Diagnostic and therapeutic approach to chronic meningitis in Brazil: a narrative review

Abstract

Background Chronic meningitis (CM) is characterized by neurological symptoms associated with the evidence of cerebrospinal fluid pleocytosis lasting > 4 weeks. Studies on the management of CM in Brazil are scarce.

Objective To critically review the literature on CM and propose a rational approach in the Brazilian scenario.

Methods Narrative literature review discussing the epidemiology, clinical evaluation, basic and advanced diagnostic testing, and empirical and targeted therapy for the most relevant causes of CM. The present review was contextualized with the local experience of the authors. In addition, we propose an algorithm for the management of CM in Brazil.

Results In Brazil, tuberculosis and cryptococcosis are endemic and should always be considered in CM patients. In addition to these diseases, neurosyphilis and other endemic conditions should be included in the differential diagnosis, including neurocysticercosis, Baggio-Yoshinari syndrome, and endemic mycosis. After infectious etiologies, meningeal carcinomatosis and autoimmune diseases should be considered. Unbiased and targeted methods should be used based on availability and clinical and epidemiological data.

Conclusion We propose a rational approach to CM in Brazil, considering the epidemiological scenario, systematizing the etiological investigation, and evaluating the timely use of empirical therapies.

Resumo

Antecedentes A meningite crônica (MC) é caracterizada por sintomas neurológicos associados à evidência de pleiocitose do líquido cefalorraquidiano por > 4 semanas. Os estudos sobre o manejo da MC no Brasil são escassos.

Objetivo Rever criticamente a literatura sobre MC e propor uma abordagem racional no cenário brasileiro.

Métodos Revisão da literatura narrativa discutindo a epidemiologia, avaliação clínica, testes diagnósticos básicos e avançados, além da terapia empírica e direcionada para as causas mais relevantes do MC. A presente revisão foi contextualizada com a experiência local dos autores. Além disso, propomos um algoritmo para o manejo da MC no Brasil.

Resultados No Brasil, a tuberculose e a criptococose são endêmicas e devem ser sempre consideradas em pacientes com MC. Além destas doenças, a neurossífilis e outras condições endêmicas devem ser incluídas no diagnóstico diferencial, incluindo: neurocisticercose, síndrome de Baggio-Yoshinari e micoses endêmicas. Após etiologias infecciosas, devem ser consideradas a carcinomatose meningeal e doenças autoimunes sistêmicas. Métodos diagnósticos devem ser utilizados com base na disponibilidade, nos dados clínicos e nos dados epidemiológicos.

Conclusão Propomos uma abordagem racional para a MC no Brasil, considerando o cenário epidemiológico, sistematizando a investigação etiológica e avaliando o uso oportuno de terapias empíricas.

Keywords

Meningitis - Diagnosis - Tuberculosis, Meningeal - Meningitis, Cryptococcal - Brazil

Palavras-chave

Meningite - Diagnóstico - Tuberculose Meníngea - Meningite Criptocócica - Brasil

Authors' Contributions

GDS: drafted the original manuscript and contributed to the study design; BFG: revised the manuscript for intellectual content; IRJ: drafted the original manuscript; HRG: revised the manuscript for intellectual content; JEV: revised the manuscript for intellectual content and designed the work.

