subacute/chronic meningitis reşat Özaras, md, prof. infection dept. [email protected]
TRANSCRIPT
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Subacute/Chronic meningitis
Reşat ÖZARAS, MD, Prof.
Infection Dept.
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Admission Acute (1 day-1 week)
Subacute (1 week-1 mo.) Chronic (> 1 mo. )
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Subacute/Chronic meningitis
• Within weeks or months
• Headache, fever, neck rigidity, mental changes
• Focal neurological signs are more frequent
• Needs specific treatment
• A diagnostic challenge
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A Case Study
• A 48-year-old female was admitted with headache, myalgia, nausea, vomiting, fatigue, anorexia and fever for 6 weeks
• Biochemistry normal• CBC normal• C-RP: 5 Xnormal, ESR 100 mm/h
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• No previous and family history– Immunosuppressive disorders/drugs– No similar signs & symptoms in the family
• No focal neurological sign• Neck rigidity +/-, Kernig and Brudzinski +• MRI showed mild contrast enhancement at
basal cranial meninges
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CSF
• Clear• Cell count: 250 /mm3, 80% lymphocytes• Glucose 10 mg/dl (blood glucose 98)• Protein 280 mg/L• Gram and EZN staining: negative
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• What is your diagnosis?
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2 days later
• CSF TB-PCR: positive
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25 days later
• CSF cultures Mycobacterium tuberculosis
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Subacute/chronic meningitis
• Infections:– TB
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TB
• May follow a slow progress• Exposure, TST/PPD(+), immune suppression • Prodrome 2-4 weeks
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• Not only menengitis,• Vasculitis, space-occupying lesion (brain
tuberculoma) – Fever– Change in mental status– Hemiplegia, paraplegia– Ocular nerve involvement
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CSF
EtiologyEtiology WBC(/mmWBC(/mm33)) Cell TypeCell Type Glucose(Mg/dL)Glucose(Mg/dL) Protein(Mg/dL)Protein(Mg/dL)
Viral Viral 50–1000 50–1000 LymphocyticLymphocytic >45 >45 <200 <200
BacterialBacterial 1000–1000–5000 5000
NeutropilicNeutropilic <40 <40 100–500 100–500
TBTB 50–300 50–300 LymphocyticLymphocytic <45 <45 50–300 50–300
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neuropathology.neoucom.edu
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Clinical Presentation
• Most common clinical findings:– Fever– Headache – Vomiting– Nuchal Rigidity
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Diagnosis
• CSF Examination– Usually lymphocytic pleocytosis– Elevated protein with severely depressed
glucose– AFB– Culture– PCR
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Diagnosis
• Other Studies– Brain imaging – demonstrates hydrocephalus,
basilar exudates and inflammation, tuberculoma, cerebral edema, cerebral infarction
• CXR– Abnormal, sometimes miliary pattern
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seattlechildren.org
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Treatment: Antimicrobial Therapy
• Start as soon as there is suspicion for TB meningitis
• Same Guidelines as those for pulmonary TB– Intensive Phase: 4 drug regimen of Isoniazid,
Rifampin, Pyrazinamide, and Ethambutol for 2 months
– Continuation Phase: Isoniazid and Rifampin for another 7 – 10 months
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Treatment: Adjunctive Therapy
• Glucocorticoids Indicated with:– rapid progression from one stage to the next– CT evidence of cerebral edema– worsening clinical signs after starting antiTb
meds– increased basilar enhancement, or moderate
to advancing hydrocephalus on head CT
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Outcomes
• Overall Poor
• Only 1/3 - 1/2 of patients demonstrate complete neurologic recovery
• Up to 1/3 of patients have residual severe neurologic deficits such as hemiparesis, blindness, seizure DO
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Another Case Study
• A 30-year-old male farmer was admitted with headache, newly-onset seizures, and fever for 1 month
• Biochemistry normal• CBC normal• C-RP: 5 Xnormal, ESR 50 mm/h
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A 30-year-old male was admitted with headache, newly-onset seizures, and fever for 1 month…
• Blood cultures were obtained• MRI: normal
• Diagnosed by a serology!...
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• Rose-Bengal test positive• Wright test positive• 2 bottles of blood culture yielded Brucella
melitensis
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Rx
• Rifampin+Doxycycline
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Subacute/chronic meningitis
• Infections:– TB– Spirochetal diseases (syphilis, Lyme’s
disease)– Brucellosis– Fungal
• Cryptococcus neoformans, Aspergillus, Candida
Toxoplasmosis,
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Neurosyphilis
• Infection of the central nervous system by Treponema pallidum
• Neurosyphilis can occur at any time after initial infection.
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utdol.com
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• Early NS– Asymptomatic– Symptomatic– Meningovascular
• Late NS– General paresis– Tabes dorsalis
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B) Significant edema in the left posterior frontal lobe.
A) Focal meningeal enhancement in the left frontal lobe with surrounding edema.
Cerebral gumma in an HIV-infected patient with recent secondary syphilis. utdol.com
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Diagnosis
• EIA: syphilis enzyme immunoassay• FTA-ABS: fluorescent treponemal antibody-absorbed test• TPPA: Treponema pallidum particle agglutination test
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Rx
• Penicillin G benzathine 2.4 million units IM once