A subacute meningitis develops over days to weeks. Chronic meningitis lasts ? 4 weeks. Possible causes are fungi, Mycobacterium tuberculosis, rickettsia, spirochetes, Toxoplasma gondii, HIV, enteroviruses, and autoimmune diseases such as rheumatic diseases (e.g., as SLE, rheumatoid arthritis) and a malignant tumor. The symptoms resemble those of other meningitis, but they are indolent. Cranial nerve palsies and infarction (due to vasculitis) may occur. The diagnosis requires the analysis of a large cerebrospinal fluid (which is typically recovered by repeated lumbar punctures) and sometimes a biopsy or a ventricular or cisternal puncture. The treatment depends on the particular cause.

Chronic meningitis can last> 25 years. Rarely has a chronic meningitis a protracted benign course and then ends spontaneously.

A subacute meningitis develops over days to weeks. Chronic meningitis lasts ? 4 weeks. Possible causes are fungi, Mycobacterium tuberculosis, rickettsia, spirochetes, Toxoplasma gondii, HIV, enteroviruses, and autoimmune diseases such as rheumatic diseases (e.g., as SLE, rheumatoid arthritis) and a malignant tumor. The symptoms resemble those of other meningitis, but they are indolent. Cranial nerve palsies and infarction (due to vasculitis) may occur. The diagnosis requires the analysis of a large cerebrospinal fluid (which is typically recovered by repeated lumbar punctures) and sometimes a biopsy or a ventricular or cisternal puncture. The treatment depends on the particular cause. Chronic meningitis can last> 25 years. Rarely has a chronic meningitis a protracted benign course and then ends spontaneously. Subacute and chronic meningitis can be caused by a wide variety of organisms and conditions. Infectious main causes subacute or chronic meningitis organism circumstances bacteria mycobacteria (Mycobacterium tuberculosis, rarely other mycobacteria) – spirochetes: Lyme disease, syphilis, leptospirosis rarely Lyme Disease: East Coast, upper Midwest, California, Oregon Brucella sp. Associated with cattle Exceptionally in the United States or other developed countries Ehrlichia sp. – Leptospira sp in connection with the exposure to the urine of rats, mice and other animals unusual in Western countries fungi Cryptococcus neoformans – C. gattii Mainly northern Pacific coast seems to have a wide distribution Coccidioides immitis southwestern US Histoplasma capsulatum central and eastern United States Blastomyces sp. Mainly central and eastern United States Sporothrix sp. (Unusual) No geographical distribution, but infection associated with rose thorns or thickets parasite Toxoplasma gondii – Retroviruses: HIV, HTLV-1 in patients with known HIV or with risk factors enteroviruses in patients with congenital immune deficiency syndrome Tuberculous meningitis M. tuberculosis are aerobic bacteria that replicate in host cells; thus the control of these bacteria depends largely on the T-cell mediated immunity from (tuberculosis (TB)). These bacteria can infect during a primary or reactivated infection, the CNS. In industrialized countries, meningitis resulting from common erwiese reactivated infections. Meningeal symptoms usually develop over days to a few weeks, but they can also quickly or gradually occur. Significantly, M. tuberculosis causes a basal meningitis, which leads to 3 complications: hydrocephalus by obstruction of the foramina Luschka and Magendie or Sylvian aqueduct vasculitis, sometimes causes arterial or venous occlusion and stroke cranial nerve deficits, in particular of the cranial nerves II, VII and VIII diagnosis tuberculous meningitis can be difficult to make. Evidence of systemic tuberculosis may be missing. The inflammation of the basal meninges, which is demonstrated by contrast-enhanced CT or -MRT, speaks for the diagnosis. Characteristic is one of the Liquorbefunden Mixed pleocytosis with a predominance of lymphocytes. Low glucose Increased protein (see table: CSF findings in meningitis) Occasionally, the first anomaly in the CSF an extremely low glucose value. The pathogen is often difficult because the acid-resistant Liquorfärbung is sensitive in ? 30% of cases. Mycobacterial Liquorkulturen are sensitive only to about 70% and last up to 6 weeks. A Liuqor-PCR to about 50-70% is sensitive. An automated nucleic acid amplification quick test, called Xpert MTB / RIF, was recommended by the WHO for the diagnosis of tuberculous meningitis. This test detects M. tuberculosis DNA and resistance to rifampicin in cerebrospinal fluid samples. Since the tuberculous meningitis has a quick, destructive course and diagnostic tests are limited, this infection should be treated on the basis of clinical suspicion. Currently, WHO recommends treatment with isoniazid, rifampicin, pyrazinamide and ethambutol for 2 months, followed by isoniazid and rifampicin over 6-7 months (tuberculosis (TB): first-line drugs). Corticosteroids (prednisone or dexamethasone) can be added if the patient stupor, coma, or neurological deficits have. Spirochetes meningitis Lyme disease is a chronic spirochete infection caused garinii in the US by Borrelia burgdorferi and in Europe by B. afzelii and B.. (Editor’s note: In Europe, Borrelia burgdorferi comes before!) The disease is spread by Ixodes ticks, the usual ticks of the deer in the United States. In the US, 95% of the cases accounted for 12 states. It is the mid-Atlantic and northeastern coastal states, Wisconsin, California, Oregon and Washington. Up to 8% of children and