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 Meningeal symptoms develop in 50% of patients during anicteric second stage of illness

Leptospirosis

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

Mollarets 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, trimethoprimsulfamethoxazole Sarcoidosis Behcets 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 Opening Pressure White blood cell count Cell differential Protein Bacterial Elevated >1000
PMN

Viral Usually normal <100

Lymphs

Fungal Variable Variable

Lymphs

Parasitic Variable Variable

Eosinophilia

Mild to Marked Elevation Normal to Low

Normal to Elevated Normal

Elevated

Elevated

Glucose

Low

Low

CSF Analysis
PMN predominate/ Lymph predominate/ Low Glucose Normal Glucose
Bacteria -Actinomyces, Listeria, Brucellosis Mumps LCM NSAIDS Sulfa Behcets Early Viral Viral CNS Malignancy Endocarditis Early Mycobacterium Early Fungal

Lymph predominate/ Low Glucose

Mycobacterium Fungi

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.