CHRONIC MENINGITISCHRONIC MENINGITISLectureLecture 11

Hakan ErdemHakan Erdem AssocAssoc Prof DrProf DrHakan Erdem, Hakan Erdem, AssocAssoc. Prof. Dr.. Prof. Dr.ESCMID ESCMID PostgraduatePostgraduate EducationEducation CourseCourse, , TurkeyTurkeyESCMID

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PresentationPresentation PlanPlan

Lesson 1Lesson 1 Lesson 2Lesson 2♣♣ CausesCauses♣♣ DefinitionDefinition of CMof CM

♣♣ CryptococcalCryptococcal meningitismeningitis♣♣ NeurosyphilisNeurosyphilis

♣♣ PathogenPathogen distributiondistribution♣♣ TuberculousTuberculous meningitismeningitis

N b ll iN b ll i

♣♣ CandidalCandidal meningitismeningitis♣♣ NeuroborreliosisNeuroborreliosis

♣♣ NeurobrucellosisNeurobrucellosis

HEHE--22

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Mycobacteriumtuberculosis

TreponemaPallidum

SBE(streptococci)

Pallidum

Listeriamonocytogenes

BACTERIALAGENTS

Borrelia spp.

Nocardia spp.

ParameningealInfections

Brucella spp.

Leptospiraspp.

Actinomycesspp

HEHE--33

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CytomegalovirusArboviruses

Mollaret-meningitis(HSV II)Echoviruses

VIRALAGENTS Herpes simplex virusMeasles virus

Mumps virusHerpes zoster virus

Lymphocyticchoriomeningitis

i

Mumps virusHerpes zoster virus

HEHE--44

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Zygomycetesspp.

Pseudalle-scheriaboydii

Sporothrixschenckii

Cryptococcusneoformans

FUNGALAGENTS

Candida spp.

Coccidioidesspp.

Aspergillusspp.

Histoplasmaspp.

Blastomycesspp.

HEHE--55

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HEHE--66

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NoninfectiousNoninfectious CausesCausesNoninfectiousNoninfectious CausesCauses

♣♣ PrimaryPrimary CNS CNS LymphomaLymphoma♣♣ BehcetBehcet diseasedisease

♣♣ Isolated Isolated angiitisangiitis of the CNSof the CNS♣♣ VogtVogt--KoyanagiKoyanagi--Harada Harada syndromesyndrome

♣♣ SystemicSystemic lupuslupus erythemotosuserythemotosus♣♣ WegenerWegener GranulomatosisGranulomatosis

SarcoidosisSarcoidosis

♣♣ ForeignForeign body in CNSbody in CNS♣♣ MigraineMigraine withwith CSF CSF pleocytosispleocytosis

MeningeosisMeningeosis carcinomatosacarcinomatosa♣♣ SarcoidosisSarcoidosis♣♣ SjögrenSjögren syndromesyndrome♣♣ CardiogenicCardiogenic ((septicseptic)) embolismembolism

♣♣ MeningeosisMeningeosis carcinomatosacarcinomatosa♣♣ Steroid responsive chronic Steroid responsive chronic

idiopathic meningitisidiopathic meningitis♣♣ CardiogenicCardiogenic ((septicseptic) ) embolismembolism p gp g♣♣ ChemicalChemical--drug induced meningitisdrug induced meningitis

HEHE--77

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DefinitionDefinitionDefinitionDefinition

♣♣ MeningitisMeningitis lastinglasting forfor 4 4 wkswks oror♣♣ SomeSome authorsauthors excludedexcluded

♣♣ OccurringOccurring concurrentlyconcurrently withwith massmass lesionslesions♣♣ AssociatedAssociated withwith previouslypreviously diagnoseddiagnosedp yp y gg

systemicsystemic diseasesdiseases♣♣ MeningitisMeningitis followingfollowing neurosurgicalneurosurgicalgg gg gg

proceduresprocedures

HEHE--88

Cohen, BA. Chronic meningitis. Curr Neurol Neurosci Rep 2005; 5:429.ESCMID O

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ColloborationColloborationInfectiousdiseases