some adults who contract Lyme disease, develop meningitis. Meningitis can be acute or chronic; usually it starts slower than an acute viral meningitis. Clues to the diagnosis are the time spent in wooded areas, and travel to an endemic area (in Europe) history with erythema migrans or other symptoms of Lyme disease Unilateral or bilateral facial paralysis (common in Lyme disease, but rarely (with most viral meningitis) papilledema well described in children with Lyme disease, but rare in viral meningitis) the Liquorbefunden typically lymphocytic pleocytosis include Moderately increased protein Normal glucose the diagnosis of Crohn Lyme based on serology tests using ELISA (enzyme-linked immunosorbent assay), followed by Western blot analysis to confirm. In some laboratories, the false-positive proportions can vary unacceptably high. The treatment of Lyme meningitis with cefotaxime or ceftriaxone for 14 days. The dose of cefotaxime is for children 150-200 mg / kg / day i.v., divided into 3-4 doses (z. B. 50 mg 3 to 4 times daily) for adults and 2 g i.v. every 8 h. The dose of ceftriaxone is 50-75 mg / kg / day for children i.v. (Maximum 2 g) once daily for adults and 2 g iv once a day. The clinician should remember that a simultaneous anaplasmosis or babesiosis is possible in severely ill patients. Syphilitic meningitis is less common and is usually a feature of meningovaskulären syphilis. Meningitis can be acute or chronic. Accompanying complications can occur such as cerebrovascular arteritis (possibly causes thrombosis with ischemia or infarction forth), retinitis, cranial nerve deficits (especially VII. Cranial nerve) or myelitis. CSF findings may be (usually lymphocytic) pleocytosis, elevated protein and low glucose levels. These anomalies can be more pronounced with AIDS patients. The diagnosis of syphilitic meningitis is based on serological tests in serum and cerebrospinal fluid and subsequent fluorescent treponemal antibody absorption test (FTA-ABS) to confirm. MR angiography cerebral angiography and can accurately distinguish between parenchymal manifestation and arteritis. Patients with syphilitic meningitis are 10-14 days treated with penicillin 12-24 million units iv per day in divided doses every 4 h (z. B. with 2-4 million units every 4 h). Cryptococcal meningitis The cryptococcal meningitis is the most common cause of chronic meningitis in the western hemisphere and the most common opportunistic infection in patients with AIDS (cryptococcosis). Common causes of cryptococcal meningitis in the US are Cryptococcus neoformans var. Neoformans (serotype D strains) C. neoformans var. Grubii (serotype A strains) C. neoformans var. Grubii causes 90% of cases. C. neoformans can occur in the soil, on trees and in the excreta of pigeons or other birds. Meningitis due to C. neoformans usually develops in immunocompromised patients, but occasionally it occurs without apparent underlying disease in patients. Another Kryptokokkenart, C. gattii has caused meningitis in the Pacific region and in the state of Washington; the pathogen can cause in people with a normal immune status meningitis. Cryptococcal meningitis cause a basal with hydrocephalus and brain nerve failures; Vasculitis is less common. Meningeal symptoms usually begin gradually, sometimes with protracted relapses and remissions. Among the Liquorbefundegehören typically lymphocytic pleocytosis Increased Protein Low glucose may be minimal, but a cellular response in patients with advanced AIDS or other heavy immunocompromised state or missing. The diagnosis of cryptococcal meningitis is based on cryptococcal antigen tests and fungal cultures; the diagnostic yield of these tests is 80-90%. Also an ink preparation can be used with a sensitivity of 50%. Patients with meningitis by C. neoformans, but without AIDS are traditionally treated with the synergistic combination of 5-fluorocytosine and amphotericin B. Patients with AIDS and cryptococcal meningitis are treated with amphotericin B plus flucytosine (if it is tolerated), followed by fluconazole. (Editor’s note: In Germany is often given the triple combination.) Fungal meningitis that occurs after epidural methylprednisolone injection There were occasional outbreaks of fungal meningitis in patients who received spinal epidural methylprednisolone injections. In jallen cases the drug was produced in a pharmacy, and there were significant violations of the sterile technique of preparation. The first outbreak in the United States (2002) resulted in 5 cases of meningitis. The most recent eruption (2012) led to 414 cases of meningitis, stroke, myelitis or other complications associated with fungal infection and 31 deaths. Outbreaks have occurred in Sri Lanka (7 cases) and Minnesota (1 case). Most cases are caused by Exophiala dermatitidis in 2002 and by Exserohilum rostratum in 2012; only a few cases were Aspergillus sp. or Cladosporium sp. caused. (Editor’s note: In Germany, no cases have been reported.) The Meningitis develops rather insidiously, often with an infection at the base of the brain; Blood vessels can be affected, resulting in vasculitis and stroke. Headache is the most common and shows symptoms, followed by changes in perception, nausea or vomiting or fever. Symptoms may be a 6-month delay after the epidural injection. Signs of meningeal irritation missing at about one third of patients. Typical CSF findings may be neutrophilic pleocytosis Increased protein often low glucose, the most