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

EtiologyEtiology WBC(/mmWBC(/mm33)) Cell TypeCell Type Glucose(Mg/dL)Glucose(Mg/dL) Protein(Mg/dL)Protein(Mg/dL)

Viral Viral 50–1000 50–1000 LymphocyticLymphocytic >45 >45 <200 <200

BacterialBacterial 1000–1000–5000 5000

NeutropilicNeutropilic <40 <40 100–500 100–500

TBTB 50–300 50–300 LymphocyticLymphocytic <45 <45 50–300 50–300

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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

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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

B) Significant edema in the left posterior frontal lobe.

A) Focal meningeal enhancement in the left frontal lobe with 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