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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
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
Viral
Enterovirus HSV
Fungal
Noninfectious
Malignant Medications NSAIDS, trimethoprimsulfamethoxazole Sarcoidosis Behcets syndrome Systemic Lupus Erythematous Endocarditis
Symptoms
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
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
Antigen testing
Cryptococcus neoformans, HSV, VZV, EBV, CMV, VDRL Significant inter- and intralab variability with PCRs
Cytology
Serum Tests
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.