Approach to a case of Chronic Meningitis

1. Dr. Shatdal Chaudhary
Associate Professor
Department of Internal Medicine
Universal College of Medical Sciences,
Bhairahawa, Nepal

2. Definition
Chronic 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

3. Five Categories of disease
Meningeal infection
Malignancy
Noninfectious inflammatory disorders
Chemical meningitis
Parameningeal infections

4. Infectious Causes
Bacterial
Brucella
Francisella tularensis
Actinomyces
Listeria-unpastuerized
Nocardia
Rarely partially treated N. Meningitis, Streptococcus or
H. Flu

5. 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
Leptospirosis
Meningeal symptoms develop in 50% of
patients during anicteric second stage of
illness

6. 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

7. Viral
Enterovirus
HSV
Mollaret’s syndrome- “Benign Recurrent Meningitis”
HIV
Lymphocytic Choriomeningitis
CMV
EBV
VZV
Mumps

8. Other Infectious Etiologies
Fungal
Cryptococcus, Coccidioides, Sporithrix, Histoplasma
Parasitic – Eosinophilic Meningitis
Angiostrongylus, Taenia solium, Schistosomiasis,
Toxoplasmosis

9. Noninfectious Causes
Malignancy
Metastastic Ca of Breast, Lung, Pancreas,
Lymphoma, Leukaemia,
Meningeal gliomatosis
Medications/ Chemical:
Subarachnoid injection
NSAIDS, trimethoprim-sulfamethoxazole
Epidermoid tumor, Craniopharyngioma,

10. Rheumatologic/ Noninfectious inflammatory
conditions:
Sarcoidosis
SLE
Bechet Syndrome
Wegners Disease
Vogt-Koyanagi-Harada Syndrome
Idiopathic

11. Symptoms
Nonspecific and similar to acute meningitis
Are determined by anatomical location of
inflammation and its consequence.

12. Symptoms
 Double vision/visual loss
 Hearing loss
 Limb weakness
 Sphincter dysfunction

13. symptoms
Hydrocephalus
Cranial neuropathies
Radiculopathy
Cognitive disturbance
Personality changes
Presence of underlying systemic illness
According to causative agent

14. Historical Clues
Travel to endemic areas – eg fungal, parasitic, lyme
TB exposure or previous positive skin test
Sexual history
Tick exposure

15. Historical Clues
Medications-specifically NSAIDs
Contact with rabbits, cats, wild game or meat
processing
Recurrent genital or oral ulcers
Weight loss, night sweats
Rash

16. CSF Analysis
Test
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

17. CSF Analysis
PMN predominate/ Lymph
Low Glucose
predominate/
Normal Glucose
Bacteria
-Actinomyces,
Listeria, Brucellosis
Mumps
LCM
NSAIDS
Sulfa
Behcet’s
Early Viral
Viral
CNS Malignancy
Endocarditis
Early Mycobacterium
Early Fungal
Lymph
predominate/
Low Glucose
Mycobacterium
Fungi

18. 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

19. Serum Tests
HIV with ELISA
VDRL/RPR
Serologies
LCM, leptospirosis, Lyme, Ehrlichia, Brucella
Blood cultures x3

20. 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

21. Treatment according to Etiological Agent
Empiric Therapy
Antituberculous therapy
Antiviral Therapy
Steroids
Persistent negative cultures
 Infectious etiology though unlikely

Trial of combination of ATT+Antifungal+Steroids