ࡱ> *( */ 0`DTimes New Roman $b b0$bWo 0DTimes New Roman (Arabic)$bWo 0 DArialNew Roman (Arabic)$bWo 0*0DWingdingsRoman (Arabic)$bWo 0 @DImpactgsRoman (Arabic)$bWo 0*PDMonotype CorsivaArabic)$bWo 0J`DArial BlacksivaArabic)$bWo 0*pDSymbollacksivaArabic)$bWo 0 ` . @n?" dd@  @@`` XP|v     A      0@87ta1ʚ;n:ʚ;g49d9d0bppp@ <4!d!d 0bb<4dddd 0bb ? %|$Chronic meningitis  CP By Dr. Mostafa Hussein &CH0.    The clinical syndrome of chronic meningitis is defined by persistent or clinically progressive signs and symptoms of meningitis, such as headache, fever, stiff neck, nausea, vomiting, lethargy and confusion associated with cerebrospinal fluid (CSF) pleocytosis and elevated protein concentrations, lasting for a duration of at least 4 weeks without improvement. This clinical syndrome accounts for 10% of all cases of meningitis and may be caused by viral, bacterial, fungal, or parasitic agents. Non infectious causes include malignancy, sarcoidosis, Behcet s syndrome and vasculitis. M M|              Various elements of the history and physical examination may aid in determining the etiology of meningitis, however in one third of the cases, a cause may not be found. Certain patterns of CSF parameters may be characteristic of specific causes of chronic meningitis.       Travel history will define the likelihood of fungal and parasitic disease. Fungal infections such as coccidioidomycoses and histoplasmosis, will be suspected based on area of residence and travel history. Exposure to animals may also provide clues to etiologic agent in chronic meningitis. For example, brucellosis, may be acquired from exposure to farm animals, leptospirosis from rats or mice, tularemia, from rabbits. Symptoms outside the central nervous system might suggest a systemic disease as a cause of chronic meningitis. For example the complaint of recurrent oral or genital ulcers will suggest Behcet s syndrome. t te       1        The history should explore risk factors for underlying disease that would predispose to chronic meningitis, particularly HIV disease.     LThe physical examination may also provide clues to the specific cause of chronic meningitis. Skin lesions, when present concomitantly with chronic meningitis as sarcoidosis and cyptococcosis, skin biopsy will have a high diagnostic yield. Eye examination, is extremely valuable as specific abnormalities may suggest tuberculosis (choroidal tubercles), sarcoidosis (granulomas), or Behcet s syndrome (uveitis). Although laboratory evaluation must be based on clinical clues, the following laboratory tests are generally part of initial evaluation. ' '                                    The disease is usually the result of the breakdown of a longstanding granuloma. In about half of all patients, this breakdown is associated with some underlying condition, such as sarcoidosis, AIDS, malnutrition, or steroid therapy. The most common symptoms include fever, headache, irritatility and may progress to meningeal signs, seizures hypertonia, vomiting, cranial nerve palcies (especially of cranial nerves III, VI, VII), coma, hemi  or paraplegia, and, ultimately, death. Duration of symptoms on presentation ranges from 2 days to 6 months. Peripheral white blood cell (WBC) counts range from low normal to very elevated (>20.000/mm3).4  E   f   \              The diagnosis is confirmed by: Acid fast bacilli are seen in 10-20% on CSF smears, CSF cultures are positive (in 30 to 75%). PCR to detect mycobacterial DNA in CSF is available, the specificity is very high (95 to 100%) however sensetivity ranges from (27 to 85%). Adenosine deaminase levels in CSF are usually elevated. Typical CSF leucocyte ranges from (10-500 cells/ml) and lymphocytic pleocytosis is a very common finding. The CSF glucose usually depressed (<30 mg/dl) and protein concentrations usually elevated. 