Chronic meningitis: Difference between revisions
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==Background== |
==Background== |
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+ | |||
+ | * Infection or inflammation of the meninges and subarachnoid space lasting 4 or more weeks |
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==Differential Diagnosis== |
==Differential Diagnosis== |
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+ | {| class="wikitable" |
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+ | !Organism |
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+ | !Risk Factors |
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+ | !Clinical Features |
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+ | !Diagnosis |
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+ | !Treatment |
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+ | |- |
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+ | |[[Brucella]] |
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+ | |unpasteurized dairy or infected animals in endemic areas |
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+ | |undulating fever, CN palsies, behavioural changes |
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+ | |serology |
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+ | |[[doxycycline]], [[ceftriaxone]], or [[rifampin]] |
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+ | |- |
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+ | |[[Tropheryma whipplei]] |
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+ | |[[Whipple disease]] |
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+ | |cognitive impairment, ataxia, ophthalmoplegia, supranuclear gaze palsy, lymphadenopathy |
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+ | |CSF PCR |
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+ | |[[ceftriaxone]] followed by [[TMP-SMX]] |
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+ | |- |
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+ | |[[Cryptococcus]] |
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+ | |cell-mediated immunodeficiency |
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+ | |encephalitis with personality changes, memory loss, headache, may have skin lesions |
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+ | |CSF CrAg |
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+ | |[[amphotericin B]] and [[flucytosine]] |
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+ | |- |
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+ | |[[Coccidioides immitis]] |
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+ | |cell-mediated immunodeficiency, in endemic area |
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+ | |headache, altered mentation, nausea/vomiting, focal deficits, can has CSF eosinophilia |
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+ | |serum and CSF serology |
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+ | |[[fluconazole]], intrathecal [[amphotericin B]] |
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+ | |- |
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+ | |[[Histoplasma capsulatum]] |
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+ | |cell-mediated immunodeficiency, in endemic area |
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+ | |constitutional symptoms |
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+ | |serum and urine antigen |
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+ | |[[amphotericin B]] followed by [[itraconazole]] |
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+ | |- |
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+ | |[[Angiostrongylus cantonensis]] |
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+ | |eating raw or undercooked shellfish, snails, or water plants in Asia and South Pacific |
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+ | |severe headache, pruritic rash, paresthesias, eosinophilia |
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+ | | |
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+ | |self-limited (2 months) |
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+ | |- |
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+ | |[[Borrelia burgdorferi]] |
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+ | |exposure to [[Ixodes]] ticks |
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+ | |preceding erythema migrans |
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+ | |serology |
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+ | |[[ceftriaxone]] |
