Recurrent meningitis

Etiologies

• Infections
  • Viral: HSV-2 (Mollaret's disease; most common cause); HSV-1; EBV
  • Bacterial: Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, Staphylococcus aureus, and Escherichia coli (particularly in children with lumbosacral malformations)
  • Fungal: Cryptococcus neoformans, Candida, Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis
  • Parasitic: Echinococcus, Strongyloides stercoralis, Toxoplasma gondii
• Malignancy: leptomeningeal metastaisis from solid malignancy, leukemic meningitis, lymphomatous meningitis
• Benign tumours: epidermoid cyst, dermoid cyst, craniopharyngioma
• Drug-induced aseptic meningitis
  • NSAIDs: ibuprofen (most common), diclofenac, naproxen, sulindac
  • Antibiotics: cotrimoxazole, cephalosporins, amoxicillin, ciprofloxacin
  • Antiepileptics: lamotrigine, carbamazepine
  • Chemotherapy: cetuximab, intrathecal chemotherapy
  • Immunosuppression: methotraxate, azathioprine, TNF-alpha inhibitors (adalimumab, infliximab, etanercept)
  • Other: IVIg
• Inflammatory/autoimmune
  • SLE
  • Behçet disease
  • Sarcoidosis
  • Sjögren syndrome
  • Vogt-Koyanagi-Harada syndrome
  • Granulomatosis with polyangiitis
  • Rheumatoid arthritis

Risk Factors

• Anatomic defects
  • Congenital: dermal sinus tract, neural tube defects (including spina bifida, encephalocele), Mondini dysplasia
  • Acquired: skull base surgery, head injury
• Immunodeficiency
  • IgG subclass deficiency
  • Complement deficiency, including properdin deficiency, terminal complement deficiency, and use of eculizumab
    • Terminal complement deficiency (C5-C9) specifically increases risk of meningococcus
    • C2-C6 deficiencies are associated with pneumococcus and meningococcus
  • Agammaglobulinemia
  • Common variable immunodeficiency (CVID)
  • HIV
  • Asplenia/hyposplenia: sickle cell disease, splenectomy, trauma
  • Immunosuppression following transplant
• Chronic parameningeal infections, including sinusitis, mastoiditis, otitis media, and osteomyelitis

Specific Patients

Terminal Complement Deficiency

• Prone to recurrent neisserial infections

Hypogammaglobulinemia

• Can develop chronic meningoencephalitis, primarily cause by:
  • Enterovirus
  • Mycoplasma

Further Reading

• Recurrent Meningitis. Curr Pain Headache Rep. 2017;21(33). doi: 10.1007/s11916-017-0635-7