6  sC  K   $   1   "  u                               Thank You C   0  ` f3f3` ff̙` ___` ff` 3ff3f>?" dd@,?lPd@   Z l<@ d`"  n?" dd@   @@``PR    @ ` ` p>> 0    (   ^T y   "yZ   S B7 C DEHFPv @?q 6 6 n(dx  G b q %(@"B y2   ZG1?"  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(( lP C  0x  ,$D  0 1Approach to the patient with chronic meningitis: 02( lP2G1 H  0޽h ? f3f3  d\p(    <d  |H<$D 0  H  0޽h ? f3f3  UM(    <  |p<$D 0  9  0Xj ,$D  0 -History in Evaluation of Chronic Meningitis: *.( lP.A-   <|) |hp$D  0<4___PPT9 4Travel. Animal exposure. Family member with tuberculosis. High risk sexual activity. Symptoms outside CNS (rash, lymphadenopathy, vision, cough, & . etc.) (( lP.q    @`H  0޽h ? f3f3  d\ (     <  |H<$D 0  H  0޽h ? f3f3T  $|(  $A $ 0& |8,$D  0 5Initial Laboratory Evaluation of Chronic Meningitis: *6( lP6A5  $ <-) !|`p$D  0<4___PPT9 Lumbar puncture, CSF: WBCs, protein, glucose, Cerebrospinal fluid cytology, VDRL, cryptococcal antigen, India ink, acid-fast stain and Mycobacterium TB PCR, large volume culture for TB and fungi. Prolonged incubation in 5% CO2 for Nocardia, Brucella, Actinomyces. CBC, ESR, liver, and renal function tests. Blood and urine culture including TB and fungi. Serology for syphilis, HIV, cryptococcal antigen, antinculear antibody, rheumatoid factor. CT scan or MRI. B( lP   8          |       -  @`H $ 0޽h ? f3f3  ld@((  (6 ( 0x 0,$D  0 a) Infectious causes: >( lPEE 0 ( 07 F,$D  0 Causes of Chronic Meningitis: 0( lPG N c  @( #",$D  0 ( <l? F>6___PPT9 AYAcanthamoeba spp. Schistosoma spp. Taenia solium ova. Toxoplasma gondii. Trypanosoma spp.$Z " Z           @`  ( <X|?  F>6___PPT9 REnteroviruses (in agammaglobulemia). Herpesviruses. Human immunodeficiency virus. $S " SV         @`  ( <? F>6___PPT9 MAspergillus spp. Candida spp. Coccidioides immitis. Cryptococcus neoformans.$N " Np          @`  ( <? F>6___PPT9 'Actinomyces spp. Borrelia burgdorferi. Brucella. Franciscella tularensis. Listeria monocytogenes. Mycobacterium tuberculosis. Neisseria meningitidis. Nocardia asteroides. Staphylococcus aureus. Treponema pallidum.$ "                    @`  ( 6?c v Parasites       @`  ( 6? c sViruses   @` ( 6L2?c  qFungi   @` ( 69?c u Bacteria       @`fB ( 6o ?cc`B ( 01 ?fB ( 6o ?  fB ( 6o ?c `B ( 01 ?c `B ( 01 ? c `B ( 01 ?c fB ( 6o ?c H ( 0޽h ? f3f3  5-,(  ,9 , 0J 5^,$D  0 b) Noninfectious causes: >( lPEE  , <Ln) |J,$D  0 BXBehcet disease. Neoplasms. Neurosarcoidosis. Systemic lupus erythematosus. Vasculitis. &Y}( PY               @`. , 0p ! sz ,$D  0 1- Tuberculosis meningitis: 0( lPG  , 0ȧ < |,$D 0 qTuberculosis remains the most common cause of chronic meningitis syndrome, it is a treatable disease even in the immunosuppressed patient. Hence the diagnosis must be made and, at times, empiric therapy may be initiated. (( lP2q  \  , 0.  ,$D  0  Bacterial: 0 ( lP G   H , 0޽h ? f3f3  d\0(  0 0 <V  |H<$D 0  H 0 0޽h ? f3f3  d\4(  4 4 <T  |q<$D 0  H 4 0޽h ? f3f3  8(  8H 8 0 `s,$D  0 2- Brucella meningitis: 0( lPG2      8 0l9 |,$D 0 CNS infection may develop from 2 months to 2 years after the initial systemic brucella infection in less than 5% of cases. And usually presents with night sweats, lymphadenopathy and hepatosplenomegaly. Most of the patients have a history of exposure to milk or milk products, contact with farm animals. The diagnosis is made by culture from blood or CSF which require special media and longer incubation (2-4 weeks) and detection of Brucella specific antibodies agglutination titers in the serum and CSF with titers of 1:160 or greater. (( lPN   L       _ H 8 0޽h ? f3f3  um<(  <M < 07 `s,$D  0 3- Actinomycosis meningitis: 0( lPG2    x < 0K |j ,$D 0 Actinomycosis can be associated with many CNS lesions, including, brain abscess, meningitis & subdural empyema. Brain abscesses appear with focal neurologic findings and many patients have evidence of dental infection, mastoiditis, sinusitis or skin infection. Actinomyces organisms are gram positive filamentous bacteria. Diagnosis usually is made by microscopic examination of CSF, or rarely by culture of the CSF. High dose pencillin remains the drug of choice. (( lP  Q  $   >          H < 0޽h ? f3f3  `X@(  @H @ 0LV `s,$D  0 4- Nocardia asteroides: 0( lPG2   f @ 0(* |w,$D 0 May also appear as chronic meningitis without brain abscess, but this is rare. Infection occurs by hematogenous spread from usually the lungs or direct spread from infected sites such as the middle ear or mastoid. Sulphonamides are the antimicrobials of choice. (( lPjc   f      K @ 0_ % ~ ,$D  0 5- Listeria monocytogenes: 0( lPG2    @ 0` r 0,$D 0 Is more likely to produce an acute meningitis, can also present as chronic meningitis. An underlying immunodeficiency state may be present in these cases. (( lP H @ 0޽h ? f3f3  x D(  D D 00v  c,$D  0 Fungal: 0 ( lP G  L D 0D Is,$D  0 1- Cryptococcal meningitis: 0( lPG2     ` D 0 d|j,$D 0 The presentation of cryptococcal meningitis is very similar to that of tuberculosis. The disease has become more common in the AIDS era and may be the first presentation of AIDS. In addition, lymphoma, systemic lupus erythromatosus, sarcoidosis and renal transplantation are important predisposing conditions. Cultures of specimens from sputum, bone marrow, or skin lesions may be useful in some patients. Spinal fluid findings as in tuberculous meningitis usually show a CSF pleocytosis. An India ink preparation yields positive results in 50% of cases. Cryptococcal antigen can be detected in 80-90% of cases by a rapid, simple latex fixation test. H78 lPZV8 lP_              D   S H D 0޽h ? f3f3   0P:(  PG P 0, s-,$D  0 2- coccidioidomycosis: 0( lPG2   q P 0p |,$D 0 GIs another common cause of chronic meningitis syndrome. The disease is secondary to pulmonary infection after inhalation of spores of coccidioides immitis. CSF parameters are non specific and CSF cultures are often negative. Detection of complement fixing antibody in the CSF is specific and 75 to 90% sensitive for diagnosis. *H8 lPZH2   K P 0 Pz_,$D  0 3- Histoplasma meningitis: 0( lPG2      P 0 W|3,$D 0 SHistoplasma capsulatum initially cause pulmonary infection, with dissemination occurring in 0.1% of patients, meningitis is a rare complication of infection occurring in 10-20% of patients with disseminated disease. The most common signs and symptoms associated with systemic disease include fever, headache, hepatosplenomegaly, Half of the patients have positive CSF culture, 90% have CSF antibody. HJ8 lPZH8 lP_@   J H P 0޽h ? f3f3   J B @T (  T: T 0  c,$D  0 Spirochetal meningitis: 0( lPG $    Z T 0  Is,$D  0 *1- syphilitic meningitis (Neurosyphilis): 0+( lP+G2     T 0DGC |M,$D 0 ZUsually occurs within 2 years of acute infection. Fever is often absent and headache