Publikationsverlauf

Eingereicht: 03. August 2021

Angenommen: 08. Dezember 2021

Artikel online veröffentlicht:
28. Dezember 2022

• References

• 1 Thakur KT, Wilson MR. Chronic Meningitis. Continuum (Minneap Minn) 2018; 24 (5, Neuroinfectious Disease): 1298-1326
• 2 Ellner JJ, Bennett JE. Chronic meningitis. Medicine (Baltimore) 1976; 55 (05) 341-369
• 3 Anderson NE, Willoughby EW. Chronic meningitis without predisposing illness–a review of 83 cases. Q J Med 1987; 63 (240) 283-295
• 4 Sulaiman T, Salazar L, Hasbun R. Acute versus subacute community-acquired meningitis: Analysis of 611 patients. Medicine (Baltimore) 2017; 96 (36) e7984
• 5 Zunt JR, Baldwin KJ. Chronic and subacute meningitis. Continuum (Minneap Minn) 2012; 18 (6 Infectious Disease): 1290-1318
• 6 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 (01) 37-44
• 7 Erdem H, Inan A, Guven E. et al. The burden and epidemiology of community-acquired central nervous system infections: a multinational study. Eur J Clin Microbiol Infect Dis 2017; 36 (09) 1595-1611
• 8 Kyu, Hmwe Hmwe, et al. Global, regional, and national burden of tuberculosis, 1990 – 2016: results from the Global Burden of Diseases, Injuries, and Risk Factors 2016 Study. The Lancet Infectious Diseases 18.12 (2018): 1329–1349
• 9 Rajasingham R, Smith RM, Park BJ. et al. Global burden of disease of HIV-associated cryptococcal meningitis: an updated analysis. Lancet Infect Dis 2017; 17 (08) 873-881
• 10 Yoshinari, Natalino Hajime, et al. Brazilian lyme-like disease or Baggio-Yoshinari syndrome: exotic and emerging Brazilian tick-borne zoonosis. Revista da Associação Médica Brasileira 56 (2010): 363–369
• 11 Talhari S, de Souza Santos MN, Talhari C. et al. Borrelia Burgdorferi “sensu lato” in Brazil: Occurrence confirmed by immunohistochemistry and focus floating microscopy. Acta Trop 2010; 115 (03) 200-204
• 12 Mantovani E, Marangoni RG, Gauditano G, Bonoldi VLN, Yoshinari NH. Amplification of the flgE gene provides evidence for the existence of a Brazilian borreliosis. Rev Inst Med Trop São Paulo 2012; 54 (03) 153-157
• 13 Gonçalves DD, Moura RA, Nunes M. et al. Borrelia burgdorferi sensu lato in humans in a rural area of Paraná State, Brazil. Braz J Microbiol 2015; 46 (02) 571-575
• 14 Miziara CSMG, Gelmeti Serrano VA, Yoshinari N. Passage of Borrelia burgdorferi through diverse Ixodid hard ticks causes distinct diseases: Lyme borreliosis and Baggio-Yoshinari syndrome. Clinics (São Paulo) 2018; 73: e394
• 15 Gouveia EA, Alves MF, Mantovani E, Oyafuso LK, Bonoldi VL, Yoshinari NH. Profile of patients with Baggio-Yoshinari Syndrome admitted at “Instituto de Infectologia Emilio Ribas”. Rev Inst Med Trop São Paulo 2010; 52 (06) 297-303
• 16 Reis F, França MC, Nucci A. et al. Chronic meningitis, hydrocephalus and spinal paraplegia in non-systemic histoplasmosis. Arq Neuropsiquiatr 2016; 74 (06) 514-515
• 17 Mialski, Rafael, et al. Chronic meningitis and hydrocephalus due to Sporothrix brasiliensis in immunocompetent adults: a challenging entity. Open forum infectious diseases. Vol. 5. No. 5. US: Oxford University Press, 2018
• 18 Kauffman CA. Central Nervous System Infection with Other Endemic Mycoses: Rare Manifestation of Blastomycosis, Paracoccidioidomycosis, Talaromycosis, and Sporotrichosis. J Fungi (Basel) 2019; 5 (03) E64
• 19 Sawanyawisuth K, Chotmongkol V. Eosinophilic meningitis. Handb Clin Neurol 2013; 114: 207-215
• 20 Agapejev S. Epidemiology of neurocysticercosis in Brazil. Rev Inst Med Trop São Paulo 1996; 38 (03) 207-216
• 21 Vidal JE, Sztajnbok J, Seguro AC. Eosinophilic meningoencephalitis due to Toxocara canis: case report and review of the literature. Am J Trop Med Hyg 2003; 69 (03) 341-343
• 22 Morassutti AL, Thiengo SC, Fernandez M, Sawanyawisuth K, Graeff-Teixeira C. Eosinophilic meningitis caused by Angiostrongylus cantonensis: an emergent disease in Brazil. Mem Inst Oswaldo Cruz 2014; 109 (04) 399-407
• 23 Medeiros GC, Thuler LCS, Bergmann A. Delay in breast cancer diagnosis: a Brazilian cohort study. Public Health 2019; 167: 88-95
• 24 Yonekawa T, Murai H, Utsuki S. et al. A nationwide survey of hypertrophic pachymeningitis in Japan. J Neurol Neurosurg Psychiatry 2014; 85 (07) 732-739
