Eosinophilic meningitis and ibuprofen therapy

Eosinophilic meningoencephalitis successfully treated with glucocorticoids and intravenous immunoglobulin: a case report

Eosinophilic meningoencephalitis is a rare inflammatory condition of the central nervous system. As a limited number of cases has been reported, debate remains on the optimal treatment. We present a case of idiopathic eosinophilic meningoencephalitis successfully treated with glucocorticoids and intravenous immunoglobulin (IVIG). After extensive evaluation to rule out other possible causes, the patient was treated with intravenous (IV) dexamethasone and showed significant improvement within a few days. However, neurologic impairment persisted, and follow-up lumbar puncture results showed only a mild decrease in pleocytosis. Even after an additional 5 days of IV methylprednisolone, cerebrospinal fluid (CSF) pleocytosis persisted, and brain magnetic resonance imaging (MRI) showed an increase in enhanced lesions, implying persistent neuroinflammation. The patient was maintained on high-dose oral prednisolone for 2 months, and additional immune-modulatory effects were treated with IVIG. Follow-up MRI at 2 months showed a significant decrease in the extent of multiple enhanced lesions and a normalized CSF profile. The patient was maintained on regular maintenance doses of IVIG for an additional 6 months without any neurologic signs or symptoms. Inflammation is the key pathophysiology underlying neurological damage in eosinophilic meningoencephalitis. A literature review revealed that corticosteroid treatment is the only anti-inflammatory treatment used in cases of idiopathic meningoencephalitis, resulting in sufficient response in most patients but only partial response or death in a few cases. This is the first case report of IVIG use in idiopathic eosinophilic meningoencephalitis, suggesting the possibility of a new treatment modality for refractory cases.

[An anti-RNP antibody-positive case of aseptic meningitis induced by non-steroidal anti-inflammatory drugs in a young woman]

A 19-year-old woman developed high fever, headache, and nausea after taking Loxoprofen for pharyngitis, followed by disturbed consciousness and nuchal stiffness. The patient and her mother had a history of Raynaud's phenomenon. Cerebrospinal fluid (CSF) examination indicated a diagnosis of aseptic meningitis and revealed high levels of Q albumin and IgG index. Anti-RNP antibodies were positive in serum and CSF. Her symptoms disappeared immediately after cessation of Loxoprofen and a drug lymphocyte stimulation test was negative, confirming a diagnosis of non-steroidal anti-inflammatory drugs (NSAIDs)-induced aseptic meningitis. It should be kept in mind that an immune abnormality such as serum and CSF anti-RNP antibodies may play a role in development of NSAIDs-induced aseptic meningitis. A history of usage of NSAIDs and a thorough examination of collagen diseases are useful for identification of the origin of aseptic meningitis in a young woman.

Cryptococcal eosinophilic meningitis in a patient with sarcoidosis

A 51-year-old African-American man with underlying pulmonary, hepatic and splenic sarcoidosis, reported a 3-day history of headache, neck stiffness and photophobia. He was not using medication for chronic sarcoidosis. Physical examination was significant for nuchal rigidity. Lumbar puncture revealed marked eosinophilia in the cerebrospinal fluid, which, on further analysis, demonstrated a positive cryptococcal antigen. HIV antibody and PCR tests were negative. Bronchoscopy and fungal blood cultures were also negative. The patient was started on amphotericin B and flucytosine, with significant clinical improvement. He recovered well without any neurological sequelae and remained symptom-free at 2-week follow-up. Cryptococcal central nervous infections are uniformly fatal if left untreated. Prompt diagnosis and treatment is essential, to prevent the associated high morbidity and mortality.

Corticosteroids for parasitic eosinophilic meningitis

BACKGROUND

Angiostrongylus cantonensis (A. cantonensis) is the major cause of infectious eosinophilic meningitis. Dead larvae of this parasite cause inflammation and exacerbate symptoms of meningitis. Corticosteroids are drugs used to reduce the inflammation caused by this parasite.

