Approach to the patient with chronic meningitis
- Daniel J Sexton, MD
Daniel J Sexton, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine
- Duke University Medical Center
Meningitis can be classified on the basis of its underlying cause, type of inflammatory response, or the time course of the illness. Based upon the time course, meningitis is defined as acute or chronic. The onset of symptoms of acute meningitis typically is abrupt with progression over hours, but some patients become ill over several days, especially when early symptoms are not appreciated. (See "Clinical features and diagnosis of acute bacterial meningitis in adults".)
Acute meningitis due to infectious causes usually does not recur. However, a small number of patients with acute meningitis may develop recurrent attacks between intervals of good health. (See "Approach to the adult with recurrent infections", section on 'Meningitis'.)
Chronic meningitis is arbitrarily defined as meningitis lasting for four weeks or more and is a complex entity with both infectious and noninfectious causes [1-7]. Although some authors attempting to define the syndrome of chronic meningitis have excluded patients with meningitis occurring concurrently with mass lesions of the central nervous system, meningitis associated with previously diagnosed systemic diseases known to cause meningitis, and meningitis following neurosurgical procedures, this definition may be too restrictive for clinical purposes . Patients with chronic meningitis usually have a subacute onset of symptoms including fever, headache, and vomiting. The symptoms can remain static, fluctuate, and/or slowly worsen. The symptoms and clinical course of chronic meningitis vary widely from patient to patient.
The differential diagnosis, clinical evaluation, prognosis, and management strategies for patients with chronic meningitis, including those in whom a diagnosis cannot be established with routine tests, will be reviewed here. Individual conditions associated with chronic meningitis are discussed separately. (See related topics.)
LIMITATIONS OF THE LITERATURE
Because of its rarity and the diversity of causes, the literature on chronic meningitis consists largely of case reports and a small number of retrospective case series from single centers. Selection, publication, and ascertainment biases greatly limit the utility of this literature for assessing the relative proportions of patients with any given etiologic diagnosis and for assessing the natural history of individual patients with chronic meningitis.
- Hopkins AP, Harvey PK. Chronic benign lymphocytic meningitis. J Neurol Sci 1973; 18:443.
- Ellner JJ, Bennett JE. Chronic meningitis. Medicine (Baltimore) 1976; 55:341.
- Adey G, Wald SL. Chronic or recurrent meningitis. Neurosurgical perspectives. Neurosurg Clin N Am 1992; 3:483.
- Coyle PK. Overview of acute and chronic meningitis. Neurol Clin 1999; 17:691.
- Hildebrand J, Aoun M. Chronic meningitis: still a diagnostic challenge. J Neurol 2003; 250:653.
- Tan TQ. Chronic meningitis. Semin Pediatr Infect Dis 2003; 14:131.
- Helbok R, Broessner G, Pfausler B, Schmutzhard E. Chronic meningitis. J Neurol 2009; 256:168.
- Cohen BA. Chronic meningitis. Curr Neurol Neurosci Rep 2005; 5:429.
- Anderson NE, Willoughby EW. Chronic meningitis without predisposing illness--a review of 83 cases. Q J Med 1987; 63:283.
- Helbok R, Pongpakdee S, Yenjun S, et al. Chronic meningitis in Thailand. Clinical characteristics, laboratory data and outcome in patients with specific reference to tuberculosis and cryptococcosis. Neuroepidemiology 2006; 26:37.
- Cheng TM, O'Neill BP, Scheithauer BW, Piepgras DG. Chronic meningitis: the role of meningeal or cortical biopsy. Neurosurgery 1994; 34:590.
- Smith JE, Aksamit AJ Jr. Outcome of chronic idiopathic meningitis. Mayo Clin Proc 1994; 69:548.
- Sugiura Y, Homma M, Yamamoto T. Difficulty in diagnosing chronic meningitis caused by capsule-deficient Cryptococcus neoformans. J Neurol Neurosurg Psychiatry 2005; 76:1460.
- Peacock JE Jr, McGinnis MR, Cohen MS. Persistent neutrophilic meningitis. Report of four cases and review of the literature. Medicine (Baltimore) 1984; 63:379.
- Talati NJ, Rouphael N, Kuppalli K, Franco-Paredes C. Spectrum of CNS disease caused by rapidly growing mycobacteria. Lancet Infect Dis 2008; 8:390.
- Noordhoek GT, Kolk AH, Bjune G, et al. Sensitivity and specificity of PCR for detection of Mycobacterium tuberculosis: a blind comparison study among seven laboratories. J Clin Microbiol 1994; 32:277.
- Marumganti AR, Murphy TF. Whipple's disease: neurological relapse presenting as headache for two years. J Gen Intern Med 2008; 23:2131.
- Wheat LJ, Batteiger BE, Sathapatayavongs B. Histoplasma capsulatum infections of the central nervous system. A clinical review. Medicine (Baltimore) 1990; 69:244.
- Scott EN, Kaufman L, Brown AC, Muchmore HG. Serologic studies in the diagnosis and management of meningitis due to Sporothrix schenckii. N Engl J Med 1987; 317:935.
- Lyons JL, Erkkinen MG, Vodopivec I. Cerebrospinal fluid (1,3)-β-D-glucan in isolated Candida meningitis. Clin Infect Dis 2015; 60:161.
- Litvintseva AP, Lindsley MD, Gade L, et al. Utility of (1-3)-β-D-glucan testing for diagnostics and monitoring response to treatment during the multistate outbreak of fungal meningitis and other infections. Clin Infect Dis 2014; 58:622.
- Lyons JL, Roos KL, Marr KA, et al. Cerebrospinal fluid (1,3)-β-D-glucan detection as an aid for diagnosis of iatrogenic fungal meningitis. J Clin Microbiol 2013; 51:1285.
- Karampatsas K, Patel H, Basheer SN, Prendergast AJ. Chronic meningitis with intracranial hypertension and bilateral neuroretinitis following Mycoplasma pneumoniae infection. BMJ Case Rep 2014; 2014.
- Kravitz GR, Davies SF, Eckman MR, Sarosi GA. Chronic blastomycotic meningitis. Am J Med 1981; 71:501.
- Calabrese LH, Furlan AJ, Gragg LA, Ropos TJ. Primary angiitis of the central nervous system: diagnostic criteria and clinical approach. Cleve Clin J Med 1992; 59:293.
- Anderson NE, Willoughby EW, Synek BJ. Leptomeningeal and brain biopsy in chronic meningitis. Aust N Z J Med 1995; 25:703.
- Charleston AJ, Anderson NE, Willoughby EW. Idiopathic steroid responsive chronic lymphocytic meningitis--clinical features and long-term outcome in 17 patients. Aust N Z J Med 1998; 28:784.
- LIMITATIONS OF THE LITERATURE
- CLINICAL FEATURES
- CSF examination and other laboratory testing
- Imaging studies
- Role of meningeal or brain biopsy
- MANAGEMENT OF PATIENTS WITH CHRONIC MENINGITIS OF UNKNOWN CAUSE
- Role of empiric therapy
- - Antituberculous therapy
- - Glucocorticoids
- - Antifungal therapy
- MIMICS OF CHRONIC MENINGITIS
- SUMMARY AND RECOMMENDATIONS