Chronic meningitis: Difference between revisions

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==Background==
  
==Background==
  +
  +
* Infection or inflammation of the meninges and subarachnoid space lasting 4 or more weeks
   
 
==Differential Diagnosis==
  
==Differential Diagnosis==
  +
{| class="wikitable"
  +
!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]]
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|[[Whipple disease]]
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|cognitive impairment, ataxia, ophthalmoplegia, supranuclear gaze palsy, lymphadenopathy
  +
|CSF PCR
  +
|[[ceftriaxone]] followed by [[TMP-SMX]]
  +
|-
  +
|[[Cryptococcus]]
  +
|cell-mediated immunodeficiency
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|encephalitis with personality changes, memory loss, headache, may have skin lesions
  +
|CSF CrAg
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|[[amphotericin B]] and [[flucytosine]]
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|-
  +
|[[Coccidioides immitis]]
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|cell-mediated immunodeficiency, in endemic area
  +
|headache, altered mentation, nausea/vomiting, focal deficits, can has CSF eosinophilia
  +
|serum and CSF serology
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|[[fluconazole]], intrathecal [[amphotericin B]]
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|-
  +
|[[Histoplasma capsulatum]]
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|cell-mediated immunodeficiency, in endemic area
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|constitutional symptoms
  +
|serum and urine antigen
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|[[amphotericin B]] followed by [[itraconazole]]
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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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|}
   
−
* '''Fungal infections'''
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*'''Fungal infections'''
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** ''[[Cryptococcus]]''
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**''[[Cryptococcus]]''
−
** ''[[Coccidioides]]''
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**''[[Coccidioides]]''
−
** ''[[Histoplasma]]''
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**''[[Histoplasma]]''
−
** ''[[Candida]]''
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**''[[Candida]]''
−
** ''[[Sporothrix]]'' (rare)
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**''[[Sporothrix]]'' (rare)
−
** ''[[Blastomyces]]'' (rare)
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**''[[Blastomyces]]'' (rare)
−
** Other rare molds: ''[[Scedosporium]]'', ''[[Aspergillus]]'', ''[[Cladophialophora]]'', and other [[dematiaceous molds]]
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**Other rare molds: ''[[Scedosporium]]'', ''[[Aspergillus]]'', ''[[Cladophialophora]]'', and other [[dematiaceous molds]]
−
* '''Bacterial infections'''
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*'''Bacterial infections'''
−
** ''[[Mycobacterium tuberculosis]]''
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**''[[Mycobacterium tuberculosis]]''
−
** ''[[Treponema pallidum]]''
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**''[[Treponema pallidum]]''
−
** ''[[Borrelia burgdorferi]]''
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**''[[Borrelia burgdorferi]]''
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** ''[[Tropheryma whipplei]]''
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**''[[Tropheryma whipplei]]''
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** ''[[Actinomyces]]'' (parameningeal, rare)
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**''[[Actinomyces]]'' (parameningeal, rare)
−
** ''[[Nocardia]]'' (with brain abscess)
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**''[[Nocardia]]'' (with brain abscess)
−
** ''[[Brucella]]'' (rare)
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**''[[Brucella]]'' (rare)
−
* '''Viral infections'''
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*'''Viral infections'''
−
** [[Echovirus]] (meningoencephalitis)
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**[[Echovirus]] (meningoencephalitis)
−
* '''Parasitic infections'''
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*'''Parasitic infections'''
−
** ''[[Acanthamoeba]]''
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**''[[Acanthamoeba]]''
−
** ''[[Balamuthia]]''
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**''[[Balamuthia]]''
−
** ''[[Taenia solium]]''
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**''[[Taenia solium]]''
−
** ''[[Angiostrongylus cantonensis]]''
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**''[[Angiostrongylus cantonensis]]''
−
* '''Other causes'''
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*'''Other causes'''
−
** Post-neurosurgical causes: infected CSF shunt, infected prosthetic material
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**[[Neurosurgical infections|Neurosurgical infection]]: [[ventricular shunt infection]], infected prosthetic material
−
** Tumours: diffuse gliomatosis, metastatic meningeal malignancies including lymphomatous meningitis
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**Tumours: [[diffuse gliomatosis]], [[metastatic meningeal malignancies]] including [[lymphomatous meningitis]]
−
** Others: sarcoidosis, Vogt-Koyanagi-Harada syndrome, Behçet syndrome, IgG4-related hypertrophic pachymeningitis
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**Others: [[sarcoidosis]], [[Vogt-Koyanagi-Harada syndrome]], [[Behçet syndrome]], [[IgG4 disease|IgG4-related hypertrophic pachymeningitis]]
   
 
==Investigations==
  
==Investigations==
  +
−
* CSF tests:
 +
*CSF tests:
−
** Glucose, protein, cell count and differential (including eosinophils)
 +
**Glucose, protein, cell count and differential (including eosinophils)
−
** India ink on centrifuged sediment
 +
**India ink on centrifuged sediment
−
** Fungal culture of 3-5 mL of CSF
 +
**Fungal culture of 3-5 mL of CSF
−
** Cytopathology for malignant cells, including PCR or flow cytometry for monoclonal B cells
 +
**Cytopathology for malignant cells, including PCR or flow cytometry for monoclonal B cells
−
** Periodic acid-Schiff stain for Whipple disease
 +
**Periodic acid-Schiff stain for Whipple disease
−
** VDRL test
 +
**VDRL test
−
** Cryptococcal antigen
  
−
** ''[[Histoplasma]]'' antigen
 +
**Cryptococcal antigen
−
** ''[[Aspergillus]]'' galactomannan antigen
 +
**''[[Histoplasma]]'' antigen
  +
**''[[Aspergillus]]'' galactomannan antigen
−
** ''[[Coccidioides]]'' antibody by complement fixation or immunodiffusion
 +
**''[[Coccidioides]]'' antibody by complement fixation or immunodiffusion
−
** PCR for [[tuberculosis]], [[Whipple disease]], [[enterovirus]], and lymphoma
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**PCR for [[tuberculosis]], [[Whipple disease]], [[enterovirus]], and lymphoma
−
** Culture for [[enterovirus]] and ''[[Acanthamoeba]]''
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**Culture for [[enterovirus]] and ''[[Acanthamoeba]]''
−
* Blood tests
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*Blood tests
−
** RPR or other routine [[syphilis]] screening
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**RPR or other routine [[syphilis]] screening
−
** Serology for ''[[Coccidioides]]'', ''[[Histoplasma]]'', ''[[Toxoplasma]]'', and ''[[Brucella]]'' antibodies
  
−
** Serology for ''[[Histoplasma]]'' antigen (may be from blood or urine)
 +
**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
 +
*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

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
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