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Chronic Meningitis

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					Chronic Meningitis

    Erin Hummert
     July 9, 2007
Definition

   Meningeal Symptoms lasting four
    weeks or more

   Symptoms can be constant, fluctuate
    or slowly worsen

   Clinical course can vary widely
    between patients
Etiology

   Infectious
       Bacterial, Mycobacterial, Spirochete,
        Viral, Fungal, Parasitic
 Malignancy
 Medications

 Rheumatologic

 Idiopathic
Bacterial

 Brucella
 Francisella tularensis
 Actinomyces
 Listeria-unpastuerized
 Ehrlichia chaffeensis
 Nocardia
 Rarely partially treated N. Meningitis,
  Streptococcus or H. Flu
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
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
Viral
   Enterovirus
   HSV
       Mollaret’s syndrome- “Benign Recurrent
        Meningitis”
   HIV
   Lymphocytic Choriomeningitis
   CMV
   EBV
   VZV
   Mumps
Other Infectious Etiologies

   Fungal
       Cryptococcus, Coccidioides,
        Sporithrix, Histoplasma


   Parasitic – Eosinophilic Meningitis
       Angiostrongylus, Taenia solium,
        Schistosomiasis, Toxoplasmosis
Noninfectious

 Malignant
 Medications – NSAIDS, trimethoprim-
  sulfamethoxazole
 Sarcoidosis

 Behcet’s syndrome

 Systemic Lupus Erythematous

 Endocarditis
Symptoms
   Nonspecific and similar to acute
    meningitis
Historical Clues

 Travel to endemic areas – eg fungal,
  parasitic, lyme
 TB exposure or previous positive skin
  test
 Sexual history

 Tick exposure
Historical Clues

 Medications-specifically NSAIDs
 Contact with rabbits, cats, wild game
  or meat processing
 Recurrent genital or oral ulcers

 Weight loss, night sweats

 Rash
       CSF Analysis
Test           Bacterial    Viral       Fungal    Parasitic
Opening        Elevated    Usually     Variable   Variable
Pressure                   normal
White blood    >1000       <100        Variable   Variable
cell count
Cell           PMN         Lymphs      Lymphs     Eosinophilia
differential
Protein        Mild to     Normal to   Elevated   Elevated
               Marked      Elevated
               Elevation
Glucose        Normal to   Normal      Low        Low
               Low
      CSF Analysis
PMN predominate/ Lymph                         Lymph
Low Glucose      predominate/                  predominate/
                 Normal Glucose                Low Glucose
Bacteria                 Viral                 Mycobacterium
 -Actinomyces,           CNS Malignancy        Fungi
 Listeria, Brucellosis   Endocarditis
Mumps                    Early Mycobacterium
LCM                      Early Fungal
NSAIDS
Sulfa
Behcet’s
Early Viral
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
Serum Tests

   HIV with ELISA

   VDRL/RPR

   Serologies
       LCM, leptospirosis, Lyme, Ehrlichia, Brucella

   Blood cultures x3
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
Empiric Therapy

   Antituberculous therapy1
       In face of negative tuberculin skin test
       One study of 28 patients with chronic
        meningitis without etiology empirically
        treated
         • Close to half with responsed to treatment with
           additional 11 with improvement in symptoms while
           on therapy
         • Study performed in endemic TB area
   Antiviral Therapy
       Case reports
Empiric Steroids

   Persistent negative cultures
   Infectious etiology though unlikely
   Smith et al3 at Mayo Clinic studied 39
    patients with chronic meningitis of unknown
    etiology
       Mean duration of symptom was 19 months
       Symptoms resolved in 19 of 39 patients
       14 of 19 had continued symptoms and 4 had
        worsening symptoms
References
   Coyle, PK. Overview of acute and chronic meningitis. Neurol Clin 1999;
    17:691.
   Sexton, Daniel (Ed). “Chronic Meningitis”. UpToDate.
   Smith, JE, Aksamit, AJ Jr. Outcome of chronic idiopathic meningitis.
    Mayo Clin Proc 1994; 69:548.

				
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