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found, but, as indicated further on, careful follow-up and repeated CSF examinations, or in some cases meningeal biopsy, will reveal in the nature of a few, and many others will resolve spontaneously They are described below, under Chronic Persistent and Recurrent Meningitis Other occasional causes include an aseptic chemical meningitis incited by rupture of a craniopharyngioma or other cystic structure containing proteinaceous uid or the introduction of a foreign substance to the subarachnoid space, but the cause in these instances is usually obvious We had a case that followed the instillation of hypertonic saline (Ratz procedure) for the relief of arachnoidal adhesions after back surgery Also, an idiosyncratic, presumably immunologic meningitis has resulted from the use of nonsteroidal anti-in ammatory drugs, intravenous immune globulin (actually a carrier chemical in the solution), and, rarely, from other drugs In respect to the rst two categories, parameningeal and partially treated bacterial infections and a smoldering paranasal sinusitis or mastoiditis may produce a CSF picture of aseptic meningitis because of intracranial extension (epidural or subdural infection) It must also be remembered that antibiotic therapy given for a systemic or pulmonary infection may suppress a bacterial meningitis to the point where mononuclear cells predominate, glucose is near normal, and organisms cannot be cultured from the CSF (although they may still be evident by Gram s stain) Careful attention to the history of recent antimicrobial therapy permits recognition of these cases Rarely, children with scarlet fever or streptococcal pharyngitis have been noted to develop meningeal signs and pleocytosis, the result of a sterile serous in ammation that does not involve invasion of the meninges by organisms The same may occur in subacute bacterial endocarditis Syphilis, cryptococcosis, and tuberculosis are the important members of the third group in which the organism may be dif cult to culture, as detailed in Chap 32 Tuberculous meningitis, in its initial stages, may masquerade as an innocent aseptic meningitis; the diagnosis may be delayed because the tubercle bacillus is dif cult to nd in stained smears, and cultures may require several weeks Typically, the CSF glucose is severely depressed, although it may be only slightly reduced early in the illness Similarly, the diagnosis of cryptococcosis, other fungal infection, or nocardiosis is occasionally missed because the organisms may be present in such low numbers as to be overlooked in smears, especially in AIDS patients Brucellosis (Mediterranean fever, Malta fever) is a rare disease, practically con ned to the Middle East, that may present as an acute meningitis or meningoencephalitis, with the CSF ndings of an aseptic meningitis The diagnosis depends on the detection of high serum antibody titers and Brucella-speci c immunoglobulins, using the ELISA In the fourth (neoplastic) group, leukemias and lymphomas are the most common sources of meningeal reactions In children, a leukemic meningitis with cells (lymphoblasts or myeloblasts) in the CSF numbering in the thousands occurs frequently in the late stages of the illness In carcinomatous meningitis, neoplastic cells extend throughout the leptomeninges and involve cranial and spinal nerve roots, producing a picture of meningoradiculitis with normal or low CSF glucose values Lymphocytic meningitis that is accompanied by cranial nerve palsies often turns out to be tuberculous if the patient is febrile and the CSF glucose is low; it is likely to be neoplastic if the patient is afebrile and the CSF glucose is normal or mildly decreased Concentrated cytologic preparations usually permit identi cation of the tumor cells These diseases are discussed in detail in Chap 31.

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Sarcoidosis, Behcet disease, intravascular lymphoma, and granulomatous angiitis are the best-known examples of a group of noninfectious in ammatory meningitides Occlusion of many small cerebral blood vessels by cholesterol emboli may also excite a reaction in meningeal vessels and a pleocytosis that includes eosinophils Each of these conditions can present with a clinical picture of meningitis alone, but more often there are indications of both meningeal and parenchymal involvement Chronic Persistent and Recurrent Meningitis (Table 33-1) Chronic and recurrent meningitides of obscure etiology always pose diagnostic problems Such patients may have a low-grade fever, headache of varying severity, and stiff neck and a predominantly mononuclear pleocytosis, sometimes with slightly raised CSF pressure There may also be minor focal neurologic signs A viral or some other type of infective in ammation is always suspected, but a search by culture methods and serology usually yields negative results Herpesvirus has been demonstrated to be the cause of a few cases as in the recurrent Mollaret type noted below Sometimes the process improves without identi caion of the cause over a period of months or a year or more; in other cases, the cause is eventually found Only a few end fatally In a series of such patients studied at the Mayo Clinic, 33 of 39 underwent a natural resolution and 2 died within 31 2 years; 14 were still symptomatic at the time of the report (Smith and Aksamit) In another series from New Zealand of 83 such patients, Anderson and colleagues ultimately found tuberculosis to be the single most common identi able cause, a smaller number being accounted for by neoplastic and cryptoTable 33-1 Causes of chronic and recurrent aseptic meningitis Infectious Tuberculosis and atypical mycobacterial Fungal (cryptococcal, coccidial, histoplasmal, blastomyces, etc) Nocardia HIV Herpes type 2 (recurrent Mollaret meningitis) Lyme disease Syphilis Brucellosis Epidural abscess or hematoma Incompletely treated bacterial meningitis Granulomatous and vasculitic Sarcoidosis Wegener granulomatosis Behcet disease Vasculitis Neoplastic Carcinomatous Lymphomatous Chemical Leakage from cerebral or spinal epidermoid tumor, dermoid cyst, craniopharyngioma, or teratoma Instillation of irritative substances by lumbar puncture, spinal anesthesia, or surgery Idiopathic Vogt-Kayanagi-Harada disease No cause determined in one-third of cases.

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