Internal

Neurology

InternalMedicine

Neurosurgery

HemotologyOncology

Rheumatology

Pathology

HEHE--99

Microbiology RadiologyESCMID O

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PathogenPathogen DistributionDistributionPathogenPathogen DistributionDistribution

♣♣ OverallOverall 8383 casescases♣♣ OverallOverall 83 83 casescases♣♣ TuberculosisTuberculosis 40 40 %%♣♣ CryptococcosisCryptococcosis 7 7 %%♣♣ MMalignancyalignancy 88 %%g yg y♣♣ UnknownUnknown causecause 34 %34 %

♣♣ 17 %17 % respondedresponded toto empiricempiric♣♣ 17 % 17 % respondedresponded toto empiricempiricantituberculousantituberculous therapytherapy

HEHE--1010

Anderson, NE, Willoughby, EW. Chronic meningitis without predisposing illness--a review of 83 cases. Quarterly journal of medicine 1987; 63:283.

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PathogenPathogen DistributionDistribution--22PathogenPathogen DistributionDistribution 22

♣♣ 114114 ptspts♣♣ 114 114 ptspts♣♣ C. C. neoformansneoformans (54 %)(54 %)

HIVHIV titi 21 %21 %♣♣ HIVHIV--negativenegatives 21 %s 21 %♣♣ HIVHIV--positives 79positives 79 %%

♣♣ M. M. tuberculosis tuberculosis (37%)(37%)♣♣ 3/43 3/43 ptspts, HIV , HIV positivepositive

Helbok R et al Chronic meningitis in Thailand Clinical characteristics laboratory data and outcome

HEHE--1111

Helbok, R, et al. Chronic meningitis in Thailand. Clinical characteristics, laboratory data and outcome in patients with specific reference to tuberculosis and cryptococcosis. Neuroepidemiology 2006; 26:37.0ESCMID

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A A StrangeStrange CaseCase♣♣ ConfusionConfusion, , irritabilityirritability, , agitationagitation

DisorientationDisorientation♣♣ DisorientationDisorientation♣♣ LanguageLanguage disturbancesdisturbances♣♣ Persecutory delusionsPersecutory delusions♣♣ Hallucinations Hallucinations ♣♣ IIncreasedncreased psychomotor activitypsychomotor activity♣♣ DisturbanceDisturbance ofof consciousnessconsciousness♣♣ DisturbanceDisturbance of of consciousnessconsciousness♣♣ AgentAgent: : Parvovirus B19Parvovirus B19

HEHE--1212Coskun O, Erdem H, Gul HC, et al. Meningoencephalitis associated with human parvovirus B19.Clin Microbiol Infect. 2008;14(12):1188-90

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TUBERCULOUS MENINGITISTUBERCULOUS MENINGITISTUBERCULOUS MENINGITISTUBERCULOUS MENINGITIS

HEHE--1313

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CaseCase FatalityFatality RatioRatio, TM, TMCaseCase FatalityFatality RatioRatio, TM, TM

1515--40 % 40 % despitedespite effectiveeffective treatmenttreatment regimensregimensHEHE--1414

1515 40 % 40 % despitedespite effectiveeffective t eatmentt eatment egimensegimens

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ThreeThree featuresfeatures dominatedominate in TM…in TM…

♣♣ ProliferativeProliferative arachnoiditisarachnoiditis♣♣ MarkedMarked at at thethe basebase♣♣ ProducesProduces fibrousfibrous massmass

♣♣ InflammatoryInflammatory processprocess♣♣ CommunicatingCommunicating hydrocephalushydrocephalus

♣♣ VasculitisVasculitis, , multiplemultiple lesionslesions♣♣ ThrombosisThrombosis

h d k h f b l ll h k

HEHE--1515

Rich, AR, McCordock, HA. Pathogenesis of tuberculous meningitis. Bull Johns Hopkins Hosp 1933; 52:5.Dastur, DK, Manghani, DK, Udani, PM. Pathology and pathogenetic mechanisms in neurotuberculosis. Radiol Clin North Am 1995; 33:733.