• 25 Smith JE, Aksamit Jr AJ. Outcome of chronic idiopathic meningitis. Mayo Clin Proc 1994; 69 (06) 548-556
• 26 Wilkinson RJ, Rohlwink U, Misra UK. et al; Tuberculous Meningitis International Research Consortium. Tuberculous meningitis. Nat Rev Neurol 2017; 13 (10) 581-598
• 27 Elias Jr J, dos Santos AC, Carlotti Jr CG. et al. Central nervous system paracoccidioidomycosis: diagnosis and treatment. Surg Neurol 2005; 63 (Suppl. 01) S13-S21 , discussion S21
• 28 Galhardo MCG, Silva MT, Lima MA. et al. Sporothrix schenckii meningitis in AIDS during immune reconstitution syndrome. J Neurol Neurosurg Psychiatry 2010; 81 (06) 696-699
• 29 Colombe B, Derradji M, Bosseray A, Massot C, Debru J-L. [Chronic meningitis: aetiologies, diagnosis and treatment]. Rev Med Interne 2003; 24 (01) 24-33
• 30 Lemos TS, Cequinel JC, Costa TP. et al. Outbreak of human brucellosis in Southern Brazil and historical review of data from 2009 to 2018. PLoS Negl Trop Dis 2018; 12 (09) e0006770
• 31 Aksamit AJ. Chronic Meningitis. N Engl J Med 2021; 385 (10) 930-936
• 32 Baldwin K, Whiting C. Chronic Meningitis: Simplifying a Diagnostic Challenge. Curr Neurol Neurosci Rep 2016; 16 (03) 30
• 33 Cheng TM, O'Neill BP, Scheithauer BW, Piepgras DG. Chronic meningitis: the role of meningeal or cortical biopsy. Neurosurgery 1994; 34 (04) 590-595 , discussion 596
• 34 Vidal JE, Peixoto de Miranda EJF, Gerhardt J, Croda M, Boulware DR. Is it possible to differentiate tuberculous and cryptococcal meningitis in HIV-infected patients using only clinical and basic cerebrospinal fluid characteristics?. S Afr Med J 2017; 107 (02) 156-159
• 35 Vidal JE, de Oliveira ACP, Hernández AV. CD4+ T-cell count and cerebrospinal fluid findings in HIV-infected patients with tuberculous meningitis. Int J Tuberc Lung Dis 2010; 14 (11) 1496-1497 , author reply 1497
• 36 Zhang B, Lv K, Bao J, Lu C, Lu Z. Clinical and laboratory factors in the differential diagnosis of tuberculous and cryptococcal meningitis in adult HIV-negative patients. Intern Med 2013; 52 (14) 1573-1578
• 37 Kox LFF, Kuijper S, Kolk AHJ. Early diagnosis of tuberculous meningitis by polymerase chain reaction. Neurology 1995; 45 (12) 2228-2232
• 38 Cresswell FV, Tugume L, Bahr NC. et al; ASTRO-CM team. Xpert MTB/RIF Ultra for the diagnosis of HIV-associated tuberculous meningitis: a prospective validation study. Lancet Infect Dis 2020; 20 (03) 308-317
• 39 Hernandez AV, de Laurentis L, Souza I. et al. Diagnostic accuracy of Xpert MTB/RIF for tuberculous meningitis: systematic review and meta-analysis. Trop Med Int Health 2021; 26 (02) 122-132
• 40 Bahr NC, Nuwagira E, Evans EE. et al; ASTRO-CM Trial Team. Diagnostic accuracy of Xpert MTB/RIF Ultra for tuberculous meningitis in HIV-infected adults: a prospective cohort study. Lancet Infect Dis 2018; 18 (01) 68-75
• 41 Donovan J, Cresswell FV, Thuong NTT, Boulware DR, Thwaites GE, Bahr NC. Tuberculous Meningitis International Research Consortium. Xpert MTB/RIF Ultra for the Diagnosis of Tuberculous Meningitis: A Small Step Forward. Clin Infect Dis 2020; 71 (08) 2002-2005
• 42 Organization WH. WHO meeting report of a technical expert consultation: non-inferiority analysis of Xpert MTB/RIF ultra compared to Xpert MTB/RIF. 2017
• 43 Frequently asked questions about the WHO Technical Expert Consultation findings on Xpert® MTB/RIF Ultra. https://www.who.int/tb/areas-of-work/laboratory/diagnostics/XpertUltraFAQs.pdf 2017
• 44 Kennedy DH, Fallon RJ. Tuberculous meningitis. JAMA 1979; 241 (03) 264-268
• 45 Kaplan JE, Benson C, Holmes KK, Brooks JT, Pau A, Masur H. Centers for Disease Control and Prevention (CDC), National Institutes of Health, HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR Recomm Rep 2009;58(RR-4):1–207, quiz CE1–CE4
• 46 Skipper C, Abassi M, Boulware DR. Diagnosis and Management of Central Nervous System Cryptococcal Infections in HIV-Infected Adults. J Fungi (Basel) 2019; 5 (03) 65
• 47 Vidal JE, Boulware DR. LATERAL FLOW ASSAY FOR CRYPTOCOCCAL ANTIGEN: AN IMPORTANT ADVANCE TO IMPROVE THE CONTINUUM OF HIV CARE AND REDUCE CRYPTOCOCCAL MENINGITIS-RELATED MORTALITY. Rev Inst Med Trop São Paulo 2015; 57 (Suppl. 19) 38-45
