Chronic meningitis

From IDWiki

Background

  • Infection or inflammation of the meninges and subarachnoid space lasting 4 or more weeks

Differential Diagnosis

Organism Risk Factors Clinical Features Diagnosis Treatment
Brucella unpasteurized dairy or infected animals in endemic areas undulating fever, CN palsies, behavioural changes serology doxycycline, ceftriaxone, or rifampin
Tropheryma whipplei Whipple disease cognitive impairment, ataxia, ophthalmoplegia, supranuclear gaze palsy, lymphadenopathy CSF PCR ceftriaxone followed by TMP-SMX
Cryptococcus cell-mediated immunodeficiency encephalitis with personality changes, memory loss, headache, may have skin lesions CSF CrAg amphotericin B and flucytosine
Coccidioides immitis cell-mediated immunodeficiency, in endemic area headache, altered mentation, nausea/vomiting, focal deficits, can has CSF eosinophilia serum and CSF serology fluconazole, intrathecal amphotericin B
Histoplasma capsulatum cell-mediated immunodeficiency, in endemic area constitutional symptoms serum and urine antigen amphotericin B followed by itraconazole
Angiostrongylus cantonensis eating raw or undercooked shellfish, snails, or water plants in Asia and South Pacific severe headache, pruritic rash, paresthesias, eosinophilia self-limited (2 months)
Borrelia burgdorferi exposure to Ixodes ticks preceding erythema migrans serology ceftriaxone
Treponema pallidum pallidum high-risk sexual contacts concurrent sexually-transmitted infections CSF VDRL penicillin

Investigations

  • CSF tests:
    • Glucose, protein, cell count and differential (including eosinophils)
    • India ink on centrifuged sediment
    • Fungal culture of 3-5 mL of CSF
    • Cytopathology for malignant cells, including PCR or flow cytometry for monoclonal B cells
    • Periodic acid-Schiff stain for Whipple disease
    • VDRL test
    • Cryptococcal antigen
    • Histoplasma antigen
    • Aspergillus galactomannan antigen
    • Coccidioides antibody by complement fixation or immunodiffusion
    • PCR for tuberculosis, Whipple disease, enterovirus, and lymphoma
    • Culture for enterovirus and Acanthamoeba
  • Blood tests
  • Brain biopsy has low diagnostic yield in chronic meningitis