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TuberculomasTuberculomas♣♣ DeepDeep--seatedseated tuberclestubercles♣♣ DueDue toto hematogenoushematogenous bacillemiabacillemia♣♣ CaseousCaseous focifoci♣♣ CaseousCaseous focifoci♣♣ NodularNodular lesionslesions

Cli i llCli i ll il til t♣♣ ClinicallyClinically silentsilent

Stevens, DL, Everett, ED. Sequential computerized axial tomography in tuberculous meningitis.

HEHE--1616

JAMA 1978; 239:642.Weisberg, LA. Granulomatous diseases of the CNS as demonstrated by computerized tomography. Comput Radiol 1984; 8:309.

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ClinicalClinical FeaturesFeatures of TM of TM PtsPts♣♣ StageStage I I ptspts

♣♣ LucidLucid, no, no focalfocal neurologicneurologic signssigns♣♣ LucidLucid, no , no focalfocal neurologicneurologic signssigns♣♣ No No evidenceevidence of of hydrocephalushydrocephalus..

♣♣ StageStage II II ptsptsgg pp♣♣ LethargyLethargy, , confusionconfusion♣♣ MildMild focalfocal signssigns

(CN (CN palsypalsy, , hemiparesishemiparesis))

♣♣ StageStage III III ptspts♣♣ DeliriumDelirium, , stuporstupor, , comacoma, , seizuresseizures♣♣ MultipleMultiple cranialcranial nervenerve palsiespalsies

dd h i l ih i l i♣♣ ±± dense dense hemiplegiahemiplegia

HEHE--1717Kent, SJ, Crowe, SM, Yung, A, et al. Tuberculous meningitis: a 30-year review. Clin Infect Dis 1993; 17:987.

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SpinalSpinal ArachnoiditisArachnoiditisSpinalSpinal ArachnoiditisArachnoiditis

Si ilSi il tt i itii iti♣♣ SimilarSimilar toto meningitismeningitis♣♣ FocalFocal inflammatoryinflammatory diseasedisease

♣♣ GelatinousGelatinous oror fibrinousfibrinous exudateexudate♣♣ SingleSingle oror multiplemultiple levelslevels

♣♣ SymptomsSymptoms, , wkswks toto mosmos

HEHE--1818

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SpinalSpinal ArachnoiditisArachnoiditis--22pp♣♣ SpinalSpinal cordcord compressioncompression

♣♣ SpinalSpinal oror radicularradicular painpain♣♣ HyperesthesiaHyperesthesia, , paresthesiasparesthesias♣♣ LowerLower MN MN paralysisparalysis♣♣ BladderBladder dysfunctiondysfunctionyy♣♣ RectalRectal sphinctersphincter dysfunctiondysfunction

♣♣ VasculitisVasculitis♣♣ VasculitisVasculitis

HEHE--1919

Wadia, NH, Dastur, DK. Spinal meningitides with radiculo-myelopathy. J Neurol Sci 1969; 8:239.ESCMID O

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AtypicalAtypical PresentationsPresentations in TMin TM♣♣ AcuteAcute, , rapidlyrapidly progressiveprogressive

Sl lSl l ii d tid ti //♣♣ SlowlySlowly progressiveprogressive dementiadementia overover mosmos//yrsyrs♣♣ PersonalityPersonality changeschanges♣♣ SocialSocial withdrawalwithdrawal♣♣ LossLoss of libidoof libido♣♣ MemoryMemory deficitsdeficits

♣♣ EncephaliticEncephalitic coursecourse♣♣ StuporStupor, , comacoma, , convulsionsconvulsions♣♣ AbscenceAbscence of of meningitismeningitis signssignsgg gg

HEHE--2020Udani, PM, Dastur, DK. Tuberculous encephalopathy with and without meningitis. Clinical features and pathological correlations. J Neurol Sci 1970; 10:541.