OBJECTIVES

To assess the efficacy and safety of corticosteroids for the treatment of eosinophilic meningitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 11), MEDLINE (1950 to November Week 3, 2014), EMBASE (1974 to December 2014), Scopus (1960 to December 2014), Web of Science (1955 to December 2014), LILACS (1982 to December 2014) and CINAHL (1981 to December 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of corticosteroids versus placebo for eosinophilic meningitis.

DATA COLLECTION AND ANALYSIS

Two review authors (SiT, SaT) independently collected and extracted study data. We graded the methodological quality of the RCTs. We identified and analysed outcomes and adverse effects.

MAIN RESULTS

We did not identifiy any new trials for inclusion or exclusion in this 2014 update. One study involving 110 participants (55 participants in each group) met our inclusion criteria. The corticosteroid (prednisolone) showed a benefit in shortening the median time to resolution of headaches (five days in the treatment group versus 13 days in the control group, P value < 0.0001). Corticosteroids were also associated with smaller numbers of participants who still had headaches after a two-week course of treatment (9.1% versus 45.5%, P value < 0.0001). The number of patients who needed repeat lumbar puncture was also smaller in the treatment group (12.7% versus 40%, P value = 0.002). There was a reduction in the median time of analgesic use in participants receiving corticosteroids (10.5 versus 25.0, P value = 0.038). There were no reported adverse effects from prednisolone in the treatment group.

AUTHORS' CONCLUSIONS

Corticosteroids significantly help relieve headache in patients with eosinophilic meningitis, who have a pain score of four or more on a visual analogue scale. However, there is only one RCT supporting this benefit and this trial did not clearly mention allocation concealment and stratification. Therefore, we agreed to grade our included study as a moderate quality trial. Future well-designed RCTs are necessary.

A rare case of Ibuprofen-induced eosinophilic meningitis in a 13-year-old girl

Eosinophilic meningoencephalitis is based on clinical manifestations and microscopic identification of eosinophils present in cerebrospinal fluid (CSF). It is caused by a variety of helminthic infections with most common being angiostrongyliasis, gnathostomiasis, toxocariasis, cysticercosis, schistosomiasis, baylisascariasis, and paragonimiasis. Many case reports are there in which parasites have been found responsible, but there are rare reports of CSF eosinophilia associated with the use of drugs. We report a case of drug-induced (ibuprofen) eosinophilic meningitis in a healthy female who presented to us with severe headache and improved dramatically after drug withdrawal.

Eosinophilic Meningitis Secondary to Intravenous Vancomycin

Eosinophilic meningitis may be due to infectious or noninfectious etiologies. Parasitic infections cause this entity most frequently and of the noninfectious causes, medications play an important role. We describe a 32-year-old male who developed eosinophilic meningitis while receiving intravenous vancomycin. No other apparent cause of the eosinophilic meningitis was appreciated. This case represents the first description of eosinophilic meningitis due to systemic vancomycin.

Recurrent case of ibuprofen-induced aseptic meningitis in mixed connective tissue disease

Although relatively uncommon, the incidence of non-steroidal anti-inflammatory drug-induced aseptic meningitis appears to be increasing among patients with connective tissue disease and also among the healthy population. Ibuprofen is the most common culprit identified. We report a case of a 28-year-old woman with mixed connective tissue disease and recent intake of ibuprofen, presenting with a recurrent episode of ibuprofen-induced aseptic meningitis.

Corticosteroids for parasitic eosinophilic meningitis

BACKGROUND

Angiostrongylus cantonensis (A. cantonensis) is the major cause of infectious eosinophilic meningitis. Dead larvae of this parasite cause inflammation and exacerbate symptoms of meningitis. Corticosteroids are drugs used to reduce inflammation caused by this parasite.

OBJECTIVES

To examine the effects and adverse events of corticosteroids in patients with eosinophilic meningitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6), MEDLINE (1950 to July Week 4, 2012), EMBASE (1974 to July 2012), Scopus (1960 to July 2012), Web of Science (1955 to July 2012), LILACS (1982 to July 2012), and CINAHL (1981 to July 2012).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of corticosteroids versus placebo for eosinophilic meningitis.

