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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]


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


  • 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



2 days later
2 days later

  • CSF TB-PCR: positive


25 days later
25 days later

  • CSF cultures Mycobacterium tuberculosis



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




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!...


  • Rose-Bengal test positive seizures, and fever for 1 month…

  • Wright test positive

  • 2 bottles of blood culture yielded Brucella melitensis


Rx seizures, and fever for 1 month…

  • Rifampin+Doxycycline


Subacute chronic meningitis3
Subacute/chronic meningitis seizures, and fever for 1 month…

  • Infections:

    • TB

    • Spirochetal diseases (syphilis, Lyme’s disease)

    • Brucellosis

    • Fungal

      • Cryptococcus neoformans, Aspergillus, Candida

        Toxoplasmosis,


Neurosyphilis
Neurosyphilis seizures, and fever for 1 month…

  • Infection of the central nervous system by Treponema pallidum

  • Neurosyphilis can occur at any time after initial infection.


utdol.com seizures, and fever for 1 month…


  • Early NS seizures, and fever for 1 month…

    • Asymptomatic

    • Symptomatic

    • Meningovascular

  • Late NS

    • General paresis

    • Tabes dorsalis


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 surrounding edema.

  • EIA: syphilis enzyme immunoassay

  • FTA-ABS: fluorescent treponemal antibody-absorbed test

  • TPPA: Treponema pallidum particle agglutination test


Rx surrounding edema.

  • Penicillin G benzathine 2.4 million units IM once


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