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Subacute/Chronic meningitis. Reşat ÖZARAS, MD , Prof. Infection Dept. [email protected] Admission A cute ( 1 day-1 week ) Suba c ute ( 1 week-1 mo.) Ch ronic (> 1 mo. ). Subacute/Chronic meningitis. W ithin weeks or months

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subacute chronic meningitis

Subacute/Chronic meningitis

Reşat ÖZARAS, MD, Prof.

Infection Dept.

[email protected]

slide2

Admission

Acute (1 day-1 week)

Subacute (1 week-1 mo.)

Chronic (> 1 mo. )

subacute chronic meningitis1
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 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
slide5

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
slide6
CSF
  • Clear
  • Cell count: 250 /mm3, 80% lymphocytes
  • Glucose 10 mg/dl (blood glucose 98)
  • Protein 280 mg/L
  • Gram and EZN staining: negative
2 days later
2 days later
  • CSF TB-PCR: positive
25 days later
25 days later
  • CSF cultures Mycobacterium tuberculosis
slide11
TB
  • May follow a slow progress
  • Exposure, TST/PPD(+), immune suppression
  • Prodrome 2-4 weeks
slide12

Not only menengitis,

  • Vasculitis, space-occupying lesion (brain tuberculoma)
    • Fever
    • Change in mental status
    • Hemiplegia, paraplegia
    • Ocular nerve involvement
clinical presentation
Clinical Presentation
  • Most common clinical findings:
    • Fever
    • Headache
    • Vomiting
    • Nuchal Rigidity
diagnosis
Diagnosis
  • CSF Examination
    • Usually lymphocytic pleocytosis
    • Elevated protein with severely depressed glucose
    • AFB
    • Culture
    • PCR
diagnosis1
Diagnosis
  • Other Studies
    • Brain imaging – demonstrates hydrocephalus, basilar exudates and inflammation, tuberculoma, cerebral edema, cerebral infarction
  • CXR
    • Abnormal, sometimes miliary pattern
treatment antimicrobial therapy
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
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
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
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
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!...
slide28

Rose-Bengal test positive

  • Wright test positive
  • 2 bottles of blood culture yielded Brucella melitensis
slide29
Rx
  • Rifampin+Doxycycline
subacute chronic meningitis3
Subacute/chronic meningitis
  • Infections:
    • TB
    • Spirochetal diseases (syphilis, Lyme’s disease)
    • Brucellosis
    • Fungal
      • Cryptococcus neoformans, Aspergillus, Candida

Toxoplasmosis,

neurosyphilis
Neurosyphilis
  • Infection of the central nervous system by Treponema pallidum
  • Neurosyphilis can occur at any time after initial infection.
slide33

Early NS

    • Asymptomatic
    • Symptomatic
    • Meningovascular
  • Late NS
    • General paresis
    • Tabes dorsalis
slide34

A) Focal meningeal enhancement in the left frontal lobe with surrounding edema.

B) Significant edema in the left posterior frontal lobe.

Cerebral gumma in an HIV-infected patient with recent secondary syphilis.

utdol.com

diagnosis2
Diagnosis
  • EIA: syphilis enzyme immunoassay
  • FTA-ABS: fluorescent treponemal antibody-absorbed test
  • TPPA: Treponema pallidum particle agglutination test
slide36
Rx
  • Penicillin G benzathine 2.4 million units IM once
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