Diagnosis of meningitis, Causes of meningitis, Tubercular, cryptococcal, fungal meningitis, Treatment, Prognosis

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CHRONIC
MENINGITIS
- Dhananjay Gupta

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INTRODUCTION
• Definition : Chronic inflammation of meninges
: Lasting > 4 weeks
• Clinical course can be constant or vary – fluctuate, worsen!

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CAUSES
1. Meningeal infections
2. Non-infectious, inflammatory disease
3. Malignancy
4. Chemical meningitis
5. Para-meningeal infections

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1. Infections
1. Bacterial • TB
• Brucella, Fransciella,
• Actinomycetes, Nocardia
• Listeria monocytogenes
• Ehrlichia chaffeensis
• Partially treated Strptococcal, H. influenza , Neisseria
2. Spirochaetes  Treponema pallidum – syphilis
 Lyme meningitis
 Leptospirosis
3. Viral  Enterovirus
 HSV – Mollaret syndrome
 HIV
 CMV
 EBV
 VZV
 Mumps
 lymphocytic chorio-meningitis

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1. Infections
4. Fungal • Cryptococcus
• Coccidioides
• Sporothrix
• Histoplasma
5. Parasitic Eosinophilic meningitis
 Toxoplasma
 Shistosoma
 Taenia solium
 Strongyloides

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2. Non – Infectious causes
1. Inflammatory • SLE
• Sarcoidosis
• Bechet’s disease
• Wegner’s disease
• Vogt – Koyanagi – harada syndrome
• Other rheumatological diseases
• Fabry disease
2. Idiopathic

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2. Non – Infectious causes
3. Malignancy • Leukaemia/ Lymphoma
• Meningeal gliomatosis
• Metastatic Ca of Breast
• Metastatic Ca of Lung
• Metastatic Ca of Prostate
• Epidermoid tumour
• Cranio-pharyngoma
4. Chemical  Sub-arachnoid injections
 NSAIDs
 TMP – SMX

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CLINICAL FEATURES

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COMPLICATIONS
1. Hydrocephalus
2. Cranial neuropathies
3. Radiculopathy ( Bannwarth’s syndrome)
4. Cognitive decline
5. Personality changes
6. Specific to the causative factor

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Approach to a patient - History
1. Contact with TB
2. Weight loss/ night sweats/ loss of appetite
3. Sexual history – syphilis, HIV
4. Travel to endemic area – parasitic/ lymes/ fungal
IN INDIA – TUBERCULOSIS IS ALWAYS A DIFFERENTIAL !

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Approach to a patient - History
5. H/o medication - NSAIDs
6. Unpasteurized milk – Brucella
7. Meat-packing industry/ cows/ sheep - Brucella
8. Recurrent oral/ genital ulcers – Bechet’s
9. Tick exposure, erythema marginans – Lyme’s

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Approach to a patient - History
11. Contact with birds – cryptococcosis
12. Exposure to bats / avian habitats – histoplasmosis
13. H/o cancer – neoplastic meningitis
14. Immuno-compromised state – HIV, TB
- Cryptococcus
- Fungal infections

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Approach to a patient - Examination
1. Cranial palsy  TB
 Lyme’s
 Syphilis
 Brucella
 Sarcoidosis
2. Oro-genital ulcers • Bechet’s
• Syphilis
• Sjogrens
• SLE
• Sarcoidosis
3. Uveitis/ iritis  Bechet’s
 Sarcoidosis
 Vogt – kayanagi – harade syndrome

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Approach to a patient - Examination
4. Poliosis  Whitening of hair/ eyelashes
 Vogt – kayanagi - harade
5. Skin rashes/ lesions • Bechet’s
• Syphilis
• SLE
• Cryptococcus
• Blastomycosis
• Coccidioidomycosis
6. Subcutaneous nodules  Cysticercosis
 Metastatic deposists
 Endocarditis

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Investigations - CSF

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Investigations - CSF
NEUTROPHILIC
PLEOCYTOSIS, LOW SUGAR
LYMPHOCYTIC,
LOW SUGAR
LYMPHOCYTIC,
NORMAL SUGAR
1. Bacterial
2. Listeria, brucellosis
3. Actinomycosis
4. Bechet’s
5. Early viral
6. Mumps
7. Drugs – Nsaids
8. Sulfa – drugs
 TB
 Fungal
a) Early TB
b) Early fungal
c) Viral meningitis
d) CNS malignancy
e) Endocarditis

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Further CSF tests
1. Gram stain/ culture
2. Cultures – aerobic/ anaerobic/ fungal/ mycobacterial
3. Antigen testing – HSV-PCR, VZV-PCR, EBV, CMV
4. TB-PCR
5. India ink, Cryptococcal – antigen
6. CSF – VDRL
7. NCC antibodies - IgG

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Serum and Blood tests
1. HIV – elisa
2. VDRL/ RPR
3. Blood cultures
4. Serologies – leptospira/ lyme/ brucella/ ehlrichia

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Supportive tests
1. Mantaux
2. Chest X-ray/ USG abdomen
3. X-ray thigh
4. Retinal examination
5. Echocardiogram
6. MRI Brain

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B) Significant edema in left posterior frontal lobe.
A) Focal meningeal enhancement in the left frontal lobe
with surrounding edema.

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Clues to diagnosis - TBM
1. Bacilli seed to meninges – make tubercles : “Rich focus”
2. Tubercles rupture into SA-space – causing meningitis
3. H/o contact
4. Pulmonary/ abdominal symptoms
5. PPD/ Montaux – can be negative in 50-65%
6. O/E : cranial nerve palsy – 6th nerve
7. Vasculitic infarcts

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Clues to diagnosis - TBM
1. CSF AFB smear : positive in 10-20%
2. CSF culture : 40-90%
3. Concurrent sputum AFB culture positive in : 14-50%
4. Decreasing CSF glucose levels on serial LP’s , without
treatment, may also suggest TBM

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Clues to diagnosis - Cryptococcal
1. Immuno-compromised host/ HIV
2. h/o high dose corticosteroid therapy
3. Usually sub-acute onset, progressive
4. However, maybe rapid progression in HIV+
5. CSF lymphocytosis 40-400
6. CSF india ink + in 50%
7. Cryptococcal antigen + 85%

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Clues to diagnosis - Syphilis
1. Treponema pallidum
2. Sexual exposure
3. Genital ulcers
4. CNS invasion occurs early in non-treated cases

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Treatment
1. According to aetiological agent
2. Empirical therapy:
• 1/3rd patients do not have a definite causative agent
• Serology test results take time
• Monitor response to therapy
• Continue diagnostic efforts
3. ATT :
• Should always be considered
• Endemic in India

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Treatment
4. ATT with steroids :
• Unless severe symptoms, avoid steroids
• Discontinue ATT if no response even after 4-6 weeks
5. Empirical Anti-fungal :
 Azoles
 Only if clinical features strongly suggestive
6. Steroids alone :
o Only if infectious cause has been ruled out
o May be auto-immune
o Upto 50% response rates reported

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