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Subacute/Chronic meningitis

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  1. Subacute/Chronic meningitis Reşat ÖZARAS, MD, Prof. Infection Dept. rozaras@yahoo.com

  2. Admission Acute (1 day-1 week) Subacute (1 week-1 mo.) Chronic (> 1 mo. )

  3. 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

  4. 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

  5. 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

  6. CSF • Clear • Cell count: 250 /mm3, 80% lymphocytes • Glucose 10 mg/dl (blood glucose 98) • Protein 280 mg/L • Gram and EZN staining: negative

  7. What is your diagnosis?

  8. 2 days later • CSF TB-PCR: positive

  9. 25 days later • CSF cultures Mycobacterium tuberculosis

  10. Subacute/chronic meningitis • Infections: • TB

  11. TB • May follow a slow progress • Exposure, TST/PPD(+), immune suppression • Prodrome 2-4 weeks

  12. Not only menengitis, • Vasculitis, space-occupying lesion (brain tuberculoma) • Fever • Change in mental status • Hemiplegia, paraplegia • Ocular nerve involvement

  13. CSF

  14. neuropathology.neoucom.edu

  15. Clinical Presentation • Most common clinical findings: • Fever • Headache • Vomiting • Nuchal Rigidity

  16. Diagnosis • CSF Examination • Usually lymphocytic pleocytosis • Elevated protein with severely depressed glucose • AFB • Culture • PCR

  17. Diagnosis • Other Studies • Brain imaging – demonstrates hydrocephalus, basilar exudates and inflammation, tuberculoma, cerebral edema, cerebral infarction • CXR • Abnormal, sometimes miliary pattern

  18. seattlechildren.org

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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!...

  24. Rose-Bengal test positive • Wright test positive • 2 bottles of blood culture yielded Brucella melitensis

  25. Rx • Rifampin+Doxycycline

  26. Subacute/chronic meningitis • Infections: • TB • Spirochetal diseases (syphilis, Lyme’s disease) • Brucellosis • Fungal • Cryptococcus neoformans, Aspergillus, Candida Toxoplasmosis,

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

  28. utdol.com

  29. Early NS • Asymptomatic • Symptomatic • Meningovascular • Late NS • General paresis • Tabes dorsalis

  30. 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

  31. Diagnosis • EIA: syphilis enzyme immunoassay • FTA-ABS: fluorescent treponemal antibody-absorbed test • TPPA: Treponema pallidum particle agglutination test

  32. Rx • Penicillin G benzathine 2.4 million units IM once