chronic meningitis dr. shatdal chaudhary
DESCRIPTION
Approach to a case of Chronic MeningitisTRANSCRIPT
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Dr. Shatdal ChaudharyAssociate Professor
Department of Internal MedicineUniversal College of Medical Sciences, Bhairahawa, Nepal
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DefinitionChronic inflammation of meninges where
Symptoms lasting for four weeks or more duration
Symptoms can be constant, fluctuate or slowly worsen
Clinical course can vary widely between patients
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Five Categories of diseaseMeningeal infectionMalignancyNoninfectious inflammatory disordersChemical meningitisParameningeal infections
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Infectious Causes
BacterialBrucellaFrancisella tularensisActinomycesListeria-unpastuerizedNocardiaRarely partially treated N. Meningitis,
Streptococcus or H. Flu
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SpirochetesTreponema pallidum
Disseminates during early infectionSerum and CSF VDRL typically positive
Lyme MeningitisTypically late summer and early fallTravel to endemic areaHistory consistent with erythema
migransLeptospirosis
Meningeal symptoms develop in 50% of patients during anicteric second stage of illness
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Mycobacterium TuberculosisBacilli seed to the meninges creating
tubercles called “Rich foci”Tubercles that rupture into subarachnoid
space causing meningitisCranial nerve palsies can occur
CN VI most frequently affected Up to 40% in children
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ViralEnterovirusHSV
Mollaret’s syndrome- “Benign Recurrent Meningitis”
HIVLymphocytic ChoriomeningitisCMVEBVVZVMumps
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Other Infectious EtiologiesFungal
Cryptococcus, Coccidioides, Sporithrix, Histoplasma
Parasitic – Eosinophilic MeningitisAngiostrongylus, Taenia solium,
Schistosomiasis, Toxoplasmosis
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Noninfectious CausesMalignancy
Metastastic Ca of Breast, Lung, Pancreas, Lymphoma, Leukaemia, Meningeal gliomatosis
Medications/ Chemical: Subarachnoid injectionNSAIDS, trimethoprim-sulfamethoxazoleEpidermoid tumor, Craniopharyngioma,
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Rheumatologic/ Noninfectious inflammatory conditions:SarcoidosisSLEBechet SyndromeWegners DiseaseVogt-Koyanagi-Harada Syndrome
Idiopathic
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SymptomsNonspecific and similar to acute
meningitisAre determined by anatomical
location of inflammation and its consequence.
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Symptoms
Double vision/visual loss Hearing loss Limb weakness Sphincter dysfunction
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symptomsHydrocephalusCranial neuropathiesRadiculopathyCognitive disturbancePersonality changesPresence of underlying systemic illnessAccording to causative agent
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Historical CluesTravel to endemic areas – eg fungal,
parasitic, lymeTB exposure or previous positive skin testSexual historyTick exposure
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Historical CluesMedications-specifically NSAIDsContact with rabbits, cats, wild game or meat
processingRecurrent genital or oral ulcersWeight loss, night sweatsRash
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CSF AnalysisTest Bacterial Viral Fungal Parasitic
Opening
Pressure
Elevated Usually normal
Variable Variable
White blood cell count
>1000 <100 Variable Variable
Cell differential
PMN Lymphs Lymphs Eosinophilia
Protein Mild to Marked Elevation
Normal to Elevated
Elevated Elevated
Glucose Normal to Low
Normal Low Low
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CSF AnalysisPMN predominate/
Low Glucose
Lymph predominate/
Normal Glucose
Lymph predominate/
Low Glucose
Bacteria
-Actinomyces,
Listeria, Brucellosis
Mumps
LCM
NSAIDS
Sulfa
Behcet’s
Early Viral
Viral
CNS Malignancy
Endocarditis
Early Mycobacterium
Early Fungal
Mycobacterium
Fungi
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Specific CSF AnalysisAntigen 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 CSFAerobicMycobacterialFungal
Cytology
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Serum TestsHIV with ELISA
VDRL/RPR
SerologiesLCM, leptospirosis, Lyme, Ehrlichia, Brucella
Blood cultures x3
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Further ExaminationsPPDCXRRetinal ExamEchocardiogramMRI
Rarely lead to specific diagnosisFocal abnormalities may be useful if brain biopsy
consideredMeningeal/Brain Biopsy
Particularly useful if focal on imagingProgressive disease despite empiric therapy
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Treatment according to Etiological Agent
Empiric TherapyAntituberculous therapy
Antiviral TherapySteroids
Persistent negative cultures Infectious etiology though unlikely
Trial of combination of ATT+Antifungal+Steroids