• 48 Hevey, Matthew A., et al. Performance of the lateral flow assay and the latex agglutination serum cryptococcal antigen test in cryptococcal disease in patients with and without HIV. Journal of clinical microbiology 58.11 (2020): e01563–20
• 49 Vidal JE, Penalva de Oliveira AC, Dauar RF, Boulware DR. Strategies to reduce mortality and morbidity due to AIDS-related cryptococcal meningitis in Latin America. Braz J Infect Dis 2013; 17 (03) 353-362
• 50 Jitmuang A, Panackal AA, Williamson PR, Bennett JE, Dekker JP, Zelazny AM. Performance of the Cryptococcal Antigen Lateral Flow Assay in Non-HIV-Related Cryptococcosis. J Clin Microbiol 2016; 54 (02) 460-463
• 51 Guidelines for The Diagnosis, Prevention and Management of Cryptococcal Disease in HIV-Infected Adults, Adolescents and Children (World Health Organization, 2018).
• 52 Williams DA, Kiiza T, Kwizera R. et al. Evaluation of fingerstick cryptococcal antigen lateral flow assay in HIV-infected persons: a diagnostic accuracy study. Clin Infect Dis 2015; 61 (03) 464-467
• 53 Vidal, José E., et al. Performance of cryptococcal antigen lateral flow assay in serum, cerebrospinal fluid, whole blood, and urine in HIV-infected patients with culture-proven cryptococcal meningitis admitted at a Brazilian referral center. Revista do Instituto de Medicina Tropical de São Paulo 60 (2018)
• 54 Wilson MR, Sample HA, Zorn KC. et al. Clinical Metagenomic Sequencing for Diagnosis of Meningitis and Encephalitis. N Engl J Med 2019; 380 (24) 2327-2340
• 55 Helbok R, Broessner G, Pfausler B, Schmutzhard E. Chronic meningitis. J Neurol 2009; 256 (02) 168-175
• 56 Glass JP, Melamed M, Chernik NL, Posner JB. Malignant cells in cerebrospinal fluid (CSF): the meaning of a positive CSF cytology. Neurology 1979; 29 (10) 1369-1375
• 57 Marrodan M, Bensi C, Alessandro L, Muggeri AD, Farez MF. Chronic and Subacute Meningitis: Differentiating Neoplastic From Non-Neoplastic Etiologies. Neurohospitalist 2018; 8 (04) 177-182
• 58 Deshpande V, Zen Y, Chan JK. et al. Consensus statement on the pathology of IgG4-related disease. Mod Pathol 2012; 25 (09) 1181-1192
• 59 Zajicek JP, Scolding NJ, Foster O. et al. Central nervous system sarcoidosis–diagnosis and management. QJM 1999; 92 (02) 103-117
• 60 da Costa Machado Jr MA, Goyanna A, Gomes LM, Goyanna F, Matos AS, Vieira LC. [Neurosarcoidosis: case report]. Arq Neuropsiquiatr 2001; 59 (2-A): 266-269
• 61 Zha BS, Nahid P. Treatment of Drug-Susceptible Tuberculosis. Clin Chest Med 2019; 40 (04) 763-774
• 62 Prasad K, Singh MB, Ryan H. Corticosteroids for managing tuberculous meningitis. Cochrane Database Syst Rev 2016; 4: CD002244
• 63 Molloy SF, Kanyama C, Heyderman RS. et al; ACTA Trial Study Team. Antifungal Combinations for Treatment of Cryptococcal Meningitis in Africa. N Engl J Med 2018; 378 (11) 1004-1017
• 64 World Health Organization. Rapid advice: diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children. (World Health Organization, 2011).
• 65 Perfect JR, Dismukes WE, Dromer F. et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis 2010; 50 (03) 291-322
• 66 Chen SC-A, Meyer W, Sorrell TC. Cryptococcus gattii infections. Clin Microbiol Rev 2014; 27 (04) 980-1024
• 67 Ahmadinejad Z. M. Rasolinejad, and A. Rezaeian. Chronic Meningitis: A study on epidemiological and clinical findings, treatment results and prognosis of 97 patients. Acta Medica Iranica (2001): 185–190
• 68 Voice RA. et al. Chronic candidal meningitis: an uncommon manifestation of candidiasis. Clinical infectious diseases 19.1 (1994):60–66
• 69 Carod-Artal F, Venturini M, Gomes E, de Mello M. [Chronic central nervous system histoplasmosis in an immunocompetent patient]. Neurologia 2008; 23 (04) 263-268
• 70 Hessler C, Kauffman CA, Chow FC. The Upside of Bias: A Case of Chronic Meningitis Due to Sporothrix Schenckii in an Immunocompetent Host. Neurohospitalist 2017; 7 (01) 30-34
• 71 Sköldenberg B, Stiernstedt G, Gårde A, Kolmodin G, Carlström A, Nord CE. Chronic meningitis caused by a penicillin-sensitive microorganism?. Lancet 1983; 2 (8341): 75-78