Brain Abscess

Brain abscess, a rare disease in the United States, can occur in single or multiple sites. It usually arises from a secondary focus outside the CNS. Examples may include upper or lower respiratory infection, intracardiac infection, penetration skull trauma, local osteomyelitis, any source of bacteremia, or no source (20%). Risk factors include IV drug use, HIV infection, and any other immunocompromised state. Common pathogens include streptococci, staphylococci, enteric gram-negative organisms, and anaerobes.

Clinically, brain abscess usually has a more aggressive onset of symptoms than bacterial meningitis. Symptoms usually present as typical meningeal irritation, along with

Box 42-9 Causes of Chronic Meningitis

Bacterial

Tuberculosis

Brucellosis

Nocardiosis

Syphilis

Lyme disease

Actinomycosis

Listeriosis

Subacute bacterial endocarditis Tularemia Leptospirosis Meningococcal infection

Fungal

Cryptococcosis

Coccidioidomycosis

Histoplasmosis

Blastomycosis

Candida

Aspergillus

Zygomycetes

Sporothrix

Viral

Retroviruses Herpesvirus Enteroviruses

Lymphocytic choriomeningitis Mumps

Parasitic

Cysticercosis

Schistosomiasis

Trichinosis

Paragonimiasis

Echinococcosis

Toxoplasmosis

Visceral larva migrans

Noninfectious

Neoplasm Vasculitis

Chemical meningitis Collagen vascular disease Behcet's disease Sarcoidosis

Systemic lupus erythematosus Fabry's disease

Foreign body in central nervous system Vogt-Koyanagi-Harada syndrome

Other

Parameningeal focus Chronic lymphocytic meningitis

Box 42-10 Laboratory Evaluation for Chronic Meningitis

Blood

Complete blood count, differential

Chemistries, erythrocyte sedimentation rate, antinuclear antibodies Human immunodeficiency virus (HIV) serology Rapid plasma reagin (RPR)

Consider angiotensin-converting enzyme (ACE), antineutrophilic cytoplasmic antibodies, specific serologies, blood smears

Cerebrospinal Fluid

Cell count with differential, protein, glucose Cytology

Venereal Disease Research Laboratories (VDRL) Cultures (TB, fungal, bacterial, viral) Stain (Gram, acid-fast, India ink) Cryptococcal antigen Oligoclonal bands, IgG index

Consider ACE; polymerase chain reaction (PCR; viruses, mycobacteria, T. whippelii); Histoplasma antigen, immunocytochemistry (T. whip-pelii and other selected agents); paired antibodies for B. burgdorferi, Brucella, Histoplasma, Coccidioides, other fungal agents; neoplastic markers

Neuroimaging

Brain MRI with contrast

Consider CT, spinal MRI, angiography

Cultures

Blood (parasites, fungi, viruses, rare bacteria) Urine (mycobacteria, viruses, fungi) Sputum (mycobacteria, fungi)

Consider gastric washings, stool, bone marrow, liver (mycobacteria, fungi)

Ancillary

Chest radiography Electrocardiography

Select testing (e.g., mammography, chest/abdominal CT) Biopsy

Extraneural sites (bone marrow, lymph node, peripheral nerve, liver, lung, skin, small bowel)

Leptomeningeal/brain (with or without special stains)

CT, Computed tomography; MRI, magnetic resonance imaging; IgG, immunoglobulin G; TB, tuberculosis.

Modified from Coyle PK. Overview of acute and chronic meningitis. Neurol Clin 1999;17:691.

Box 42-11 Causes of Viral Meningitis

Enteroviruses Echovirus Poliovirus

Coxsackieviruses A and B Herpesviruses

Herpes simplex virus (HSV) types 1 and 2 Varicella-zoster virus (VZV) Lymphocytic choriomeningitis Flaviviruses (St. Louis encephalitis) Morbillivirus (measles) Bunyaviruses (LaCrosse) Epstein-Barr virus (EBV) Adenoviruses Cytomegalovirus (CMV) Mumps

Hepatitis B virus (HBV)

Human immunodeficiency virus (HIV)

in 5% to 10% of patients. Morbidity is significant and includes the risk of epilepsy (10%-70%), focal neurologic sequelae (25%), and cognitive impairment (15%). Overall mortality is 5% to 10%.

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