Subacute chronic meningitis
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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

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Subacute chronic meningitis

Subacute/Chronic meningitis

Reşat ÖZARAS, MD, Prof.

Infection Dept.

[email protected]


Subacute chronic meningitis

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


Subacute chronic meningitis

  • 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


Subacute chronic meningitis

CSF

  • Clear

  • Cell count: 250 /mm3, 80% lymphocytes

  • Glucose 10 mg/dl (blood glucose 98)

  • Protein 280 mg/L

  • Gram and EZN staining: negative


Subacute chronic meningitis

  • What is your diagnosis?


2 days later

2 days later

  • CSF TB-PCR: positive


25 days later

25 days later

  • CSF cultures Mycobacterium tuberculosis


Subacute chronic meningitis2

Subacute/chronic meningitis

  • Infections:

    • TB


Subacute chronic meningitis

TB

  • May follow a slow progress

  • Exposure, TST/PPD(+), immune suppression

  • Prodrome 2-4 weeks


Subacute chronic meningitis

  • Not only menengitis,

  • Vasculitis, space-occupying lesion (brain tuberculoma)

    • Fever

    • Change in mental status

    • Hemiplegia, paraplegia

    • Ocular nerve involvement


Subacute chronic meningitis

CSF


Subacute chronic meningitis

neuropathology.neoucom.edu


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


Seattlechildren org

seattlechildren.org


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!...


Subacute chronic meningitis

  • Rose-Bengal test positive

  • Wright test positive

  • 2 bottles of blood culture yielded Brucella melitensis


Subacute chronic meningitis

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.


Subacute chronic meningitis

utdol.com


Subacute chronic meningitis

  • Early NS

    • Asymptomatic

    • Symptomatic

    • Meningovascular

  • Late NS

    • General paresis

    • Tabes dorsalis


Subacute chronic meningitis

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


Subacute chronic meningitis

Rx

  • Penicillin G benzathine 2.4 million units IM once


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