DATA COLLECTION AND ANALYSIS

Two review authors (SiT, SaT) independently collected and extracted study data. We graded the methodological quality of the RCTs. We identified and analyzed outcomes and adverse effects.

MAIN RESULTS

One study involving 110 participants (55 participants in each group) met our inclusion criteria. The corticosteroid (prednisolone) showed a benefit in shortening the median time to resolution of headaches (five days in the treatment group versus 13 days in the control group, P < 0.0001). Corticosteroids were also associated with smaller numbers of participants who still had headaches after a two-week course of treatment (9.1% versus 45.5%, P < 0.0001). There was a reduction in median time of analgesics use in participants receiving corticosteroids (10.5 versus 25.0, P = 0.038). There were no reported adverse effects from prednisolone in the treatment group.

AUTHORS' CONCLUSIONS

Corticosteroids significantly help relieve headache in patients with eosinophilic meningitis. However, there is only one RCT supporting this benefit and this trial did not clearly mention allocation concealment and stratification. Future well-designed RCTs may be necessary.

Update on eosinophilic meningoencephalitis and its clinical relevance

Eosinophilic meningoencephalitis is caused by a variety of helminthic infections. These worm-specific infections are named after the causative worm genera, the most common being angiostrongyliasis, gnathostomiasis, toxocariasis, cysticercosis, schistosomiasis, baylisascariasis, and paragonimiasis. Worm parasites enter an organism through ingestion of contaminated water or an intermediate host and can eventually affect the central nervous system (CNS). These infections are potentially serious events leading to sequelae or death, and diagnosis depends on currently limited molecular methods. Identification of parasites in fluids and tissues is rarely possible, while images and clinical examinations do not lead to a definitive diagnosis. Treatment usually requires the concomitant administration of corticoids and anthelminthic drugs, yet new compounds and their extensive and detailed clinical evaluation are much needed. Eosinophilia in fluids may be detected in other infectious and noninfectious conditions, such as neoplastic disease, drug use, and prosthesis reactions. Thus, distinctive identification of eosinophils in fluids is a necessary component in the etiologic diagnosis of CNS infections.

Eosinophilic meningoencephalitis: psychiatric presentation and treatment

Eosinophilic meningoencephalitis (EM) is usually a self-limited neurological illness commonly accompanied by a variety of neurological symptoms. The presence of acute psychotic symptoms in EM, however, has not previously been reported, and there is no literature to guide its treatment and management. In this case report, the onset of psychotic symptoms in a hypoactive delirium and their significant improvement following the administration of atypical antipsychotics are described in a boy with EM. This case report demonstrates the efficacy and safety of antipsychotic agents during the acute phase of meningoencephalitis.

Characteristics of meningitis caused by Ibuprofen: report of 2 cases with recurrent episodes and review of the literature

Ibuprofen is a common nonsteroidal antiinflammatory drug that is the most frequent cause of aseptic meningitis induced by drugs. The incidence of this type of aseptic meningitis is increasing, mainly among patients with underlying autoimmune connective tissue disorder, but also among healthy people. We report 2 patients with recurrent meningitis caused by ibuprofen mimicking bacterial meningitis: the first patient a woman with dermatomyositis and the second patient a previously healthy woman who developed autoimmune thyroiditis a few months later. We then review 71 episodes of ibuprofen-related meningitis in 36 patients reported in the literature. Twenty-two patients (61%) presented with an autoimmune connective tissue disorder, mainly systemic lupus erythematosus, and 22 (61%) had recurrent episodes. Most episodes consisted of an acute meningeal syndrome with a predominance of neutrophils in cerebrospinal fluid (CSF) in 72.2% of episodes and elevated protein in the CSF, so the clinical presentation of this type of aseptic meningitis may be quite similar to that of acute bacterial meningitis. CSF glucose levels are usually normal, which may help to differentiate between these 2 types of meningitis. In some cases the clinical presentation is that of meningoencephalitis with neurologic focal deficits. Although based on the close relation between the administration of ibuprofen and the onset of symptoms, especially if previous episodes have occurred, the diagnosis of ibuprofen-induced aseptic meningitis is a diagnosis by exclusion. If the clinical picture is compatible with bacterial meningitis, empirical antibiotic therapy must be administered until negativity of cultures and other microbiologic tests is determined. Rechallenge to ibuprofen reproduces the symptoms and confirms the diagnosis, but is usually not advised. Whatever the clinical presentation, physicians must consider the possibility of ibuprofen-related meningitis or meningoencephalitis in patients taking ibuprofen, especially if they are suffering from an autoimmune connective tissue disorder. On the other hand, we think it would be appropriate to screen for autoimmune disease in previously healthy patients diagnosed with ibuprofen-related meningitis or meningoencephalitis. Finally, we propose that meningitis due to ibuprofen be included in the list of causes of recurrent aseptic meningitis.

