Discussed a case with a recurrent headache - Recurrent meningitis, evaluation, management, different causes for recurrent meningitis and evaluation part.

1. A Case Of Recurrent
Meningitis
Dr.Arul Selvan Unit
Presenter: Dr.M.Ramesh Babu

2. Brief History
• Mrs. S, 37 Yrs working woman presented with recurrent attacks
of
• Neck pain
• Headache
• Fever - Feb.2018

3. HOPI
• PWAN till Sep.2017, when she brought to ER with complaints
of irrelevant talks, difficulty in speech, difficulty in naming the
family members - episodic in nature, each episode last for 15 -
20 min, for 1 day duration, treated in ER and discharged.
• She was normal till Feb.2018 - presented with severe neck pain,
throbbing type, spreads holocranial, a/w photo & phono phobia,
nausea and vomiting, affects her ADL. Fever high grade
intermittent, not a/w chills and rigours, sweating. Got admitted
and evaluated with CSF studies and imaging, treated with
steroids and symptom free for till Mar.2018

4. • In Mar. 2018 - readmitted with similar symptoms, evaluated
with CSF studies and imaging, treated with ATT and steroids,
settled in 3-4 days and continued ATT with maintenance dose
of steroids.
• In June and Oct. 2018 - also admitted and got evaluated with
CSF studies and continued the same medications.

5. • Now present admission on 27.06.19 with similar complaints ℅ Fever
3days, severe neck pain, headache.
• H/o U/L headache on & off 5-6 yrs, mild to moderate severity, non
pulsatile, without any associated symptoms, not affecting her ADL, and
subsides with paracetamol.
• H/o small dark pigmented papule like lesions over the both shoulders on
& off.
• No h/o LOC/ seizures
• No h/o joint pains, skin rashes
• No h/o loss of appetite or weight loss
• No h/o fall or trauma

6. • Not a Hypertensive or Diabetic, Hypothyroid since 14 yrs on
thyroxine supplementation. PCOD - 11yrs
• F/H - Nil significant
• Personal H/o - Nil significant
• Drug h/o - No Ayurvedic/ native medicine intake
• Travel H/o - Nil significant

7. History Summary
• Mrs. S 37 yrs old working woman presented with recurrent
attacks of neck pain, headache, fever since 2018 feb. with
repeated admissions, CSF analysis and imaging, on ATT with
good response to steroids. Now again readmitted with similar
complaints on background h/o chronic headache and skin
lesions.

8. Possibilities
• Recurrent Meningitis
• ? Viral
• ? TB
• ? Sarcoidosis
• ? IgG4
• ? Malignant

9. • GPE: Moderatly built and obese - BMI = 40.9 kg/m2
• Dark pigmented papule lesions over both the shoulders+
• Vitals : Stable
• CNS Exam: conscious, alert, oriented
• HMF - N, Speech - N
• Olfaction - N
• Visual acuity - N, Color vision -N, Field of
• Fundus - N

10. • Other CN’ s- Normal
• Motor , sensory , cerebellum - N
• Neck supple
• Gait - N
• Cranium and Spine - Mild tenderness over left side of the neck
• CVS Exam : N
• Other systemic exam: N

11. • HB- 10.2%
• TC- 12.03 K, P - 76%, L- 19%, M-5%
• Platelets - 3.59 lakhs
• ESR - 54 mm/hr
• RBS - 126
• S.Creat - 0.7
• B.Urea - 26
• T. Bil - 0.9
• SGPT - 45 U/L
• ALP - 117 U/L
• S.Alb - 4.4 g/dl
• S.Globulin - 2.8 g/dl

12. CSF
Anlaysis
Cells Protein Sugar X pert C/S ME panel
AFB/ Bact.
Pack
3.2.18
WBC-
180,RBC-
100
L- 99%
60 31 -VE -VE -VE -VE
1.3.18
WBC-565,
RBC- 50, L-
99%
135.5 24 (103) -VE -VE NOT DONE -VE
5.6.18
WBC- 340,
50 RBC L-
96%,
128 42 -VE -VE NOT DONE
-VE (Fungal
also)
7.10.18
WBC -420,
RBC-200,
L-90%
155.5 25 -VE -VE -VE -VE
29.06.19
WBC-260,
RBC-50, L-
90%
75.4 57 (112) -VE -VE -VE -VE

