Recurrent aseptic meningitis
Introduction
Introduction to recurrent aseptic meningitis Recurrent aseptic meningitis (recurrentasepticmeningitis) refers to meningitis with recurrent episodes, fever, neck stiffness and other meningeal irritation, while cerebrospinal fluid examination is mainly lymphocytosis and mild protein increase, generally lasting for several days Rapid and natural relief, the symptoms disappear completely in the intermittent period, the cerebrospinal fluid is completely restored to normal, and the course of the disease is benign, which can be repeated for several years. The disease was first described by Mollaret (1944), because the cerebrospinal fluid was not stained with Gram staining and bacterial culture, so it was called aseptic meningitis or "Mollaret meningitis"; Mollaret speculated in the 1952 report. It is related to viral infection; in 2000, DeBiasi and Tyler will cause the cause of recurrent aseptic meningitis, which is divided into 9 categories. It is also recommended that the name of Mollaret meningitis should refer to recurrent aseptic meningitis that uses appropriate diagnostic measures to determine the cause. basic knowledge The proportion of illness: 0.0035% Susceptible people: more common in children and young adults Mode of infection: non-infectious Complications: nausea and vomiting
Cause
Cause of recurrent aseptic meningitis
Infectivity (20%):
(1) Virus: Herpes simplex virus type I, type II, enterovirus, Epstein-Barr virus, human T lymphotropic virus-1 (HTLV-1) and Kikuchis disease.
(2) Others: Cryptococcus neoformans, Borrelia burgdorferi, Whipple disease.
Intracranial and intraspinal tumors and cysts (20%):
(1) Epithelioid and dermoid cysts and tumors: craniopharyngioma, pituitary abscess, pituitary adenoma, glioblastoma, ependymoma, neural tube cyst, neuroepithelial cyst.
(2) arteriovenous malformation: Galen venous hemangioma, cavernous hemangioma.
Drug and chemical (20%):
(1) Non-steroidal anti-inflammatory analgesics: ibuprofen, naproxen, sulindac, tolmetine (tolmetin).
(2) fungicides: sulfa drugs sulfamethoxazole, penicillin, cephalosporin, isoniazid, ciprofloxacin.
(3) Others: OKT3, IVIg, carbamazepine (amide).
5. Recurrent inflammatory disease Familial Mediterranean fever, infant inflammatory multisystem disease.
6. Connective tissue disease systemic lupus erythematosus (SLE), sarcoidosis, multiple polychondritis, mixed connective tissue disease.
7. uveal meningeal inflammatory syndrome Koyanagi-Harada syndrome, Behcet syndrome (Baisai syndrome).
8. Complement and immunoglobulin deficiency complement regulatory protein factor I deficiency, IgG subclass 3 deficiency.
9. Miscellaneous Ferrol-Besnier disease with neurological deficits and cerebrospinal fluid lymphocytosis headache.
DeBiasi and Tyler pointed out that the most common causes are herpes simplex virus and drugs and chemicals, followed by intracranial tumors and cysts, systemic lupus erythematosus, sarcoidosis and Behcet's disease; rare diseases due to familial Mediterranean fever, Uveal meningeal inflammatory syndrome (Koyanagi-Harada syndrome) and complement and immunoglobulin deficiency.
Pathogenesis
In addition to Mollaret recurrent meningitis, various other causes of meningitis pathogenesis, and the immune status of the patient's body, the potential of the pathogen in the body, the possibility of pathogen infection, the application of drugs and chemicals have an important relationship.
The immunological study of Mollaret meningitis did not find a constant result, but most patients had normal immune function. Some of them only had elevated IgG in the cerebrospinal fluid during the attack period, and IL-6, TNF-2 or prostaglandin E2 increased, but its significance was unknown.
Lymphocytosis occurs in the cerebrospinal fluid. Polynuclear leukocytes and lymphocytes can be mixed within the first 24 hours after the disease. In some patients, more than half of the cells are large and mononuclear. They are called Mollaret cells and rapidly decrease after 24 hours. The diameter is 18pm. ±3m, irregular circular shape, unclear cytoplasm, fine vacuoles (Evens, 1993), fragile, if not taken early in the attack and immediate examination may be rare, some authors pointed out by electron microscopy and immunocytochemistry The Mollaret cells actually belong to the monocyte-macrophage system and are active monocytes. Szabo et al. discovered in 1983 that the cells were from the third ventricle-like cyst; Kuroda et al. (1991) reported that the Mollaret cells were from The exfoliated cells of the neurocutaneous dermoid cyst of the cisterna magna, Mollaret cells are not necessarily present in patients with Mollaret meningitis, and are not unique pathological manifestations of the disease.
