Subacute/Chronic meningitis Reşat ÖZARAS, MD, Prof. Infection Dept.

Subacute/Chronic
meningitis
Reşat ÖZARAS, MD, Prof.
Infection Dept.
rozaras@yahoo.com
Admission
Acute (1 day-1 week)
Subacute (1 week-1 mo.)
Chronic (> 1 mo. )
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
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
• 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
CSF
•
•
•
•
•
Clear
Cell count: 250 /mm3, 80% lymphocytes
Glucose 10 mg/dl (blood glucose 98)
Protein 280 mg/L
Gram and EZN staining: negative
• What is your diagnosis?
2 days later
• CSF TB-PCR: positive
25 days later
• CSF cultures Mycobacterium tuberculosis
Subacute/chronic meningitis
• Infections:
– TB
TB
• May follow a slow progress
• Exposure, TST/PPD(+), immune suppression
• Prodrome 2-4 weeks
• Not only menengitis,
• Vasculitis, space-occupying lesion (brain
tuberculoma)
–
–
–
–
Fever
Change in mental status
Hemiplegia, paraplegia
Ocular nerve involvement
CSF
Etiology
WBC(/mm3)
Cell Type
Viral
50–1000
Lymphocytic >45
<200
Bacterial
1000–
5000
Neutropilic
100–500
TB
50–300
Lymphocytic <45
Glucose(Mg/dL)
<40
Protein(Mg/dL)
50–300
neuropathology.neoucom.edu
Clinical Presentation
• Most common clinical findings:
– Fever
– Headache
– Vomiting
– Nuchal Rigidity
Diagnosis
• CSF Examination
– Usually lymphocytic pleocytosis
– Elevated protein with severely depressed
glucose
– AFB
– Culture
– PCR
Diagnosis
• Other Studies
– Brain imaging – demonstrates hydrocephalus,
basilar exudates and inflammation,
tuberculoma, cerebral edema, cerebral
infarction
• CXR
– Abnormal, sometimes miliary pattern
seattlechildren.org
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
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
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
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
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!...
• Rose-Bengal test positive
• Wright test positive
• 2 bottles of blood culture yielded Brucella
melitensis
Rx
• Rifampin+Doxycycline
Subacute/chronic meningitis
• Infections:
– TB
– Spirochetal diseases (syphilis, Lyme’s
disease)
– Brucellosis
– Fungal
• Cryptococcus neoformans, Aspergillus, Candida
Toxoplasmosis,
Neurosyphilis
• Infection of the central nervous system by
Treponema pallidum
• Neurosyphilis can occur at any time after
initial infection.
utdol.com
• Early NS
– Asymptomatic
– Symptomatic
– Meningovascular
• Late NS
– General paresis
– Tabes dorsalis
A) Focal meningeal enhancement
B) Significant edema in the
in the left frontal lobe with
left posterior frontal lobe.
surrounding edema.
Cerebral gumma in an HIV-infected patient with recent secondary syphilis.
utdol.com
Diagnosis
• EIA: syphilis enzyme immunoassay
• FTA-ABS: fluorescent treponemal antibody-absorbed test
• TPPA: Treponema pallidum particle agglutination test
Rx
• Penicillin G benzathine 2.4 million units IM
once