Recurrent meningitis: Difference between revisions

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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

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

@@ Line 1: / Line 1: @@
+==Etiologies==
-== Differential Diagnosis ==
+*Infections
-* Immune defects
+**Viral: [[HSV-2]] (Mollaret's disease; most common cause); [[HSV-1]]; [[EBV]]
-** Asplenia
+**Bacterial: [[Streptococcus pneumoniae]], [[Haemophilus influenzae]], [[Neisseria meningitidis]], [[Staphylococcus aureus]], and [[Escherichia coli]] (particularly in children with lumbosacral malformations)
-** Hypogammaglobulinemia
+**Fungal: [[Cryptococcus neoformans]], [[Candida]], [[Histoplasma capsulatum]], [[Coccidioides immitis]], [[Blastomyces dermatitidis]]
-** Complement deficiences
+**Parasitic: [[Echinococcus]], [[Strongyloides stercoralis]], [[Toxoplasma gondii]]
-* Parameningeal focus of infection
+*Malignancy: leptomeningeal metastaisis from solid malignancy, leukemic meningitis, lymphomatous meningitis
-* Structural abnormalities
+*Benign tumours: epidermoid cyst, dermoid cyst, craniopharyngioma
-** Post-neurosurgery
+*[[Drug-induced aseptic meningitis]]
-** CSF leak or fistula
+**NSAIDs: [[ibuprofen]] (most common), [[diclofenac]], [[naproxen]], [[sulindac]]
-** Dermal sinuses
+**Antibiotics: [[cotrimoxazole]], [[cephalosporins]], [[amoxicillin]], [[ciprofloxacin]]
-** Epidermoid cysts
+**Antiepileptics: [[lamotrigine]], [[carbamazepine]]
-** Craniopharyngioma
+**Chemotherapy: [[cetuximab]], intrathecal chemotherapy
-* Drugs
+**Immunosuppression: [[methotraxate]], [[azathioprine]], [[TNF-alpha inhibitors]] ([[adalimumab]], [[infliximab]], [[etanercept]])
-** [[Septra]]
+**Other: [[IVIg]]
-** NSAIDs
+*Inflammatory/autoimmune
-** IVIg
-** OKT3
+**[[SLE]]
+**[[Behçet disease]]
-** Phenytoin
+**[[Sarcoidosis]]
-* Infections
+**[[Sjögren syndrome]]
-** [[HSV]] (Mollaret's disease)
+**[[Vogt-Koyanagi-Harada syndrome]]
-* Inflammatory
+**[[Granulomatosis with polyangiitis]]
-** SLE
+**[[Rheumatoid arthritis]]
-** Behcet's
-== Specific Patients ==
+== Risk Factors ==
+* Anatomic defects
-=== Terminal Complement Deficiency ===
+** Congenital: [[dermal sinus tract]], [[Neural tube defect|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==
-* Prone to recurrent [[Neisserial species|neisserial infections]]
+===Terminal Complement Deficiency===
-=== Hypogammaglobulinemia ===
+*Prone to recurrent [[Neisseria species|neisserial infections]]
-* Can develop chronic meningoencephalitis, primarily cause by:
-** [[Enterovirus]]
+===Hypogammaglobulinemia===
-** [[Mycoplasma]]
+*Can develop chronic meningoencephalitis, primarily cause by:
+**[[Enterovirus]]
+**[[Mycoplasma]]
+== Further Reading ==
+* Recurrent Meningitis. ''Curr Pain Headache Rep''. 2017;21(33). doi: [https://doi.org/10.1007/s11916-017-0635-7 10.1007/s11916-017-0635-7]
 [[Category:CNS infections]]