Prevention
Recurrent aseptic meningitis prevention
Early symptoms are not obvious and are easily overlooked by patients.
1. Pay attention to enhance physical fitness and prevent upper respiratory tract infections.
2. Newborns and children actively implement planned immunization as required.
3. Comprehensive treatment to prevent recurrence.
Complication
Recurrent aseptic meningitis complications Complications, nausea and vomiting
Although the disease is rapid onset and recurrent, it lasts for several days to several weeks, but it can be relieved without special treatment. In addition to the primary disease (such as SLE), no other systemic complications have been found. data.
Symptom
Recurrent aseptic meningitis symptoms common symptoms convulsion muscle pain illusion light allergy nausea coma
The disease is more common in children and young adults, and both men and women can get sick.
Evens (1993) described the clinical manifestations and characteristics of nearly 50 cases of Mollaret meningitis in previous literature:
1. Most of the onset is sudden fever, nausea, vomiting, myalgia, and headache.
2. Meningeal irritation signs such as: Kernig and Brudzinski signs positive.
3. Focal neurological symptoms are rare, only transient reports of transient neurological disorders such as convulsions, hallucinations, delirions, coma, diplopia, pupils, brain cranial and pathological signs, but these symptoms should be considered Other diagnoses.
4. Symptoms peak in a few hours, lasting for hours to 1 week, then symptoms and signs disappear completely, and cerebrospinal fluid returns to normal.
5. The interval between two episodes is from a few days or weeks to months or years, and the longest period of the disease is reported to be up to 28 years, during which at least 13 episodes occur (Tyler et al., 1983).
6. In patients with non-Mollaret meningitis, the clinical manifestations are based on different causes, such as systemic lupus erythematosus with facial butterfly erythema or discoid erythema, skin allergies to sunlight, kidney damage, blood Find the diagnosis basis of lupus cells and anti-dsDNA antibody positive and Sm antibody positive.
Examine
Examination of recurrent aseptic meningitis
1. Mollaret meningitis has lymphocytosis in the cerebrospinal fluid. The protein is mildly elevated and the sugar content is normal. Mollaret cells can be found within the first 24 hours after the disease, and rapidly decrease after 24 hours.
2. In patients with non-Mollaret meningitis, selective examination according to different causes; such as suspected systemic lupus erythematosus, can find lupus cells, anti-dsDNA antibodies, anti-Sm antibody positive and other diagnostic basis; herpes simplex virus The cause should be found in the cerebrospinal fluid by PCR detection of the pathogen or positive reaction of the virus antibody in the blood.
3. The surrounding white blood cells can increase.
4. ESR increases.
5. Other optional examination items include: blood routine, blood electrolytes, blood sugar, urea nitrogen, and urine routine.
6. X-ray film inspection
(1) A chest pill can be found in viral pneumonia.
(2) cranial and sinus flat films can be found in skull osteomyelitis, paranasal sinusitis, mastoiditis, but the CT examination of the above lesions is more clear.
7. CT, MRI examination of early CT or brain MRI examination can be normal, meningeal manifestations can be seen when there are neurological complications, and can be found ependymitis, subdural effusion, enhanced MRI scan for diagnosis of meningitis It is more sensitive than enhanced CT scan, and it can show meningeal exudation and cortical response when MRI scan is enhanced.
Diagnosis
Diagnosis and diagnosis of recurrent aseptic meningitis
In the diagnosis of recurrent aseptic meningitis, if it is Mollaret meningitis, it is usually based on repeated episodes of the patient, each time onset, fever, meningeal irritation and cerebrospinal fluid mononuclear cells, which lasts for several days to several weeks. Although no special treatment has been given, it can be diagnosed by itself.
It must be distinguished from some potentially recurrent chronic meningitis that can be diagnosed with modern diagnostic techniques.
Herpes simplex virus and Epstein-Barr virus may cause meningitis caused by the same virus multiple times in the same patient; however, there are also cases where meningitis is caused by different viruses.
These must use PCR amplification technology to detect cerebrospinal fluid pathogens for diagnosis.
Another example is a small abscess in the scalp that may become a lesion that penetrates the skull and becomes the cause of recurrent bacterial meningitis.
