem, localizing neurological signs, or evidence of a raised ICP),a CT or MRI scan is
recommended prior to lumbar puncture[33].The CSF sample is examined for presence and types of white blood
cells, red blood cells, protein content and glucose level [33].CSF findings in different forms of meningitis is
important. The concentration of glucose level is high in bacterial meningitis but low in tuberculous, fungal and
in malignant meningitis, and normal in acute viral meningitis. Protein level high in acute, tuberculous, fungal
and malignant meningitis respectively, but normal level in acute viral meningitis.The cells count(PMNs) >
300/mm3
in acute bacterial meningitis, but mononuclear < 3003
in acute viral meningitis,mononuclear,PMNs,<
3003
in tuberculous meningitis,< 3003
in fungal meningitis and usually mononuclear in malignant
meningitis[35].
A latex agglutination test useful in meningitis caused by Streptococcus pneumonia, Neisseriameningitidis,
Haemophilus influenza,Escherichia coli and group B streptococci.Similarly limulus lysate test may be positive
in meningitis caused by Gram-negative bacteria, but it is of limited use unless other tests have been
unhelpful[33].Serum serology can be helpful for cocidioidomycosis,brucellosis(agglutinin only),Lyme disease,
and syphilis. In patients with clinical syndrome compatible with neurosyphilis but negative VDRL or RPR,
atreponemal test should be requested. Positive treponemal tests preferably should be confirmed by different
treponemal test, because false-positive reaction occur.Serum cryptococcal and Histoplasma antigen test can be
done, though urine Histoplasma antigen is preferred over serum[19] Gram staining of the sample(CSF) may
demonstrate bacteria in bacterial meningitis, but absence of bacteria does not exclude bacterial meningitis as
they are only seen in 60% of cases; this figure is reduced by further 20% if antibiotics were administered before
sample taken[33].If tuberculous meningitis is suspected the sample is processed for Ziehl-Neelsenstain, which
has a low sensitivity, and tuberculosis culture, which takes long time to process; Polymerase chain
reaction(PCR) is being used increasingly. PCR is used to amplify small traces of bacterial DNA in order to
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detect the presence of bacterial or viral DNA in CSF; it is a highly sensitive and specific test[1].Diagnosis of
cryptococcal meningitis can be made at low cost by an India ink stain of CSF; however testing for cryptococcal
antigen in blood or serum is more sensitive, particularly in people with AIDS[31].
VI. THERAPY AND PREVENTION
Therapy of suspected tuberculous meningitis.Patients with high fever and rapid decline in consciousness may
be candidates for empirical therapy for tuberculous meningitis with a four-drug regimen (Isoniazid,
Rifampin,Pyrazinamide, and Ethambutol(with assessment of visual acuity and color discrimination should be
performed).Immigrants from countries with a high incidence of tuberculosis and patients with a history of
tuberculosis in the household member are at especially high risk. Before therapy, several milliliters of CSF
should be cultured for mycobacteria and sediment examined for fluorochrome stain for acid fast bacilli. If there
are lung lesions, sputum to be smeared and cultured for acid fast bacteria as well as Acid –fast stains should be
done and nuclear acid amplification test (NAAT) of CSF requested. Administration of corticosteroids can cloud
the clinical response by decreasing fever and improving CSF abnormalities [36,19].Despite the controversy,
most authorities advocate the use of corticosteroids in selected cases[37].
Fungal meningitis such as cryptococcal meningitis is treated with long courses of high dose antifungals, such
as amphotericin B and flucytosine[38].Raised intracranial pressure is common in fungal meningitis, and
frequent(ideally daily) lumbar punctures to relieve the pressure are recommended[38].
Prevention .Prevention against meningitis include (a) bacterial and viral meningitis are contagious like common
cold or flu, both can be transmitted through droplets of respiratory secretions during close contact, such as
kissing, sneezing or coughing on someone, but cannot be spread by only breathing air where a person with
meningitis has been [39].Viral meningitis is spread by enteroviruses, and is most commonly spread through
fecal contamination. The risk of infection can be decreased by changing the behavior that led to transmission
[38].(b)vaccination against Haemophilus influenza , meningococcus, Streptococcus pneumonia and childhood
BCG vaccination(Bacillus Calmette-Guerin) significantly reduce the rate of tuberculous meningitis[40,41,36].
VI. CONCLUSION
Chronic meningitis is a diagnostic challenge to clinicians. Early diagnosis by lumbar puncture;MRI
imaging and prompt antibiotic therapy have a better outcome,
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