Chronic meningitis

Diagnosis of meningitis, Causes of meningitis, Tubercular, cryptococcal, fungal meningitis, Treatment, Prognosis

1. CHRONIC MENINGITIS - Dhananjay Gupta

2. INTRODUCTION Definition : Chronic inflammation of meninges : Lasting > 4 weeks Clinical course can be constant or vary – fluctuate, worsen!

3. CAUSES Meningeal infections Non-infectious, inflammatory disease Malignancy Chemical meningitis Para-meningeal infections

4. 1. Infections 1. Bacterial TB Brucella, Fransciella , Actinomycetes, Nocardia Listeria monocytogenes Ehrlichia chaffeensis Partially treated Strptococcal , H. influenza , Neisseria 2. Spirochaetes Treponema pallidum – syphilis Lyme meningitis Leptospirosis 3. Viral Enterovirus HSV – Mollaret syndrome HIV CMV EBV VZV Mumps lymphocytic chorio -meningitis

5. 1. Infections 4. Fungal Cryptococcus Coccidioides Sporothrix Histoplasma 5. Parasitic Eosinophilic meningitis Toxoplasma Shistosoma Taenia solium Strongyloides

6. 2. Non – Infectious causes 1. Inflammatory SLE Sarcoidosis Bechet’s disease Wegner’s disease Vogt – Koyanagi – harada syndrome Other rheumatological diseases Fabry disease 2. Idiopathic

7. 2. Non – Infectious causes 3. Malignancy Leukaemia/ Lymphoma Meningeal gliomatosis Metastatic Ca of Breast Metastatic Ca of Lung Metastatic Ca of Prostate Epidermoid tumour Cranio- pharyngoma 4. Chemical Sub-arachnoid injections NSAIDs TMP – SMX

8. CLINICAL FEATURES

9. COMPLICATIONS Hydrocephalus Cranial neuropathies Radiculopathy ( Bannwarth’s syndrome) Cognitive decline Personality changes Specific to the causative factor

10. Approach to a patient - History Contact with TB Weight loss/ night sweats/ loss of appetite Sexual history – syphilis, HIV Travel to endemic area – parasitic/ lymes / fungal IN INDIA – TUBERCULOSIS IS ALWAYS A DIFFERENTIAL !

11. Approach to a patient - History H/o medication - NSAIDs Unpasteurized milk – Brucella Meat-packing industry/ cows/ sheep - Brucella Recurrent oral/ genital ulcers – Bechet’s Tick exposure, erythema marginans – Lyme’s

12. Approach to a patient - History Contact with birds – cryptococcosis Exposure to bats / avian habitats – histoplasmosis H/o cancer – neoplastic meningitis Immuno-compromised state – HIV, TB - Cryptococcus - Fungal infections

13. Approach to a patient - Examination 1. Cranial palsy TB Lyme’s Syphilis Brucella Sarcoidosis 2. Oro-genital ulcers Bechet’s Syphilis Sjogrens SLE Sarcoidosis 3. Uveitis/ iritis Bechet’s Sarcoidosis Vogt – kayanagi – harade syndrome

14. Approach to a patient - Examination 4. Poliosis Whitening of hair/ eyelashes Vogt – kayanagi - harade 5. Skin rashes/ lesions Bechet’s Syphilis SLE Cryptococcus Blastomycosis Coccidioidomycosis 6. Subcutaneous nodules Cysticercosis Metastatic deposists Endocarditis

15. Investigations - CSF

16. Investigations - CSF NEUTROPHILIC PLEOCYTOSIS, LOW SUGAR LYMPHOCYTIC, LOW SUGAR LYMPHOCYTIC, NORMAL SUGAR Bacterial Listeria, brucellosis Actinomycosis Bechet’s Early viral Mumps Drugs – Nsaids Sulfa – drugs TB Fungal Early TB Early fungal Viral meningitis CNS malignancy Endocarditis

17. Further CSF tests Gram stain/ culture Cultures – aerobic/ anaerobic/ fungal/ mycobacterial Antigen testing – HSV-PCR, VZV-PCR, EBV, CMV TB-PCR India ink, Cryptococcal – antigen CSF – VDRL NCC antibodies - IgG

18. Serum and Blood tests HIV – elisa VDRL/ RPR Blood cultures Serologies – leptospira / lyme / brucella / ehlrichia

19. Supportive tests Mantaux Chest X-ray/ USG abdomen X-ray thigh Retinal examination Echocardiogram MRI Brain

20. B) Significant edema in left posterior frontal lobe. A) Focal meningeal enhancement in the left frontal lobe with surrounding edema.

21. Clues to diagnosis - TBM Bacilli seed to meninges – make tubercles : “Rich focus” Tubercles rupture into SA-space – causing meningitis H/o contact Pulmonary/ abdominal symptoms PPD/ Montaux – can be negative in 50-65% O/E : cranial nerve palsy – 6 th nerve Vasculitic infarcts

22. Clues to diagnosis - TBM CSF AFB smear : positive in 10-20% CSF culture : 40-90% Concurrent sputum AFB culture positive in : 14-50% Decreasing CSF glucose levels on serial LP’s , without treatment, may also suggest TBM

23. Clues to diagnosis - Cryptococcal Immuno-compromised host/ HIV h/o high dose corticosteroid therapy Usually sub-acute onset, progressive However, maybe rapid progression in HIV+ CSF lymphocytosis 40-400 CSF india ink + in 50% Cryptococcal antigen + 85%

24. Clues to diagnosis - Syphilis Treponema pallidum Sexual exposure Genital ulcers CNS invasion occurs early in non-treated cases

25. Treatment According to aetiological agent Empirical therapy : 1/3 rd patients do not have a definite causative agent Serology test results take time Monitor response to therapy Continue diagnostic efforts ATT : Should always be considered Endemic in India

26. Treatment ATT with steroids : Unless severe symptoms, avoid steroids Discontinue ATT if no response even after 4-6 weeks Empirical Anti-fungal : Azoles Only if clinical features strongly suggestive Steroids alone : Only if infectious cause has been ruled out May be auto-immune Upto 50% response rates reported