may be the sole complaint. The diagnosis is suggested by positive result on treponemal tests and CSF VDRL tests. (( lP2    @ T 0JC .s,$D  0 2- Lyme disease:0( lPG2    T 0\SC {|,$D 0 ,FBorrelia burgdorferi can cause chronic meningitis as a second stage of lyme disease, months after tick exposure and initial infection. Bell s palsy and radiculopathic syndromes are most common. Meningitis patients are often seen without fever but with headache, photophobia, and stiff neck. 4$( lPx    3  L  | H T 0޽h ? f3f3g  PX(  X X 0DcC |,$D 0 =Other spirochetal diseases, including leptospirosis and relapsing fever, may present with meningitis in addition to other systemic symptoms. (( lPN     Y & X 0lC Ys,$D  0 Viral infections: 0( lPG P X 0@C f|P ,$D 0 Chronic meningitis caused by echovirus or coxsackie virus occurs in patients with agammaglobulinemia or multiple myeloma. HIV infection itself may cause mental status abnormalities and a chronic CSF pleocytosis. (( lP*        O    H X 0޽h ? f3f3N  `\v(  \6 \ 0C Vs,$D  0 Neurocysticercosis: 0( lPG$   \ 0,C |,$D 0 lTThe pork tape worm Taenia solium is the most common agent causing parasitic disease of the CNS. The infection is acquired by eating food contaminated with stool containing the eggs of the tape worm, these eggs hatch in the small intestine, and the larvae invade the blood stream and infect muscle, eye and brain. The larvae mature into cysts in these sites and remain asymptomatic for an average of 5 years. Symptoms develop as the larvae begin to die, simulating an inflammatory response. Intraparynchymal neurocysticercosis commonly results in a febrile seizures and focal neurologic deficits. XU( lP4  O   m # 2     H \ 0޽h ? f3f3D  p`l(  `4 ` 0<5C |,$D 0 (Diagnosis is suggested by the presence of multiple calcified or cystic lesions on head CT or MRI in a person with a history of having been in an endemic area. Serologic tests of serum and CSF are helpful in making the diagnosis, CSF serology is positive in about 85% of patients with meningitis. ()( lP)( H ` 0޽h ? f3f3  iad(  d@ d 088C <0,$D  0 ,Noninfectious causes of chronic meningitis: 0-( lP-G , H d 0̦C s^,$D  0 1- Metastatic carcinoma:0( lPG2     ) d 0C R|,$D 0 From an unsuspected primary carcinoma in the breast or lung can cause a chronic meningitis syndrome, as can lymphoma and melanoma. In many cases, back pain, radicular pain & cranial nerve abnormalities also will be present. Most patients have a CSF pleocytosis. Cytology is positive for malignant cells in 50% to 80% of patients CSF lactate dehydrogenase has recently been shown to be a useful test. Findings on CT and MRI imaging usually will be positive. (( lPj   R   Q  f H d 0޽h ? f3f3  ~vh(  h@ h 0DC Ls,$D  0 2- Sarcoidosis: 0( lPG2     h 0DC |8,$D 0 Present with neurologic findings in 5% of patients. Cranial abnormalities, peripheral neuropathy, and focal cerebral lesions are most common. Aseptic meningitis rarely occurs without other manifistations of sarcoidosis. CSF pleocytosis was noted in 40% of patients, and low glucose content in only 10%. When the disease is suspected, careful examination of optic and other cranial nerves as well as evaluation of other systems is crucial. Diagnosis usually made outside the CNS, such as biopsy of lymph node, liver or parotid. (( lP            % H h 0޽h ? f3f3  ogl(  l\ l 0tC s,$D  0 ,3- Bechcet s disease: 0( lPG2     c l 0dC -|$ ,$D 0 Usually is recognized by the triad of oral or genital ulcers, skin lesions and uveitis. Meningoencephalitis develop in 25% of patients, often in association with flare-up of other symptoms. CSF pleocytosis is present, with elevated protein and normal sugar. (( lPjO    W   4 H l 0޽h ? f3f3!  