Date post: | 03-Apr-2018 |
Category: |
Documents |
Upload: | farid-al-fansuri |
View: | 219 times |
Download: | 1 times |
of 20
7/28/2019 Chronic Meningitis Hummert
1/20
Chronic Meningitis
Erin Hummert
July 9, 2007
7/28/2019 Chronic Meningitis Hummert
2/20
Definition
Meningeal Symptoms lasting fourweeks or more
Symptoms can be constant, fluctuateor slowly worsen
Clinical course can vary widelybetween patients
7/28/2019 Chronic Meningitis Hummert
3/20
Etiology
Infectious
Bacterial, Mycobacterial, Spirochete,
Viral, Fungal, Parasitic Malignancy
Medications
Rheumatologic Idiopathic
7/28/2019 Chronic Meningitis Hummert
4/20
Bacterial
Brucella
Francisella tularensis
Actinomyces Listeria-unpastuerized
Ehrlichia chaffeensis
Nocardia Rarely partially treated N. Meningitis,
Streptococcus or H. Flu
7/28/2019 Chronic Meningitis Hummert
5/20
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 ofillness
7/28/2019 Chronic Meningitis Hummert
6/20
Mycobacterium Tuberculosis
Bacilli seed to the meninges creating
tubercles called Rich foci
Tubercles that rupture intosubarachnoid space causing
meningitis
Cranial nerve palsies can occur CN VI most frequently affected
Up to 40% in children
7/28/2019 Chronic Meningitis Hummert
7/20
Viral
Enterovirus
HSV Mollarets syndrome- Benign Recurrent
Meningitis HIV
Lymphocytic Choriomeningitis
CMV
EBV VZV
Mumps
7/28/2019 Chronic Meningitis Hummert
8/20
Other Infectious Etiologies
Fungal
Cryptococcus, Coccidioides,
Sporithrix, Histoplasma
Parasitic Eosinophilic Meningitis
Angiostrongylus, Taenia solium,Schistosomiasis, Toxoplasmosis
http://images.google.com/imgres?imgurl=http://microbewiki.kenyon.edu/images/4/4b/23231D.jpg&imgrefurl=http://microbewiki.kenyon.edu/index.php/Cryptococcus&h=343&w=275&sz=121&hl=en&start=5&um=1&tbnid=qLYluC8DAIOhjM:&tbnh=120&tbnw=96&prev=/images%3Fq%3Dcryptococcus%26svnum%3D10%26um%3D1%26hl%3Den7/28/2019 Chronic Meningitis Hummert
9/20
Noninfectious
Malignant
Medications NSAIDS, trimethoprim-
sulfamethoxazole Sarcoidosis
Behcets syndrome
Systemic Lupus Erythematous Endocarditis
7/28/2019 Chronic Meningitis Hummert
10/20
Symptoms
Nonspecific and similar to acute
meningitis
7/28/2019 Chronic Meningitis Hummert
11/20
Historical Clues
Travel to endemic areas eg fungal,
parasitic, lyme
TB exposure or previous positive skintest
Sexual history
Tick exposure
7/28/2019 Chronic Meningitis Hummert
12/20
Historical Clues
Medications-specifically NSAIDs
Contact with rabbits, cats, wild game
or meat processing Recurrent genital or oral ulcers
Weight loss, night sweats
Rash
7/28/2019 Chronic Meningitis Hummert
13/20
CSF Analysis
Test Bacterial Viral Fungal Parasitic
Opening
Pressure
Elevated Usually
normal
Variable Variable
White blood
cell count
>1000
7/28/2019 Chronic Meningitis Hummert
14/20
CSF Analysis
PMN predominate/
Low Glucose
Lymph
predominate/
Normal Glucose
Lymph
predominate/
Low Glucose
Bacteria
-Actinomyces,
Listeria, Brucellosis
Mumps
LCM
NSAIDSSulfa
Behcets
Early Viral
Viral
CNS Malignancy
Endocarditis
Early Mycobacterium
Early Fungal
Mycobacterium
Fungi
7/28/2019 Chronic Meningitis Hummert
15/20
Specific CSF Analysis
Antigen testing Cryptococcus neoformans, HSV, VZV, EBV,
CMV, VDRL
Significant inter- and intralab variability withPCRs
Cultures if routine cultures negative mayneed 10-20 ml of CSF Aerobic
Mycobacterial Fungal
Cytology
7/28/2019 Chronic Meningitis Hummert
16/20
Serum Tests
HIV with ELISA
VDRL/RPR
Serologies
LCM, leptospirosis, Lyme, Ehrlichia, Brucella
Blood cultures x3
7/28/2019 Chronic Meningitis Hummert
17/20
Further Examinations
PPD
CXR
Retinal Exam
Echocardiogram MRI
Rarely lead to specific diagnosis
Focal abnormalities may be useful if brain biopsyconsidered
Meningeal/Brain Biopsy Particularly useful if focal on imaging
Progressive disease despite empiric therapy
7/28/2019 Chronic Meningitis Hummert
18/20
Empiric Therapy
Antituberculous therapy1
In face of negative tuberculin skin test
One study of 28 patients with chronic
meningitis without etiology empiricallytreated
Close to half with responsed to treatment withadditional 11 with improvement in symptoms whileon therapy
Study performed in endemic TB area
Antiviral Therapy
Case reports
7/28/2019 Chronic Meningitis Hummert
19/20
Empiric Steroids
Persistent negative cultures
Infectious etiology though unlikely
Smith et al3
at Mayo Clinic studied 39patients 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
7/28/2019 Chronic Meningitis Hummert
20/20
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.