Ibuprofen-Associated Aseptic Meningitis

Aseptic meningitis is a rare condition associated with ibuprofen use. It is a diagnosis of exclusion and should be considered only after all infectious and most well-known noninfectious causes have been ruled out. The mechanism of ibuprofen-induced aseptic meningitis is not fully understood; however, most believe it is caused by a hypersensitivity-related reaction. Common symptoms of aseptic meningitis include headache, fever, nuchal rigidity, and confusion. Cerebral spinal fluid analysis generally reveals pleocytosis (the predominant white blood cell varies), with high protein concentrations and normal to low glucose concentrations. Autoimmune diseases and connective tissue diseases may predispose an individual to this condition. It is treated solely by withdrawal of the medication, although supportive treatment is often necessary. It is important that health care practitioners recognize this condition so that they are able to treat and prevent recurrence through patient education.

Three-dimensional stereotactic surface projection study of freezing of gait and brain perfusion image in Parkinson's disease

Gait disturbance is a cardinal symptom in patients with Parkinson's disease. Among the gait disturbances, freezing of gait is a unique and troublesome symptom, but its mechanism is unclear. We compared brain perfusion images using three-dimensional stereotactic surface projection analysis of N-isopropyl-p-123I iodoamphetamine single photon emission computed tomography between Parkinson's disease patients with freezing of gait and those without. Twenty-four cases (freezing of gait group) with Parkinson's disease with freezing of gait, and 31 Hoehn and Yahr stage-matched cases (no freezing of gait group) with Parkinson's disease without freezing of gait were studied. Bilateral Brodmann area 11 perfusion of the freezing of gait group decreased significantly compared to that of the no freezing of gait group. The Brodmann area 11 may play important roles in gait, and impairment in this region may have a close relationship with freezing of gait in Parkinson's disease.

Cerebrospinal fluid catecholamine levels in Japanese encephalitis patients with movement disorders

Norepinephrine and dopamine have important role in movement disorders but their role in movement disorders associated with Japanese encephalitis (JE) has not been evaluated. Therefore, in the present study, cerebrospinal fluid (CSF) catecholamine levels and its metabolites in JE patients with movement disorders were compared with those without JE. CSF was collected by lumbar puncture and analyzed by HPLC-ED. Norepinephrine, dopamine and homovanillic acid concentrations were significantly (P<0.005) lower in JE patients compared to control groups. Low levels of catecholamines in JE associated movement disorders compared to idiopathic Parkinson's disease and other extrapyramidal symptoms may be due to severe structural damage to thalamus, basal ganglia and brainstem in JE patients as revealed by MRI findings.

Drug-induced aseptic meningitis

Drug-induced aseptic meningitis (DIAM) is an important entity. This article reviews the literature on this rare idiosyncratic event which may occur after local or systemic drug administration. The data on this adverse reaction is predominantly collated from anecdotal case reports and case series.