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SignsSigns of TB of TB outsideoutside thethe CNS CNS gg

♣♣ OfOf diagnosticdiagnostic importanceimportance♣♣ Of Of diagnosticdiagnostic importanceimportance♣♣ AbnormalitiesAbnormalities on CXRon CXR♣♣ OftenOften absentabsent oror nonspecificnonspecific♣♣ TSTTST

♣♣ PositivePositive in in thethe majoritymajority♣♣ NegativeNegative resultresult doesdoes not not excludeexcludegg

HEHE--2121

Hinman, AR. Tuberculous meningitis at Cleveland Metropolitan General Hospital 1959 to 1963. Am Rev Respir Dis 1967; 95:670.Kennedy, DH, Fallon, RJ. Tuberculous meningitis. JAMA 1979; 241:264.

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FundoscopicFundoscopic ExaminationExaminationFundoscopicFundoscopic ExaminationExamination

OO thi dthi d ff tt iliili TBTB♣♣ OneOne--thirdthird of of ptspts, , miliarymiliary TBTB♣♣ ChoroidalChoroidal tuberclestubercles

♣♣ MultipleMultiple♣♣ IllIll--defineddefined♣♣ YellowYellow--whitewhite nodulesnodules

HEHE--2222

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RadiodiagnosticsRadiodiagnostics in TMin TM

Ozates M Kemaloglu S Gurkan F et al CT of the brain in tuberculous meningitis A review of 289 patients Ozates, M, Kemaloglu, S, Gurkan, F, et al. CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiol 2000; 41:13.Kingsley, DP, Hendrickse, WA, Kendall, BE, et al. Tuberculous meningitis: role of CT in management and prognosis. J Neurol Neurosurg Psychiatry 1987; 50:30.

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TwoTwo CommunityCommunity--BasedBased SeriesSeriesyy

♣♣ HydrocephalusHydrocephalus, 75 %, 75 %♣♣ HydrocephalusHydrocephalus, 75 %, 75 %♣♣ BasilarBasilar meningealmeningeal enhancementenhancement, 38 %, 38 %

C b lC b l i f ti f t 1515 30 %30 %♣♣ CerebralCerebral infarctsinfarcts, 15, 15--30 %30 %♣♣ TuberculomasTuberculomas, 5, 5--10 %10 %

HEHE--2424

1. Bhargava, S, Gupta, AK, Tandon, PN. Tuberculous meningitis--a CT study. Br J Radiol 1982; 55:189.2. Ozates, M, Kemaloglu, S, Gurkan, F, et al. CT of the brain in tuberculous meningitis. A review of 289 patients.

Acta Radiol 2000; 41:13.

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Hydrocephalus Marked basilarenhancement

Vasculitis

Advanced MeningiticDisease

Vasculitis

POORİ

Basalganglia

infarction

PROGNOSİS

Decreasedlevel of

consciousness

Raised ICP> 40 cm H2O

Ozates, M,, et al. CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiol 2000; 41:13.Kingsley, DP, et al. Tuberculous meningitis: role of CT in management and prognosis. J Neurol Neurosurg Psychiatry 1987; 50:30.

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TherapeuticTherapeutic ConcernsConcerns InIn TMTMpp

1. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations 1998. Joint Tuberculosis Committee of the British Thoracic Society. Thorax 1998; 53:536.

2. Blumberg, HM, Burman, WJ, Chaisson, RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med 2003; 167:603./ f S y f A f A J R p C C ;

3. Anderson, NE, Willoughby, EW. Chronic meningitis without predisposing illness--a review of 83 cases. Q J Med 1987; 63:283.

4. Thwaites GE, Schoeman JF. Update on tuberculosis of the central nervous system: pathogenesis, diagnosis, and treatment.Clin Chest Med. 2009 Dec;30(4):745-54.

