Fungal meningitis differential diagnosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby; Prince Tano Djan, BSc, MBChB [2]
Overview
The differential diagnosis of fungal meningitis includes a range of medical conditions that can be broadly classified into infectious and non infectious. The cerebrospinal fluid analysis and radiological findings help distinguishing fungal meningitis from other causes of meningitis example bacterial meningitis, protozoal meningeal infection, viral meningeal infection, and non-infectious causes.
Differential Diagnosis
Fungal meningitis must be differentiated from other causes of meningeal irritation as shown below:
- Meningeal infection
- Non infectious causes
- Behçet's syndrome
- Chronic benign lymphocytic meningitis
- Chemical meningitis
- Drug hypersensitivity
- Isolated granulomatous angiitis of the nervous system
- Granulomatosis with polyangiitis (Wegener's)
- Malignancy
- Mollaret's meningitis
- Sarcoidosis
- Systemic lupus erythematosus
- Vogt-Koyanagi-Harada syndrome[1]
Differentiating fungal meningitis from other diseases
Diseases | Diagnostic tests | Physical Examination | Symptoms | Past medical history | Other Findings | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Na+, K+, Ca2+ | CT /MRI | CSF Findings | Gold standard test | Neck stiffness | Motor or Sensory deficit | Papilledema | Bulging fontanelle | Cranial nerves | Headache | Fever | Altered mental status | |||
Brain tumour[2][3] | + | Cancer cells[4] | MRI | + | + | + | + | + | + | Cachexia, gradual progression of symptoms | ||||
Delirium tremens | + | Clinical diagnosis | + | + | + | + | + | + | Alcohol intake, sudden witdrawl or reduction in consumption | Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, | ||||
Subarachnoid hemorrhage[5] | + | Xanthochromia[6] | CT scan without contrast[7][8] | + | + | + | + | + | + | + | + | Trauma/fall | Confusion, dizziness, nausea, vomiting | |
Stroke | + | Normal | CT scan without contrast | + | + | + | + | + | TIAs, hypertension, diabetes mellitus | Speech difficulty, gait abnormality | ||||
Neurosyphilis[9][10] | + | ↑ Leukocytes and protein | CSF VDRL-specific | + | + | + | + | + | + | Unprotected sexual intercourse, STIs | Blindness, confusion, depression, | |||
Viral encephalitis | + | Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose | Clinical assesment | + | + | + | + | + | + | + | Tick bite/mosquito bite/ viral prodome for several days | Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes | ||
Herpes simplex encephalitis | + | Clinical assesment | + | + | + | + | + | History of hypertension | Delirium, cortical blindness, cerebral edema, seizure | |||||
Wernicke’s encephalopathy | Normal | + | + | + | History of alcohol abuse | Ophthalmoplegia, confusion | ||||||||
CNS abscess | + | ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protein, ↑ red blood cells, lactic acid >500mg | Contrast enhanced MRI is more sensitive and specific,
Histopathological examination of brain tissue |
+ | + | + | + | + | + | + | History of drug abuse, endocarditis, ↓ immune status | High grade fever, fatigue,nausea, vomiting | ||
Drug toxicity | + | + | Lithium, Sedatives, phenytoin, carbamazepine | |||||||||||
Conversion disorder | Diagnosis of exclusion | + | + | + | + | + | Tremors, blindness, difficulty swallowing | |||||||
Electrolyte disturbance | ↓ or ↑ | Depends on the cause | + | + | Confusion, seizures | |||||||||
Febrile convulsion | Not performed in first simple febrile seizures | Clinical diagnosis and EEG | + | + | + | + | Family history of febrile seizures, viral illness or gastroenteritis | Age > 1 month, | ||||||
Subdural empyema | + | Clinical assesment and MRI | + | + | + | + | + | + | History of relapses and remissions | Blurry vision, urinary incontinence, fatigue | ||||
Hypoglycemia | ↓ or ↑ | Serum blood glucose | + | + | + | History of diabetes | Palpitations, sweating, dizziness, low serum glucose |
Differentiating fungal meningitis from other causes of meningitis
Fungal meningitis may be differentiated from other causes of meningitis by cerebrospinal fluid examination as shown below:[12][13][14][15][16]
Cerebrospinal fluid level | Normal level | Bacterial meningitis[15] | Viral meningitis[15] | Fungal meningitis | Tuberculous meningitis[17] | Malignant meningitis[12] |
---|---|---|---|---|---|---|
Cells/ul | < 5 | >300 | 10-1000 | 10-500 | 50-500 | >4 |
Cells | Lymphocyte:Monocyte 7:3 | Granulocyte > Lymphocyte | Lymphocyte > Granulocyte | Lympho.>Granulocyte | Lymphocytes | Lymphocytes |
Total protein (mg/dl) | 45-60 | Typically 100-500 | Normal or slightly high | High | Typically 100-200 | >50 |
Glucose ratio (CSF/plasma)[13] | > 0.5 | < 0.3 | > 0.6 | <0.3 | < 0.5 | <0.5 |
Lactate (mmols/l)[14] | < 2.1 | > 2.1 | < 2.1 | >3.2 | > 2.1 | >2.1 |
Others | ICP:6-12 (cm H2O) | CSF gram stain, CSF culture, CSF bacterial antigen | PCR of HSV-DNA, VZV | CSF gram stain, CSF india ink | PCR of TBC-DNA | CSF tumor markers such as alpha fetoproteins, CEA |
References
- ↑ Koroshetz WJ. Chapter 382. Chronic and Recurrent Meningitis. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
- ↑ Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
- ↑
- ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
- ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
- ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
- ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
- ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
- ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
- ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
- ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
- ↑ 12.0 12.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
- ↑ 13.0 13.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
- ↑ 14.0 14.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
- ↑ 15.0 15.1 15.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
- ↑ Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.
- ↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.