Dr. Shatdal ChaudharyAssociate Professor

Department of Internal MedicineUniversal College of Medical Sciences, Bhairahawa, Nepal

DefinitionChronic 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

Five Categories of diseaseMeningeal infectionMalignancyNoninfectious inflammatory disordersChemical meningitisParameningeal infections

Infectious Causes

BacterialBrucellaFrancisella tularensisActinomycesListeria-unpastuerizedNocardiaRarely partially treated N. Meningitis,

Streptococcus or H. Flu

SpirochetesTreponema pallidum

Disseminates during early infectionSerum and CSF VDRL typically positive

Lyme MeningitisTypically late summer and early fallTravel to endemic areaHistory consistent with erythema

migransLeptospirosis

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

Mycobacterium TuberculosisBacilli seed to the meninges creating

tubercles called “Rich foci”Tubercles that rupture into subarachnoid

space causing meningitisCranial nerve palsies can occur

CN VI most frequently affected Up to 40% in children

ViralEnterovirusHSV

Mollaret’s syndrome- “Benign Recurrent Meningitis”

HIVLymphocytic ChoriomeningitisCMVEBVVZVMumps

Other Infectious EtiologiesFungal

Cryptococcus, Coccidioides, Sporithrix, Histoplasma

Parasitic – Eosinophilic MeningitisAngiostrongylus, Taenia solium,

Schistosomiasis, Toxoplasmosis

Noninfectious CausesMalignancy

Metastastic Ca of Breast, Lung, Pancreas, Lymphoma, Leukaemia, Meningeal gliomatosis

Medications/ Chemical: Subarachnoid injectionNSAIDS, trimethoprim-sulfamethoxazoleEpidermoid tumor, Craniopharyngioma,

Rheumatologic/ Noninfectious inflammatory conditions:SarcoidosisSLEBechet SyndromeWegners DiseaseVogt-Koyanagi-Harada Syndrome

Idiopathic

SymptomsNonspecific and similar to acute

meningitisAre determined by anatomical

location of inflammation and its consequence.

Symptoms

Double vision/visual loss Hearing loss Limb weakness Sphincter dysfunction

symptomsHydrocephalusCranial neuropathiesRadiculopathyCognitive disturbancePersonality changesPresence of underlying systemic illnessAccording to causative agent

Historical CluesTravel to endemic areas – eg fungal,

parasitic, lymeTB exposure or previous positive skin testSexual historyTick exposure

Historical CluesMedications-specifically NSAIDsContact with rabbits, cats, wild game or meat

processingRecurrent genital or oral ulcersWeight loss, night sweatsRash

CSF AnalysisTest 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

CSF AnalysisPMN predominate/

Low Glucose

Lymph predominate/

Normal Glucose

Lymph predominate/

Low Glucose

Bacteria

-Actinomyces,

Listeria, Brucellosis

Mumps

LCM

NSAIDS

Sulfa

Behcet’s

Early Viral

Viral

CNS Malignancy

Endocarditis

Early Mycobacterium

Early Fungal

Mycobacterium

Fungi

Specific CSF AnalysisAntigen 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 CSFAerobicMycobacterialFungal

Cytology

Serum TestsHIV with ELISA

VDRL/RPR

SerologiesLCM, leptospirosis, Lyme, Ehrlichia, Brucella

Blood cultures x3

Further ExaminationsPPDCXRRetinal ExamEchocardiogramMRI

Rarely lead to specific diagnosisFocal abnormalities may be useful if brain biopsy

consideredMeningeal/Brain Biopsy

Particularly useful if focal on imagingProgressive disease despite empiric therapy

Treatment according to Etiological Agent

Empiric TherapyAntituberculous therapy

Antiviral TherapySteroids

Persistent negative cultures Infectious etiology though unlikely

Trial of combination of ATT+Antifungal+Steroids