AGENTS OF ASEPTIC

MENINGITIS (BACTERIAL
AND FUNGAL)

Dr Pooja Pandey
Senior Resident
Department of Microbiology
ESIC Faridabad
 Aseptic meningitis: Infectious etiology is unidentified
(aseptic meaning lack of infection)

 Include agents other than acute bacterial meningitis;

such as the agents of acute viral meningitis and chronic
meningitis
CAUSES OF ASEPTIC MENINGITIS (BACTERIAL)

Mycobacterium tuberculosis

Borrelia burgdorferi (Lyme disease)

Treponema pallidum (tertiary syphilis)

Rare bacterial agents - Nocardia, Actinomyces,

Leptospira and Brucella
CAUSES OF ASEPTIC MENINGITIS (FUNGAL)

1. Cryptococcus neoformans

2. Candida albicans

3. Blastomyces dermatitidis

4. Histoplasma capsulatum

5. Coccidioides immitis

6. Aspergillus species

7. Sporothrix schenckii

8. Pseudallescheria boydii

9. Cladophialophora bantiana
TUBERCULOUS
MENINGITIS (TBM)
● TBM results from the hematogenous spread of
primary or post-primary pulmonary TB

● Disease evolves over 1–2 weeks or longer

 CLINICAL FEATURES

● Headache, slight mental changes, low-grade fever,

malaise, night sweat, anorexia, and irritability

● Evolve acutely with severe headache, confusion,

lethargy, altered sensorium, and neck rigidity

● Cranial nerves paresis (ocular nerves in particular) -

frequent finding
● Stroke - due to involvement of cerebral arteritis

● Ultimately - progresses towards coma, with

hydrocephalus and intracranial hypertension
LABORATORY DIAGNOSIS

● Culture of CSF - Gold standard test

Time consuming,

takes 4–8 weeks by Lowenstein-Jensen

medium and

2-3 weeks by automated liquid culture -

Mycobacteria Growth Indicator Tube (MGIT)
● GeneXpert assay: Automated real-time PCR,
sensitivity of up to 80%

● Imaging studies (CT and MRI) – hydrocephalus

and abnormal enhancement of basal cisterns
 TREATMENT OF TUBERCULOUS MENINGITIS

● Treatment - initiated immediately upon a positive GeneXpert MTB/RIF

result

● Negative result does not exclude a diagnosis of TB and requires further

diagnostic workup

● Responds well to anti-tubercular therapy, if started early

● Adjunctive glucocorticoids - used to reduce the CSF pressure, resulting

in faster resolution
NEUROBORRELIOSIS
(LYME DISEASE)
● Lyme disease - caused by Borrelia
burgdorferi, transmitted by tick bite

● Cutaneous lesions and arthritis; CNS

infections

● Manifestations: Meningitis, subtle

encephalitic signs, cranial neuritis
(including bilateral facial palsy), and
radiculoneuropathy
● CSF findings - elevated lymphocytes (~100 cells/ μL),
elevated protein levels and normal or slightly low glucose level

● Meningopolyneuritis: Radicular pain with CSF pleocytosis,

without meningeal or encephalitic signs - called as
Bannwarth’s syndrome

● Resolve completely within a month, but rarely chronic

neurologic disease may occur later
● Treatment: IV ceftriaxone for 14–28 days

● Alternatively IV cefotaxime or IV penicillin G can be

given
 QUESTION

A 12-year-old boy, after a camping trip near a wooded area

in Shimla, is taken to the emergency room after complaining
of a headache. He has an erythema migrans rash around
what appears to be a tick bite.

What is the likely diagnosis?

NEUROSYPHILIS
(TREPONEMA
PALLIDUM)
● Neurosyphilis - tertiary form of syphilis - develops in
about 10% of untreated patients

● Sexually transmitted disease

● Invasion of CNS - early within first few weeks of

infection, followed by years of asymptomatic period
CLINICAL MANIFESTATIONS
● Asymptomatic neurosyphilis

● Meningeal syphilis

● Meningovascular syphilis

● General paresis of insane

● Tabes dorsalis
 LABORATORY DIAGNOSIS
● CSF analysis: Increased lymphocytes (>5/μL), and increased
protein level (>45 mg/dL)

● CSF VDRL test: Nontreponemal test, detects antibodies against

cardiolipin antigen derived from bovine heart

● FTA-ABS test (fluorescent treponemal antibody absorption)

● PCR-based tests
 TREATMENT OF NEUROSYPHILIS
● Aqueous crystalline or procaine penicillin G is given for 10–
14 days

● Re-treatment if non-treponemal titres in CSF do not

decrease by four-folds within 2 years of completion of
treatment

● Patients with penicillin allergy, desensitization to penicillin

has to be done, following which penicillin is administered
 QUESTION:

Q. A 45 year old HIV positive male presents to the emergency

department with altered mental status, fever, headache, and
blurred vision. A lumbar puncture is performed and he is found to
have a high opening pressure but only 7 WBC’s. Fungal cultures
yield a wet and mucoid colony on Sabouraud Agar. A wet prep is
performed and yields a perfectly round organism that is between
5 and 8 micrometers in diameter.