sensitive assay for a Exserohilum meningitis is a PCR test, available through the Center for Disease Control and Prevention (CDC, Atlanta, USA); in a few cases, the diagnosis can be made because of the culture. (Editor’s note: Such cases have not yet occurred in Germany.) It can be assumed an Aspergillus meningitis when the Galaktomannanspiegel are increased in the cerebrospinal fluid; the diagnosis is based on the culture. Meningitis by Exophiala sp. or Exserohilum sp. are rare, and a clear-cut treatment is not known. Initial However, voriconazole is 6 mg / kg / day i.v. recommended. The dosage should be adjusted to the blood levels of the drug. Liver enzymes and sodium levels should be measured at regular intervals during the 2-3 weeks after initiation of treatment. Prognosis is reserved, and appropriate treatment does not guarantee survival. Other fungal meningitis Coccidioides, Histoplasma, Blastomyces, Sporothrix and Candida sp. can cause chronic meningitis caused by C. neoformans is similar to all. Coccidioides sp. are limited to the American Southwest (primarily southern Utah, New Mexico, Arizona and California). Histoplasma sp. and Blastomyces sp. occur predominantly in the central and eastern United States. So if patients live with subacute meningeal symptoms in this region or travel there, doctors should take the appropriate causative fungi. Among the Liquorbefundegehören typically lymphocytic pleocytosis Increased Protein Low glucose Candida sp. can also cause polymorphonuclear pleocytosis. The Coccidioides meningitis is more therapierestistent and may require lifelong treatment with fluconazole. Voriconazole and amphotericin B were also used. The treatment of other fungal meningitis is usually with amphotericin B. Other causes of chronic meningitis rarely justify other infectious organisms and some non-pathogen-related diseases (see Table: Causes of non-infectious meningitis) is a chronic meningitis. Non-pathogen-related causes include non-infectious causes. Cancers autoimmune rheumatic diseases, including SLE, rheumatoid arthritis and Sjogren’s syndrome Intracranial arteritis Neurosarcoidosis Behcet’s syndrome Chronic idiopathic meningitis: Chronic idiopathic meningitis Occasionally there is a chronic, usually lymphocytic meningitis over months or even years, but no organisms will be identified, and it does not lead to death. In some patients, meningitis finally remitted spontaneously. Generally, empirical studies of antifungal agents or corticosteroids were not helpful. Chronic meningitis in patients with HIV infection Meningitis is common in HIV-infected patients. Most abnormalities in the cerebrospinal fluid are the result of HIV infection that penetrates early in the course of infection in the CNS. The onset of meningitis and meningeal symptoms often coincides with the seroconversion. Meningitis can then remit or follow a steady or fluctuating course. However, many other organisms can cause chronic meningitis in patients with HIV infection. These include C. neoformans (most common), M. tuberculosis, Treponema pallidum, Borrelia burgdorferi, Toxoplasma gondii, Coccidioides immitis and other fungi. A CNS lymphoma can also lead to similar findings as meningitis in these patients. Whatever the cause is parenchymal lesions may develop. Diagnosis GRF Analysis The clinical findings are often nonspecific. However, note the careful search for a systemic infection or disorder to a cause of meningitis. Sometimes risk factors point (z. B. immunodeficiency, HIV infection, or risk factors, recent stay in endemic areas) and occasionally special neurological deficits (z. B. certain cranial nerve deficits) to specific causes through such. B. meningitis due to C. neoformans in HIV-infected patients or infection with C. immitis in patients who live in the southwestern United States. Typically, the CSF findings include lymphocytic pleocytosis. Many infections that cause chronic meningitis, the cerebrospinal fluid contains a few of the organisms, so the identification of the pathogen is difficult. Thus, the diagnosis using the Laiquors over time may require several withdrawals, especially for cultures. For CSF analysis typically Aerobic and anaerobic bacterial culture mycobacterial and fungal culture cryptococcal antigen test antigen or serological tests include special stains (eg. As acid-fast staining, ink) cytology should the CSF findings do not provide diagnosis and cause meningitis morbidity or be progressive, are more invasive tests displayed (eg. as cisternal or ventricular puncture, biopsy). Sometimes organisms are obtained from the ventricular or cisternal CSF if the CSF is negative in the lumbar region. MRI or CT can be performed to identify the main areas of inflammation on biopsy; an untargeted meningeal biopsy brings a very low yield. Treatment Treating the cause Treatment is aimed at the cause from (mycobacterial, fungal meningitis Spirochäten- and: see above; to other causes. S elsewhere in the MSD Manual.). Conclusion Note the risk factors (eg. As spent in endemic areas time, HIV infection, or risk factors, immune deficiency, rheumatoid autoimmune diseases) to identify likely causes. Careful review of a systemic infection or disease can support the diagnosis. CSF analysis for numerous withdrawals may be needed because the liquor may contain only a few pathogens; sometimes the diagnosis requires a cisternal puncture or ventricular and / or biopsy.

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