Makindo Medical Notes

Introduction

• Chronic meningitis – meningitis lasting >4 weeks.
• Recurrent meningitis – repeated episodes separated by clinical recovery.
• Unlike acute meningitis (rapid onset), chronic meningitis has a slow or fluctuating course.
• Diagnosis is challenging and requires systematic evaluation. Both immunocompromised and immunocompetent patients may be affected.

Etiology

Causes are broadly infectious or non-infectious.

• Infectious:
  • Mycobacterial: Mycobacterium tuberculosis (worldwide leading cause).
  • Fungal: Cryptococcus neoformans, Histoplasma – common in immunosuppressed.
  • Spirochetes: Treponema pallidum (neurosyphilis), Borrelia burgdorferi (Lyme disease).
  • Chronic bacteria: Brucella, Nocardia, chronic otitis/sinusitis sources.
  • Viruses: Persistent HIV, JC virus, herpes reactivation.
  • Parasitic: Neurocysticercosis (Taenia solium).
• Non-infectious:
  • Autoimmune/inflammatory: Neurosarcoidosis, SLE, CNS vasculitis.
  • Neoplastic: Carcinomatous meningitis (breast, lung), lymphoma/leukaemia.
  • Chemical meningitis: Post intrathecal drug, surgery, CSF leak.
  • Congenital/anatomical defects: Dermal sinus, recurrent CSF leak.

Clinical Presentation

• General: Persistent headache, low-grade fever, malaise, weight loss.
• Meningeal signs: Nuchal rigidity, photophobia, phonophobia.
• Neurological: Cranial nerve palsies (III, VI, VII), seizures, confusion, focal deficits.
• Associated: Chronic sinus/ear infection, systemic disease clues (e.g. rash, uveitis, pulmonary TB).

Investigations

• Blood: FBC, U&E, LFTs, ESR/CRP, HIV, syphilis, Lyme, ANA/ANCA, ACE.
• CSF analysis:
  • Opening pressure often ↑
  • Lymphocytic pleocytosis
  • Protein ↑, glucose ↓ (esp. TB/fungal)
  • Gram/AFB/fungal stains & cultures
  • Viral PCR, cryptococcal antigen, VDRL
  • Cytology if malignancy suspected
• Imaging:
  • MRI brain (better than CT) – meningeal enhancement, hydrocephalus, tuberculomas, carcinomatosis.
  • CT CAP or PET for systemic malignancy or TB focus.
• Other: Biopsy of lymph node/meningeal tissue if unclear; ophthalmology exam (uveitis, papilloedema); EEG if seizures.

Management

• Infectious:
  • TB meningitis: Standard 4-drug TB regimen + corticosteroids.
  • Fungal: Amphotericin B ± flucytosine → fluconazole maintenance (e.g. cryptococcus).
  • Bacterial: Tailor to culture/sensitivities.
  • Viral: Supportive, ART for HIV, aciclovir for HSV if suspected.
• Non-infectious:
  • Autoimmune: Corticosteroids ± immunosuppressants (methotrexate, azathioprine).
  • Neoplastic: Intrathecal chemo (MTX, cytarabine), systemic therapy, radiotherapy.
• Symptomatic: Analgesics, anticonvulsants, manage raised ICP (diuretics, shunt if hydrocephalus).
• Supportive: Admit, MDT care (neuro, ID, oncology, rheum).

Prognosis

• Infectious: Early Rx → good recovery; delay → permanent deficits or death.
• Autoimmune: Often steroid-responsive but relapses possible.
• Neoplastic: Poor prognosis – palliation often the goal.

Conclusion

Chronic/recurrent meningitis is a diagnostic puzzle. Think beyond infection: autoimmune, malignant, anatomical, and drug-related causes. Early CSF studies and MRI are essential. A structured approach and MDT input improve outcomes.

References

• Tunkel AR, et al. Practice Guidelines for Bacterial Meningitis. Clin Infect Dis. 2004.
• Schut ES, et al. Chronic meningitis features. Ann Neurol. 2008.
• Rock RB, et al. CNS Tuberculosis. Clin Microbiol Rev. 2008.
• Marbaniang SP, Sharma N. Approach to chronic meningitis. Indian J Med Res. 2019.