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+ | |- |
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+ | |[[Treponema pallidum pallidum]] |
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+ | |high-risk sexual contacts |
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+ | |concurrent sexually-transmitted infections |
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+ | |CSF VDRL |
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+ | |[[penicillin]] |
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+ | |} |
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− | * |
+ | *'''Fungal infections''' |
− | ** |
+ | **''[[Cryptococcus]]'' |
− | ** |
+ | **''[[Coccidioides]]'' |
− | ** |
+ | **''[[Histoplasma]]'' |
− | ** |
+ | **''[[Candida]]'' |
− | ** |
+ | **''[[Sporothrix]]'' (rare) |
− | ** |
+ | **''[[Blastomyces]]'' (rare) |
− | ** |
+ | **Other rare molds: ''[[Scedosporium]]'', ''[[Aspergillus]]'', ''[[Cladophialophora]]'', and other [[dematiaceous molds]] |
− | * |
+ | *'''Bacterial infections''' |
− | ** |
+ | **''[[Mycobacterium tuberculosis]]'' |
− | ** |
+ | **''[[Treponema pallidum]]'' |
− | ** |
+ | **''[[Borrelia burgdorferi]]'' |
− | ** |
+ | **''[[Tropheryma whipplei]]'' |
− | ** |
+ | **''[[Actinomyces]]'' (parameningeal, rare) |
− | ** |
+ | **''[[Nocardia]]'' (with brain abscess) |
− | ** |
+ | **''[[Brucella]]'' (rare) |
− | * |
+ | *'''Viral infections''' |
− | ** |
+ | **[[Echovirus]] (meningoencephalitis) |
− | * |
+ | *'''Parasitic infections''' |
− | ** |
+ | **''[[Acanthamoeba]]'' |
− | ** |
+ | **''[[Balamuthia]]'' |
− | ** |
+ | **''[[Taenia solium]]'' |
− | ** |
+ | **''[[Angiostrongylus cantonensis]]'' |
− | * |
+ | *'''Other causes''' |
− | ** |
+ | **[[Neurosurgical infections|Neurosurgical infection]]: [[ventricular shunt infection]], infected prosthetic material |
− | ** |
+ | **Tumours: [[diffuse gliomatosis]], [[metastatic meningeal malignancies]] including [[lymphomatous meningitis]] |
− | ** |
+ | **Others: [[sarcoidosis]], [[Vogt-Koyanagi-Harada syndrome]], [[Behçet syndrome]], [[IgG4 disease|IgG4-related hypertrophic pachymeningitis]] |
==Investigations== |
==Investigations== |
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+ | |||
− | * |
+ | *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 |
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− | ** |
+ | **Cryptococcal antigen |
− | ** |
+ | **''[[Histoplasma]]'' antigen |
+ | **''[[Aspergillus]]'' galactomannan antigen |
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− | ** |
+ | **''[[Coccidioides]]'' antibody by complement fixation or immunodiffusion |
− | ** |
+ | **PCR for [[tuberculosis]], [[Whipple disease]], [[enterovirus]], and lymphoma |
− | ** |
+ | **Culture for [[enterovirus]] and ''[[Acanthamoeba]]'' |
− | * |
+ | *Blood tests |
− | ** |
+ | **RPR or other routine [[syphilis]] screening |
− | ** Serology for ''[[Coccidioides]]'', ''[[Histoplasma]]'', ''[[Toxoplasma]]'', and ''[[Brucella]]'' antibodies |
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− | ** |
+ | **Serology for ''[[Coccidioides]]'', ''[[Histoplasma]]'', ''[[Toxoplasma]]'', and ''[[Brucella]]'' antibodies |
+ | **Serology for ''[[Histoplasma]]'' antigen (may be from blood or urine) |
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− | * |
+ | *Brain biopsy has low diagnostic yield in chronic meningitis |
[[Category:CNS infections]] |
[[Category:CNS infections]] |
Latest revision as of 04:00, 5 February 2022
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 |
- Fungal infections
- Cryptococcus
- Coccidioides
- Histoplasma
- Candida
- Sporothrix (rare)
- Blastomyces (rare)
- Other rare molds: Scedosporium, Aspergillus, Cladophialophora, and other dematiaceous molds
- Bacterial infections
- Mycobacterium tuberculosis
- Treponema pallidum
- Borrelia burgdorferi
- Tropheryma whipplei
- Actinomyces (parameningeal, rare)
- Nocardia (with brain abscess)
- Brucella (rare)
- Viral infections
- Echovirus (meningoencephalitis)
- Parasitic infections
- Other causes
- Neurosurgical infection: ventricular shunt infection, infected prosthetic material
- Tumours: diffuse gliomatosis, metastatic meningeal malignancies including lymphomatous meningitis
- Others: sarcoidosis, Vogt-Koyanagi-Harada syndrome, Behçet syndrome, IgG4-related hypertrophic pachymeningitis
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
- RPR or other routine syphilis screening
- Serology for Coccidioides, Histoplasma, Toxoplasma, and Brucella antibodies
- Serology for Histoplasma antigen (may be from blood or urine)
- Brain biopsy has low diagnostic yield in chronic meningitis