Eosinophilic meningitis

Eosinophilic meningitis is a rare clinical entity that can be useful in narrowing the differential diagnosis of central nervous system disease. It is defined by the presence of 10 or more eosinophils/microL in the cerebrospinal fluid (CSF) or a CSF eosinophilia of at least 10%. The most common cause is invasion of the central nervous system by helminthic parasites, particularly Angiostrongylus cantonensis, but other infections as well as noninfectious conditions may also be associated. This review describes the etiologies of eosinophilic meningitis, focusing primarily on the helminths that cause CSF eosinophilia.

Drug-induced aseptic meningitis: diagnosis and management

Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. It is a diagnosis of exclusion, and clinical signs and CSF findings vary greatly. The body of evidence regarding DIAM is largely in the form of anecdotal case reports and must be interpreted carefully bearing this in mind. The major categories of causative agents are nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulin, intrathecal agents, vaccines and a number of other less frequently reported agents. There appears to be an association between DIAM and connective tissue disease, particularly systemic lupus erythematosus, and ibuprofen. There are 2 major proposed mechanisms for DIAM. The first involves direct irritation of the meninges by intrathecal administration of the drug, and the second involves immunological hypersensitivity to the drug, most likely type III and type IV hypersensitivity. Recognition and diagnosis of DIAM is important, as it is treatable by withdrawal of the drug and recurrence is prevented. The outcome of DIAM is generally good, usually without long term sequelae. This article describes the case reports of DIAM in the current literature and discusses the diagnosis and management of this rare complication.

Angiostrongylus cantonensis eosinophilic meningitis

In the past 50 years, Angiostrongylus cantonensis, the most common cause of eosinophilic meningitis, has spread from Southeast Asia to the South Pacific, Africa, India, the Caribbean, and recently, to Australia and North America, mainly carried by cargo ship rats. Humans are accidental, "dead-end" hosts infected by eating larvae from snails, slugs, or contaminated, uncooked vegetables. These larvae migrate to the brain, spinal cord, and nerve roots, causing eosinophilia in both spinal fluid and peripheral blood. Infected patients present with severe headache, vomiting, paresthesias, weakness, and occasionally visual disturbances and extraocular muscular paralysis. Most patients have a full recovery; however, heavy infections can lead to chronic, disabling disease and even death. There is no proven treatment for this disease. In the authors' experience, corticosteroids have been helpful in severe cases to relieve intracranial pressure as well as neurologic symptoms due to inflammatory responses to migrating and eventually dying worms.

Meningeal metastases: clinical aspects and diagnosis

The authors review the clinical and diagnostic aspects involved in leptomeningeal disease due to solid tumours, leukaemias and lymphomas. The importance of the combination of clinical findings with cerebral spinal fluid (CSF) examination and imaging studies in making an early diagnosis is underlined. The raising prevalence of this complication of systemic cancer deserves specific attention on the part of neurologists involved in consultation liason with general medicine and oncology.

Idiopathic eosinophilic meningoencephalitis in rottweiler dogs: three cases (1992-1997)

We report three cases of eosinophilic meningitis in young male Rottweiler type dogs in New Zealand. No cause for the disease was identified. There were variable clinical signs referable to central nervous system dysfunction, and a variable response to treatment.

Central nervous system Hodgkin's disease relapsing with eosinophilic pleocytosis

Hodgkin's disease affecting the central nervous system is infrequent. Multiple lumbar punctures are sometimes required for cytological diagnosis. In this case fluoroscopy-guided cisternal puncture and routine lumbar punctures were used to obtain cerebrospinal fluid (CSF) samples for cytological analysis. Reed-Sternberg cells were observed on the CSF sample obtained through the cisternal puncture while none were seen in the samples obtained with routine lumbar punctures. Without cytology, the diagnosis of meningeal carcinomatosis remains elusive. In conclusion, cisternal punctures should be entertained early in the evaluation for meningeal carcinomatosis, particularly if lumbar punctures have been unsuccessful.

Drug- and chemical-induced aseptic meningitis: a review of the literature

OBJECTIVE

The primary objective of this article is to provide readers with case reports of drug- or chemical-induced aseptic meningitis (DCAM) described in the medical literature. Background information regarding the classification of DCAM, incidence, proposed mechanisms, associated risk factors, clinical management, and sequelae is presented.