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Isoniazid10 mg/kg (initially)5 mg/kg (300 mg)

Rifampin10 mg/kg (600 mg)

Ethambutol(15-25 mg/kg)

Streptomycin15 mg/kg(max 1g)

Pyrazinamide15-30 mg/kg

(max 2g)g g ( g)

Excellentpenetration

( g) ( g)

Withinflammation

Slightdiffusion

Diffusesfreely

10-20 %Sufficient y

INH, RIF, PZA,either EMB or SM

2 MOS

Strain SIf PZA is

Tuberculoma

Strain Somitted

INH 300 mgRIF 600 mg

INH 300 mgRIF 600 mg

HEHE--2727

RIF 600 mg10 MOS

RIF 600 mg16 MOSESCMID

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DrugDrug resistantresistant TM, no TM, no guidelineguideline existexist……gg gg

HEHE--2828

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An early diagnosis, before the onset of coma andAn early diagnosis, before the onset of coma andfocal neurologic deficit, focal neurologic deficit, thusthus leadingleading toto treatmenttreatment……

ThwaitesThwaites GE, Tran TH. GE, Tran TH. TuberculousTuberculous meningitis: manymeningitis: many questions, too few answers. questions, too few answers. Lancet Neurol. 2005;Lancet Neurol. 2005; 4(3):1604(3):160––70.70.

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Severe Pt fails to Pts with lessSeveresymptoms

Pt fails toimprove

severesymptoms

MicrobiolDiagnosisNegative

Contactwith aTB pt

Priorpositive

TST

Even if TSTnegative

EMPIRICANTI-TBCTHERAPY

No improvement4-6 WKS

MicrobiolDiagnosis

STOPANTI-TBC4-6 WKS

Negative THERAPYESCMID O

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CSF CSF ValuesValues UnderUnder TM TM TherapyTherapy

LUMBAR LUMBAR PUNCTUREPUNCTURE

WBC/mmWBC/mm33 MNL %MNL % GlucoseGlucose

((mmolmmol/l)/l)

ProteinProtein

(mg/dl)(mg/dl)PUNCTUREPUNCTURE RangeRange MedianMedian RangeRange MedianMedian RangeRange MedianMedian RangeRange MedianMedian

Initial Initial puncturepuncture 2525--310310 190190 6060--100100 9090 1.051.05--2.382.38 2.272.27 0.960.96--66 1.781.78

1st m1st monthonth 5050--300300 210210 1010--100100 8080 1.221.22--7.27.2 2.712.71 0.270.27--2.92.9 0.960.96

3rd 3rd monthmonth 1010--210210 7575 6060--100100 100100 1.441.44--12.812.8 2.832.83 0.240.24--3.23.2 0.60.63rd 3rd monthmonth

6th 6th montmonthh 00--5555 2020 00--100100 100100 1.51.5--3.053.05 2.382.38 0.30.3--1.551.55 0.770.77

9th 9th month month 00--1010 00 00--100100 00 2.72.7--3.383.38 3.163.16 0.20.2--0.70.7 0.250.25

12th 12th monthmonth 00--35*35* 00 00--100100 00 1.331.33--33 2.772.77 0.230.23--1.71.7 0.390.39

ErdemErdem H, H, AksoyAksoy B, B, KilicKilic S, S, et al.. et al.. Profiles of biochemical parameters in central nervous system fluid during the Profiles of biochemical parameters in central nervous system fluid during the therapeutic courses of adult Mycobacterium tuberculosis meningitis.therapeutic courses of adult Mycobacterium tuberculosis meningitis. Scand J Infect Dis. 2006;38(8):710Scand J Infect Dis. 2006;38(8):710--2.2.

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ThTh i i id blid bl idid hh dj idj iThereThere is is considerableconsiderable evidenceevidence thatthat adjunctiveadjunctiveglucocorticoidglucocorticoid therapytherapy is is beneficialbeneficial in TMin TM

ThwaitesThwaites, GE, Nguyen, DB, Nguyen, HD, et al. , GE, Nguyen, DB, Nguyen, HD, et al. DexamethasoneDexamethasone for the treatment of for the treatment of tuberculoustuberculous meningitis in meningitis in adolescents and adults. N adolescents and adults. N EnglEngl J Med 2004; J Med 2004; 351(17):1741351(17):1741--51.51.