13. • HSV PCR 1& 2 - Neg
• CUE - N
• Vasculits panel- Neg.
• S. ACE - 65U/lL (8-52)
• S.Ca 2+ - 9.3 mg/dl
• S. IgG4 - 19.8 (2-121)
• Viral Markers - Neg
• RPR - Neg.
• HLA - B15 /B5 - awaited
• S. Lyme antibodies - awaited

14. CT -
27/06/19

16. MRI
03/19

19. PET
CT
1/7/19
• Normal

20. Chest Xray

21. Summary
• Mrs. S 37 yrs old woman presented with symptoms of
meningitis, with lymphocytic predominant, high protein and
low glucose CSF picture with good response to steroids, not
much response to ATT since feb.2018, on the background
of chronic headache, skin lesions, hypothyroid and PCOD.

22. Final Diagnosis
• Chronic recurrent steroid responsive Lymphocytic Meningitis

23. Discussion
• Chronic Meningitis : Commonly diagnosed when
• 1) a characteristic neurologic syndrome exists for > 4 weeks
without clinical improvement.
• 2) and is associated with a persistent inflammatory response in
the cerebrospinal fluid (CSF) (white blood cell count
>5/microLitres).

24. Two clinical forms of chronic
meningitis
• 1) symptoms are chronic and persistent
• 2) there are recurrent, discrete episodes with complete resolution
of meningeal inflammation between episodes without specific
therapy.

25. Five categories of Chronic Meningitis
• Meningeal infection
• Malignancy
• Noninfectious inflammatory disorders
• Chemical meningitis
• Parameningeal infections

26. Approach to the patient with
Chronic meningitis
Once chronic meningitis is confirmed by CSF examination, effort
is focused on identifying the cause by:
• (1) further analysis of the CSF
• (2) diagnosis of an underlying systemic infection or
noninfectious inflammatory condition, or
• (3) examination of meningeal biopsy

27. Infectious causes of Chronic Meningitis
1. Common Bacterial Causes
• Partially treated suppurative meningitis
• Parameningeal infection
• Mycobacterium tuberculosis
• Lyme disease (Bannwarth’s syndrome): Borrelia burgdorferi
• Syphilis (secondary, tertiary): Treponema pallidum

28. Viral
• Enterovirus
• HSV
Mollaret’s syndrome- “Benign Recurrent Meningitis”
• HIV
• Lymphocytic Choriomeningitis
• CMV
• EBV
• VZV
• Mumps

29. • Helminthic Causes
• Cysticercosis
• Gnathostoma
• Angiostrongylus
• Fungal - Cryptococcal
• Protozoal - Toxoplasma gondii

30. Noninfectious causes of meningitis
1. Malignancy
2. Chemicals / Medicines (may cause recurrent meningitis) - NSAIDS,
Trimethoprim-sulfamethoxazole
3. Primary inflammation
• CNS sarcoidosis
• Systemic lupus erythematosus
• Behcet’s syndrome (recurrent meningitis)
• Chronic benign lymphocytic meningitis
• Drug hypersensitivity
• Wegener’s granulomatosis

31. PMN Predominant /
Low Glucose
Lymphocyte
Predominant / Normal
Glucose
Lymphocyte
Predominant / Low
Glucose
Bacteria-Actinomyces,
Listeria, Brucellosis
Mumps
LCM
NSAIDS
Sulfa
Behcet’s
Early Viral
Viral
CNS Malignancy
Endocarditis
Early Mycobacterium
Early Fungal
Mycobacterium
Fungi

32. Low CSF Glucose Syndromes
Bacterial meningitis Syphilis
Tuberculous meningitis Chemical meningitis
Fungal meningitis Subarachnoid meningitis
Sarcoidosis Mumps meningitis
Meningeal carcinomatosis Herpes simplex encephalitis
Amebic meningitis Hypoglycemia
Cysticercosis Trichinosis

34. Take Home Message
• Chronic recurrent meningitis - is a rare condition
• Good clinical history, extensive investigation and follow up is
required for the diagnosis.
• Most commonly come across conditions are - TB, Fungal,
Mollaret’s, malignant, chemical or drug induced.
• Brian biopsy is the final option for diagnosis.

35. Thank you