DATA SOURCES

A MEDLINE search was used to identify pertinent background literature and case reports of DCAM.

DATA EXTRACTION

All case reports of DCAM involve anecdotal information. A critical analysis of a causal relationship to the implicated drug or chemical and the appearance of meningeal involvement is presented. Animal data are included when pertinent.

DATA SYNTHESIS

DCAM is a rare adverse event associated with numerous agents. Patients present with a variety of clinical signs and symptoms and laboratory findings of cerebral spinal fluid, when obtained, vary greatly. Most patients fully recover without sequelae.

CONCLUSIONS

Numerous drugs and chemicals have been implicated in the medical literature as producing DCAM. Two proposed mechanisms of DCAM have been theorized: a delayed hypersensitivity-type reaction and direct meningeal irritation. The nonsteroidal antiinflammatory drugs, certain antibiotics, radiographic agents, and muromonab-CD3 have been most frequently implicated. There appears to be an association between the occurrence of the hypersensitivity-type reactions and underlying collagen vascular or rheumatologic disease.

Drug-induced aseptic meningitis. Diagnosis leads to quick resolution

Drug-induced aseptic meningitis is a syndrome that should be considered in the differential diagnosis of acute and recurrent aseptic meningitis. It has been observed in all age-groups and can occur following the use of a wide spectrum of pharmaceutical agents. Presumptive diagnosis is made by demonstrating the resolution of symptoms after drug withdrawal, and definitive diagnosis is made by conducting a drug rechallenge. Fortunately, the syndrome is usually benign and resolves quickly following drug cessation.

Ibuprofen-associated meningitis in a woman with only serologic evidence of a rheumatologic disorder

A case of ibuprofen-associated meningitis is reported in a previously healthy 26-year-old woman. The association was substantiated with a rechallenge. She had no symptoms of rheumatoid factor and a positive antibody to the intranuclear antigen SS-A.

Neoplastic meningitis with eosinophilic pleocytosis in Hodgkin's disease: a case with cerebellar dysfunction and a review of the literature

A 31-year-old man had Hodgkin's disease (stage IIA, nodular sclerosis) in apparent remission after radiotherapy. Nine months after the diagnosis of Hodgkin's disease, he developed neoplastic meningitis with eosinophilic pleocytosis and neurologic findings suggestive of peri-fourth ventricle infiltration. Morphologic and surface marker analysis of cerebrospinal fluid cells showed large numbers of T-lymphocytes and Reed-Sternberg variant cells positive for CD15, the Lex hapten expressed on myeloid cells and on a variety of malignant cells. Therapy with intrathecal methotrexate, oral dexamethasone, and cranial irradiation resulted in prompt resolution of his cerebrospinal fluid abnormalities and neurologic deficits. Ten months after the diagnosis of eosinophilic meningitis, systemic relapse of Hodgkin's disease occurred in right iliac and inguinal lymph nodes. The diagnosis, pathogenesis, and therapy of this unusual complication of Hodgkin's disease are reviewed.

Severe systemic hypersensitivity reaction to ibuprofen occurring after prolonged therapy

A 23-year-old woman with systemic lupus erythematosus had a severe hypersensitivity reaction to the drug ibuprofen. The reaction, documented by rechallenge during hospitalization, was characterized by marked hypotension, fever, rigors, conjunctivitis, meningitis, nausea, arthralgias, and leukopenia. In addition to illustrating the potential diagnostic confusion with infection or lupus flare, this case is of interest in that the reaction developed suddenly despite the patient's uneventful use of the drug for over two years. Collected cases are reviewed from the literature, and the common features are summarized.

[Fatal eosinophilic meningoencephalitis following lacquer poisoning. Case report and differential diagnostic considerations]

The authors report about a 43-year-old male patient, who suffered from an acute toxic brain injury. Twelve days prior to death, after sealing his floor, he experienced progressively increasing headache without fever; the CSF examination disclosed marked eosinophilia. The clinical and pathomorphological features of his illness are discussed and together with the various possible etiologies of eosinophilia in the CSF.