pI(  p p 0|C M2,$D  0  Conclusion 0 ( lP G$   p 0C "|\,$D 0 VChronic meningitis is caused by a wide variety of infectious and noninfectious pathogens that remain difficult to diagnose. Careful attention to exposure and travel history, physical examination findings, and patterns of CSF abnormalities all are important in determining the etiology for the meningitis. In addition, the performance of specialized laboratory evaluations specific for the various agents that cause chronic meningitis can further aid in pinpointing the cause. *8 lPn H p 0޽h ? f3f3  F> t(  t t S +   <$D  0   H t 0޽h ? f3f3rx *!8IBDgFKfM+ST[[7owy{g7'Aj *( */ 0`DTimes New Roman bb0bWo 0DTimes New Roman (Arabic)bWo 0 DArialNew Roman (Arabic)bWo 0*0DWingdingsRoman (Arabic)bWo 0 @DImpactgsRoman (Arabic) Oh+'07 hp  0 < HT\Chronic meningitis arb3ic MC:\Program Files\Microsoft Office\Templates\Presentation Designs\Soaring.pot\arb3ogr554Microsoft PowerPointoso@3Θ@ <@`ax?Gt6g  2:& &&#TNPP2OMie & TNPP &&TNPP    && "--- $  $   $- $(( $(22( $2<<2- $<FF<- $FPPF $PZZP- $ZddZ $dnnd- $nxxn- $xx- $ $- $- $- $- $- $ $- $- $- $- $- $- $- $- $""- $",,"- $,66,- $6@@6- $@JJ@- $JTTJ- $T^^T- $^hh^- $hrrh- $r||r- $||- $- $- $- $- $- $- $- $- $- $- $- $- $- $- $- $&&- $&00&- $0::0- $:DD:- $DNND- $NXXN- $XbbX- $bllb- $lvvl~- $vvz- $w- $s- $o- $l- $h- $d- $a- $]- $Y- $W- $S- $O- $L- $  H- $  D- $  B- $ ** >- $*44*:- $4>>48- $>HH>4- $HRRH0- $R\\R.- $\ff\*- $fppf&- $pzzp#- $zz- $- $- $- $ - $- $- "--&&&&W&--&&/v- $WaaW/w- $akka/x- $kuuk0y- $uu0z- $1{- $1}- $2- $3- $4- $4- $5- $6- $7- $9- $:- $;- $<- $  =- $  ?- $@- $)) B- $)33)!C- $3==3"D- $=GG="F- $GQQG#G- $Q[[Q$H- $[ee[%J- $eooe%L- $oyyo&M- $yy'N- $'P- $(Q- $)R- $)T- $*U- $+V- $+W- $,Y- $,Z- $-[- $-\- $.]- $.^- $/^- $/_- $##0`- $#--#0`- $-77-0a- $7AA71b- $AKKA1b- $KUUK1c- $U__U1c- $_ii_1c- $issi2d- $s}}s2d- $}}2d- $2e- $ $2e- $ $3f- $&&& "- &($UWr0AVm&5(AJIfPSU&tb&-&& &&-&&($UWr0AVm&5(AJIfPSU&&/v- $WaaW/w- $akka/x- $kuuk0y- $uu0z- $1{- $1}- $2- $3- $4- $4- $5- $6- $7- $9- $:- $;- $<- $  =- $  ?- $@- $)) B- $)33)!C- $3==3"D- $=GG="F- $GQQG#G- $Q[[Q$H- $[ee[%J- $eooe%L- $oyyo&M- $yy'N- $'P- $(Q- $)R- $)T- $*U- $+V- $+W- $,Y- $,Z- $-[- $-\- $.]- $.^- $/^- $/_- $##0`- $#--#0`- $-77-0a- $7AA71b- $AKKA1b- $KUUK1c- $U__U1c- $_ii_1c- $issi2d- $s}}s2d- $}}2d- $2e- $ $2e- $ $3f- $&- --&&&X 3f"--:%4Sp/^!Bfy* 4$<<DSJlORTU--&&&G& - &Gy& --h-- @*Impact- .$2 ?Chronic meningitis ;8&785R7787!2. f.$2 ;Chronic meningitis ;8&785R7787!2.--I1H-- f@JMonotype Corsiva- . 2 By :&.@Times New Roman- . 2 Dr. .. .2 *Mostafa =   . .2 Hussein 2$$.--"System-&TNPP &Root EntrydO)Pn_,pCurrent UserDSummaryInformation(k8PowerPoint Document(8  PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint Thank You    $_ MISR COMPTERMISR COMPTER_arb3arb3  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijlmnopqrstuvwxyz{|}~Root EntrydO)`ax?@Current User,SummaryInformation(k8PowerPoint Document(8DocumentSummaryInformation8bWo 0*PDMonotype CorsivaArabic)bWo 0J`DArial BlacksivaArabic)bWo 0*pDSymbollacksivaArabic)bWo 0 ` . @n?" dd@  @@`` XP|v     A      0@87ta1ʚ;n:ʚ;g49d9d0bppp@ <4!d!d 0bb<4dddd 0bb ? %b$Chronic meningitis  CP By Dr. Mostafa Hussein &CH0.    