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Recurrent Benign Lymphocytic Meningitis RBLM

Objectives. Review the principles of the evaluation of cerebrospinal fluidList the common etiologies of aseptic meningitisDiscuss the etiology, presentation, diagnosis, and treatment of RBLM. CSF evaluation. Cell count (nl=0-5 WBC)WBC>1000: 87% sensitive for bacterial meningitisViral meningitis: WBC usually <100DifferentialCan have PMN predominance in early stages of viral/fungal/TB meningitis>10% of cases of bacterial meningitis will have lymphocyte predominance.

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Recurrent Benign Lymphocytic Meningitis RBLM

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    1. Recurrent Benign Lymphocytic Meningitis (RBLM) Eric Edwards, MD AM Report 1/11/08

    2. Objectives Review the principles of the evaluation of cerebrospinal fluid List the common etiologies of aseptic meningitis Discuss the etiology, presentation, diagnosis, and treatment of RBLM

    3. CSF evaluation Cell count (nl=0-5 WBC) WBC>1000: 87% sensitive for bacterial meningitis Viral meningitis: WBC usually <100 Differential Can have PMN predominance in early stages of viral/fungal/TB meningitis >10% of cases of bacterial meningitis will have lymphocyte predominance

    4. CSF evaluation (continued) Gram stain 60-80% sensitive in untreated bacterial meningitis Lab experience important Protein (nl 15-45 mg/dl) Bacterial: Avg. 400 (20-2000) Viral: 75 (10-400) Will be elevated in traumatic tap Correction: Subtract 1 mg per 1000 RBCs Glucose (nl: 2/3 of serum glucose) Up to 50% of cases of bacterial meningitis will have normal glucose

    6. Aseptic Meningitis Definition: Evidence for meningeal inflammation with negative routine bacterial cultures #1 cause: Enteroviruses (Echovirus, coxsackievirus, etc.) Summer-fall months HIV HSV (2>1) Other viruses Spirochetes (syphilis, lyme) Tick-borne (RMSF, erlichiosis) Fungal (Cryptococcus Coccidioides) TB

    7. Pierre Mollaret* (1898-1987)

    8. RBLM: Etiology and Pathogenesis HSV-2 Dormant in sacral dorsal root ganglia Retrograde seeding of CSF HSV-1 (less frequently) Other viruses have been implicated

    9. RBLM: Presentation Recurrent episodes of fever and meningism Acute onset Maximum intensity within hours of onset 1-3 day course Self limited Time between episodes can vary from weeks to years

    10. RBLM: Diagnosis Lymphocytic pleocytosis Large granular plasma cells during first 24h HSV PCR

    12. RBLM: Treatment Controversial Acyclovir has not been shown to alter the disease course.

    13. Summary The “classic” CSF findings in various types of meningitis are not hard and fast rules. Enteroviruses are the most common cause of aseptic meningitis. RBLM is caused by HSV-2 in ~90% of cases. RBLM is self-limited; no evidence for acyclovir.

    14. References 1. Shalabi M, Whitley RJ. Recurrent Benign Lymphocytic Meningitis. Clin Infect Dis. 2006 Nov 1; 43(9): 1194-7. 2. Seehusen DA et. al. Cerebrospinal Fluid Analysis. Am Fam Phys. 2003 Sep 15; 68(6): 1103-8. 3. Tedder DG et. al. Herpes Simplex Virus as a Cause of Benign Recurrent Lymphocytic Meningitis. Ann Intern Med. 1994 Sep 1; 121(5): 334-8. 4. Mirakhur M, McKenna M. Recurrent herpes simplex type 2 virus (Mollaret) meningitis. J Am Board Fam Pract. 2004 Jul-Aug; 17(4):303-5. 5. Johnson RP. Aseptic Meningitis in Adults. http://www.utdol.com

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