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HEHE--3333

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NEUROBRUCELLOSISNEUROBRUCELLOSISNEUROBRUCELLOSISNEUROBRUCELLOSIS

HEHE--3434

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DefinitionDefinitionDefinitionDefinition

♣♣ ThreeThree featuresfeatures♣♣ ThreeThree featuresfeatures♣♣ Neurological picture not explained Neurological picture not explained

by any other neurological diseaseby any other neurological diseaseby any other neurological diseaseby any other neurological disease♣♣ EvidenceEvidence of of brucellarbrucellar infectioninfection

II fl tfl t lt ti i CSFlt ti i CSF♣♣ IInflammatorynflammatory alteration in CSFalteration in CSF♣♣ CNS CNS involvementinvolvement, 1.7 % , 1.7 % toto 10 %10 %

Gul HC, Erdem H, Gorenek L, et al. Management of neurobrucellosis: an assessment of 11 cases. Intern Med. 2008;47(11):995 1001

HEHE--3535

2008;47(11):995-1001.Akdeniz H, Irmak H, Anlar O, Demiroz AP. Central nervous system brucellosis: presentation, diagnosis and treatment. The Journal of infection. 1998 May;36(3):297-301.

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TypesTypes ofof NeurobrucellosisNeurobrucellosisTypesTypes of of NeurobrucellosisNeurobrucellosis

♣♣ DDiffuseiffuse involvementinvolvement♣♣ MeningoencephalitisMeningoencephalitisg pg p♣♣ MyelitisMyelitis♣♣ CerebellarCerebellar involvementinvolvement

♣♣ PolyradiculoneuropatPolyradiculoneuropathhy y

HEHE--3636

Franco MP, Mulder M, Gilman RH, Smits HL. Human brucellosis. The Lancet infectious diseases. 2007 Dec;7(12):775-86.ESCMID

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Complaints on AdmissionComplaints on AdmissionHeadacheHeadache (57 %)(57 %)Fever Fever (57 %)(57 %)Sweating Sweating (30 %)(30 %)Sweating Sweating (30 %)(30 %)Weight lossWeight loss (28 %)(28 %)Back painBack pain (23 %)(23 %)Walking difficultyWalking difficulty (17 %)(17 %)Walking difficultyWalking difficulty (17 %)(17 %)Nausea Nausea && Vomiting Vomiting (17 %)(17 %)Weakness in the extremities Weakness in the extremities (15 %)(15 %)Sensory loss in the extremitiesSensory loss in the extremities (13 %)(13 %)y xy x ( )( )Hearing lossHearing loss (10 %)(10 %)Blurred visionBlurred vision (6 %)(6 %)Urinary incontinenceUrinary incontinence (4 %)(4 %)Double vision Double vision (4 %)(4 %)Memory deficit Memory deficit (2(2 %)%)AmenorrheaAmenorrhea (3 cases) *(3 cases) *F l i iF l i i (0 5 %)(0 5 %)

HEHE--3737

Fecal incontinenceFecal incontinence (0.5 %)(0.5 %)

GulGul HC, HC, ErdemErdem H, H, BekBek S.S.. . Overview of Overview of neurobrucellosisneurobrucellosis: a pooled analysis of 187 : a pooled analysis of 187 cases.Intcases.Int J Infect Dis. J Infect Dis. 2009 Nov;13(6):e3392009 Nov;13(6):e339--43. 43.