The clinical syndrome of chronic meningitis is defined by persistent or clinically progressive signs and symptoms of meningitis, such as headache, fever, stiff neck, nausea, vomiting, lethargy and confusion associated with cerebrospinal fluid (CSF) pleocytosis and elevated protein concentrations, lasting for a duration of at least 4 weeks without improvement. This clinical syndrome accounts for 10% of all cases of meningitis and may be caused by viral, bacterial, fungal, or parasitic agents. Non infectious causes include malignancy, sarcoidosis, Behcet s syndrome and vasculitis. M M|              Various elements of the history and physical examination may aid in determining the etiology of meningitis, however in one third of the cases, a cause may not be found. Certain patterns of CSF parameters may be characteristic of specific causes of chronic meningitis.       Travel history will define the likelihood of fungal and parasitic disease. Fungal infections such as coccidioidomycoses and histoplasmosis, will be suspected based on area of residence and travel history. Exposure to animals may also provide clues to etiologic agent in chronic meningitis. For example, brucellosis, may be acquired from exposure to farm animals, leptospirosis from rats or mice, tularemia, from rabbits. Symptoms outside the central nervous system might suggest a systemic disease as a cause of chronic meningitis. For example the complaint of recurrent oral or genital ulcers will suggest Behcet s syndrome. t te       1        The history should explore risk factors for underlying disease that would predispose to chronic meningitis, particularly HIV disease.     LThe physical examination may also provide clues to the specific cause of chronic meningitis. Skin lesions, when present concomitantly with chronic meningitis as sarcoidosis and cyptococcosis, skin biopsy will have a high diagnostic yield. Eye examination, is extremely valuable as specific abnormalities may suggest tuberculosis (choroidal tubercles), sarcoidosis (granulomas), or Behcet s syndrome (uveitis). Although laboratory evaluation must be based on clinical clues, the following laboratory tests are generally part of initial evaluation. ' '                                    The disease is usually the result of the breakdown of a longstanding granuloma. In about half of all patients, this breakdown is associated with some underlying condition, such as sarcoidosis, AIDS, malnutrition, or steroid therapy. The most common symptoms include fever, headache, irritatility and may progress to meningeal signs, seizures hypertonia, vomiting, cranial nerve palcies (especially of cranial nerves III, VI, VII), coma, hemi  or paraplegia, and, ultimately, death. Duration of symptoms on presentation ranges from 2 days to 6 months. Peripheral white blood cell (WBC) counts range from low normal to very elevated (>20.000/mm3).4  E   f   \              The diagnosis is confirmed by: Acid fast bacilli are seen in 10-20% on CSF smears, CSF cultures are positive (in 30 to 75%). PCR to detect mycobacterial DNA in CSF is available, the specificity is very high (95 to 100%) however sensetivity ranges from (27 to 85%). Adenosine deaminase levels in CSF are usually elevated. Typical CSF leucocyte ranges from (10-500 cells/ml) and lymphocytic pleocytosis is a very common finding. The CSF glucose usually depressed (<30 mg/dl) and protein concentrations usually elevated. 6  sC  K   $   1   "  u                               Thank You C   r5  ՜.+,0    e narb8q "Times New RomanTimes New Roman (Arabic)Arial WingdingsImpactMonotype Corsiva Arial BlackSymbolSoaringChronic meningitis  PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint PowerPoint