SubacuteChronic meningitis Reat ZARAS MD Prof Infection Dept
Subacute/Chronic meningitis Reşat ÖZARAS, MD, Prof. Infection Dept. rozaras@yahoo. com
Admission Acute (1 day-1 week) Subacute (1 week-1 mo. ) Chronic (> 1 mo. )
Subacute/Chronic meningitis • Within weeks or months • Headache, fever, neck rigidity, mental changes • Focal neurological signs are more frequent • Needs specific treatment • A diagnostic challenge
A Case Study • A 48 -year-old female was admitted with headache, myalgia, nausea, vomiting, fatigue, anorexia and fever for 6 weeks • Biochemistry normal • CBC normal • C-RP: 5 Xnormal, ESR 100 mm/h
• No previous and family history – Immunosuppressive disorders/drugs – No similar signs & symptoms in the family • No focal neurological sign • Neck rigidity +/-, Kernig and Brudzinski + • MRI showed mild contrast enhancement at basal cranial meninges
CSF • • • Clear Cell count: 250 /mm 3, 80% lymphocytes Glucose 10 mg/dl (blood glucose 98) Protein 280 mg/L Gram and EZN staining: negative
• What is your diagnosis?
2 days later • CSF TB-PCR: positive
25 days later • CSF cultures Mycobacterium tuberculosis
Subacute/chronic meningitis • Infections: – TB
TB • May follow a slow progress • Exposure, TST/PPD(+), immune suppression • Prodrome 2 -4 weeks
• Not only menengitis, • Vasculitis, space-occupying lesion (brain tuberculoma) – – Fever Change in mental status Hemiplegia, paraplegia Ocular nerve involvement
CSF Etiology WBC(/mm 3) Cell Type Glucose(Mg/d. L) Viral 50– 1000 Lymphocytic >45 <200 Bacterial 1000– 5000 Neutropilic 100– 500 TB 50– 300 Lymphocytic <45 <40 Protein(Mg/d. L) 50– 300
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Clinical Presentation • Most common clinical findings: – Fever – Headache – Vomiting – Nuchal Rigidity
Diagnosis • CSF Examination – Usually lymphocytic pleocytosis – Elevated protein with severely depressed glucose – AFB – Culture – PCR
Diagnosis • Other Studies – Brain imaging – demonstrates hydrocephalus, basilar exudates and inflammation, tuberculoma, cerebral edema, cerebral infarction • CXR – Abnormal, sometimes miliary pattern
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Treatment: Antimicrobial Therapy • Start as soon as there is suspicion for TB meningitis • Same Guidelines as those for pulmonary TB – Intensive Phase: 4 drug regimen of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol for 2 months – Continuation Phase: Isoniazid and Rifampin for another 7 – 10 months
Treatment: Adjunctive Therapy • Glucocorticoids Indicated with: – rapid progression from one stage to the next – CT evidence of cerebral edema – worsening clinical signs after starting anti. Tb meds – increased basilar enhancement, or moderate to advancing hydrocephalus on head CT
Outcomes • Overall Poor • Only 1/3 - 1/2 of patients demonstrate complete neurologic recovery • Up to 1/3 of patients have residual severe neurologic deficits such as hemiparesis, blindness, seizure DO
Another Case Study • A 30 -year-old male farmer was admitted with headache, newly-onset seizures, and fever for 1 month • Biochemistry normal • CBC normal • C-RP: 5 Xnormal, ESR 50 mm/h
A 30 -year-old male was admitted with headache, newly -onset seizures, and fever for 1 month… • Blood cultures were obtained • MRI: normal • Diagnosed by a serology!. . .
• Rose-Bengal test positive • Wright test positive • 2 bottles of blood culture yielded Brucella melitensis
Rx • Rifampin+Doxycycline
Subacute/chronic meningitis • Infections: – TB – Spirochetal diseases (syphilis, Lyme’s disease) – Brucellosis – Fungal • Cryptococcus neoformans, Aspergillus, Candida Toxoplasmosis,
Neurosyphilis • Infection of the central nervous system by Treponema pallidum • Neurosyphilis can occur at any time after initial infection.
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• Early NS – Asymptomatic – Symptomatic – Meningovascular • Late NS – General paresis – Tabes dorsalis
A) Focal meningeal enhancement B) Significant edema in the left frontal lobe with left posterior frontal lobe. surrounding edema. Cerebral gumma in an HIV-infected patient with recent secondary syphilis. utdol. com
Diagnosis • EIA: syphilis enzyme immunoassay • FTA-ABS: fluorescent treponemal antibody-absorbed test • TPPA: Treponema pallidum particle agglutination test
Rx • Penicillin G benzathine 2. 4 million units IM once
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