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Physical FindingsPhysical Findingsy gy gMeningealMeningeal irritationirritation (37 %)(37 %)ConfusionConfusion (18 %)(18 %)HepatomegalyHepatomegaly (1(155 %)%)HypoesthesiaHypoesthesia (12 %)(12 %)SplenomegalySplenomegaly (11 %)(11 %)p g yp g yConvulsionsConvulsions (8 %)(8 %)HemiparesisHemiparesis (4.5 %)(4.5 %)ParaplegiaParaplegia (4 %)(4 %)p gp g ( )( )DysarthriaDysarthria (4 %)(4 %)DiplopiaDiplopia (4 %)(4 %)PapilledemaPapilledema (3 %)(3 %)pp (3 %)(3 %)Coma Coma (3 %)(3 %)Ataxia Ataxia ((11 %)%)PancreatitisPancreatitis (0 5 %)(0 5 %)

HEHE--3838

PancreatitisPancreatitis (0.5 %)(0.5 %)

GulGul HC, HC, ErdemErdem H, H, BekBek S.S.. . Overview of Overview of neurobrucellosisneurobrucellosis: a pooled analysis of 187 : a pooled analysis of 187 cases.Intcases.Int J Infect Dis. J Infect Dis. 2009 Nov;13(6):e3392009 Nov;13(6):e339--43. 43.

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ComplicationsComplicationsCranial Cranial nerve nerve involvementinvolvement (19 %)(19 %)

1.1. 8th CN, 19 cases8th CN, 19 cases2.2. 6th CN,14 cases6th CN,14 cases3.3. 7th CN, 3 cases7th CN, 3 cases

(7 ) (7 ) Polyneuropathy/radiculopathyPolyneuropathy/radiculopathy (7 %) (7 %)

Depression Depression ((55 %) %)

ParaplegiaParaplegia (4 %)(4 %)p gp gStrokeStroke syndromessyndromes (3.2 %)(3.2 %)

1.1. Subarachnoid hemorrhage 1 caseSubarachnoid hemorrhage 1 case2.2. Subdural Subdural haematomahaematoma, 1 case, 1 case3.3. Ischemia 4 casesIschemia 4 cases

AAbscessesbscesses (3 %)(3 %)1.1. Brain abscess, 3 casesBrain abscess, 3 cases2.2. Spinal cord abscess, 1 caseSpinal cord abscess, 1 case3.3. Epidural abscess, 1 caseEpidural abscess, 1 case44 CerebellarCerebellar abscess 1 caseabscess 1 case4.4. CerebellarCerebellar abscess, 1 caseabscess, 1 case

HydrocephalusHydrocephalus (1.5 %)(1.5 %)

Intracranial Intracranial hypertensionhypertension (0.5 %)(0.5 %)ypypDeath Death (0.5 %)(0.5 %)

GulGul HC, HC, ErdemErdem H, H, BekBek SS. . Overview of Overview of neurobrucellosisneurobrucellosis: a pooled analysis of 187 cases.: a pooled analysis of 187 cases. IntInt J Infect Dis. J Infect Dis. 2009 ;13(6):e3392009 ;13(6):e339--43. 43.

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HEHE--4040PappasPappas G,G, AkritidisAkritidis N,N, ChristouChristou LL.. TreatmentTreatment ofof neurobrucellosisneurobrucellosis:: WhatWhat isis knownknown andand whatwhat remainsremains totobebe answeredanswered..ExpertExpert RevRev AntiAnti InfectInfect TherTher.. 20072007 ;;55((66))::983983--9090..

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PillPills

Pills plusceftriaxone

CURE

HEHE--4141GulGul HC,HC, ErdemErdem H,H, GorenekGorenek LL etet alal.. ManagementManagement ofof neurobrucellosisneurobrucellosis:: anan assessmentassessmentofof 1111 casescases.... InternIntern MedMed.. 20082008;;4747((1111))::995995--10011001..

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HEHE--4242PappasPappas G,G, AkritidisAkritidis N,N, ChristouChristou LL.. TreatmentTreatment ofof neurobrucellosisneurobrucellosis:: WhatWhat isis knownknown andand whatwhat remainsremains totobebe answeredanswered..ExpertExpert RevRev AntiAnti InfectInfect TherTher.. 20072007 ;;55((66))::983983--9090..

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