Chronic and Recurrent MeningitisPrepared By: DR.KUCHA

outline Introduction Five categories of disease account for most

cases chronic meningitis Two clinical forms of chronic meningitis Symptoms & signs Of chronic meningitis APPROACH TO THE PATIENT WITH CHRONIC

MENINGITIS CAUSES OF CHRONIC MENINGITIS

Infectious Non infectious

Introduction The condition is most commonly diagnosed

when :

1) a characteristic neurologic syndrome exists for > 4 weeks

2) and is associated with a persistent inflammatory response in the cerebrospinal fluid (CSF) (white blood cell count >5/microLitres).

Five categories of disease account for most cases o chronic meningitis

(1) meningeal infections(2) malignancy(3) noninfectious inflammatory

disorders(4) chemical meningitis, and(5) parameningeal infections.

Two clinical forms of chronic meningitis

1) symptoms are chronic and persistent 2) there are recurrent, discrete episodes with complete resolution of meningeal

inflammation between episodes without specific therapy.

Symptoms & signs Of chronic meningitis

SYMPTOMS SIGNS

Chronic headache +/– Papilledema

Neck or back pain Brudzinski's sign

Facial weakness Peripheral seventh CN palsy

Double vision Palsy of CNs III, IV, VI

Visual loss Papilledema, optic atrophy

Hearing loss Eighth CN palsy

Arm or leg weakness Myelopathy or radiculopathy

Numbness in arms or legs Myelopathy or radiculopathy

Clumsiness Ataxia

APPROACH TO THE PATIENT WITH CHRONIC MENINGITIS

Once chronic meningitis is confirmed by CSF examination, effort is focused on identifying the cause by:(1) further analysis of the CSF(2) diagnosis of an underlying

systemic infection or noninfectious inflammatory condition, or

(3) examination of meningeal biopsy tissue.

APPROACH TO THE PATIENT WITH CHRONIC MENINGITIS

Proper analysis of the CSF is essential; if the possibility of raised intracranial

pressure (ICP) exists, a brain imaging study should be performed before LP.

In pts with communicating hydrocephalus caused by impaired resorption of CSF, LP is safe and may lead to temporary improvement.

However, if ICP is elevated because of a mass lesion, brain swelling, or a block in ventricular CSF outflow (obstructive hydrocephalus), then LP carries the potential risk of brain herniation. Obstructive hydrocephalus usually requires direct ventricular drainage of CSF.

INFECTIOUS CAUSES OF CHRONIC MENINGITIS Common Bacterial Causes Helminthic

Causes

Partially treated suppurative meningitis Cysticercosis

Parameningeal infection Gnathostoma

Mycobacterium tuberculosis Angiostrongylus

Lyme disease (Bannwarth’s syndrome): Borrelia burgdorferi

Syphilis (secondary, tertiary): Treponema pallidum

Fungal Causes Protozoal Causes

Cryptococcus neoformans Toxoplasma gondii

Coccidioides immitis, Aspergillus sp. Trypanosomiasis

Candida sp. Histoplasma capsulatum

INFECTIOUS CAUSES OF CHRONIC MENINGITIS

Viral Causes

Mumps HIV (acute retroviral syndrome)Lymphocytic choriomeningitis Herpes simplex (HSV)Echovirus

Obstructive hydrocephalus usually requires direct ventricular drainage of CSF.

Noninfectious causes of meningitis

Malignancy

Chemical compounds(may cause recurrent meningitis)

Primary inflammation

CNS sarcoidosisSystemic lupus erythematosusBehcet’s syndrome (recurrent meningitis)Chronic benign lymphocytic meningitisDrug hypersensitivityWegener’s granulomatosis