What biochemical would you do next to confirm the identity of this

organism?
CRYPTOCOCCAL
MENINGITIS
● Cryptococcal meningitis is caused by a capsulated
yeast called Cryptococcus neoformans - capable of
producing potentially fatal meningitis in HIV
infected people
 SPECIES AND SEROTYPES

● Two species: C.neoformans and C. gattii and four

serotypes A, B, C and D

● Two varieties—C. neoformans var. grubii and C.

neoformans var. Neoformans

● C. gattii is antigenically diverse and corresponds to the

serotypes B and C
PATHOGENESIS
● Infection is acquired by inhalation of aerosolized
forms of Cryptococcus

● Immunocompetent individuals - defense

mechanisms limit the infection

● Low immunity - pulmonary infection - dissemination

through blood

● CNS spread: Cross blood-brain barrier - migrate

directly across the endothelium or carried inside the
macrophages as “Trojan horse”
Virulence factors:

● Polysaccharide capsule

● Antiphagocytic and also inhibits the host’s local immune

responses

● Ability to make melanin by enzyme phenyloxidase

● Other enzymes – Phospholipase and urease

Risk factors :

● Patients with advanced HIV infection with CD4 T cell counts less
than 200/μL

● Patients with hematologic malignancies

● Transplant recipients

● Patients on immunosuppressive or steroid therapy

CLINICAL MANIFESTATIONS

● Pulmonary cryptococcosis: First and the most common presentation

● Cryptococcal meningitis: Chronic meningitis, with headache, fever,

sensory and memory loss, cranial nerve paresis and loss of vision (due
to optic nerve involvement)

● Skin lesions

● Osteolytic bone lesions

 EPIDEMIOLOGY
● Geographical distribution: C. neoformans var. grubii (serotype A)
strains are found worldwide

● C. neoformans var. neoformans (serotype D) strains are restricted

to Europe

● C. gattii is confined to tropics

● Habitat: C. neoformans – soils contaminated with avian

excreta and pigeon droppings
LABORATORY DIAGNOSIS

● Specimens - CSF, blood or skin scrapings

DIRECT DETECTION METHODS
● Negative staining: Modified
India ink stain and nigrosin
stain - demonstrate the
capsule

● Gram staining - Gram-

positive round budding yeast
cells
Other stains:

● Mucicarmine stain: Stains the carminophilic cell wall of

C. neoformans
● Masson-Fontana stain: Demonstrates the
production of melanin

● Alcian blue stain to demonstrate the capsule

● Capsular Antigen detection: from CSF or serum

by latex agglutination test
CULTURE

● SDA without antibiotics, blood agar or

chocolate agar and incubated at 37°C

● Blood inoculated in biphasic blood culture

bottles

● Colonies - Mucoid creamy white and yeast

like
Confirmation of Cryptococcus species:

● Niger seed agar and bird seed agar

● Growth at 37°C

● Urease test is positive

● Assimilation of inositol and nitrate

● Mouse pathogenicity test

QUESTION:
Q. A 45 year old HIV positive male presents to the emergency
department with altered mental status, fever, headache, and
blurred vision. A lumbar puncture is performed and he is found to
have a high opening pressure but only 7 WBC’s. Fungal cultures
yield a wet and mucoid colony on Sabouraud Agar. A wet prep is
performed and yields a perfectly round organism that is
between 5 and 8 micrometers in diameter.

What biochemical would you do next to confirm the identity of this

organism?
PARASITIC ENCEPHALITIS

 Acanthoemeba species
 Naegleria fowleri
 Balamuthia mandrillaris
 Baylisascaris procyonis
 Toxocara canis and Toxocara cati
 Angiostrongylus cantonensis
 Taenia solium
 Schistosoma japonicum
FREE LIVING AMOEBAE

 Small, freely living, widely distributed in soil and water and

can cause opportunistic infections in humans.
 Naegleria fowleri : primary amoebic meningoencephalitis
(PAM).
 Acanthamoeba species: granulomatous amoebic encephalitis
(GAE) and amoebic keratitis in contact lens wearers.
FREE LIVING AMOEBAE: FORMS
 Naegleria is a free-living
amoeba, typically found in
warm fresh water, such as
ponds, lakes, rivers and
swimming pools.
 Exists in nature as cyst and
trophozoite forms
LIFE CYCLE AND PATHOGENICITY
PRIMARY AMOEBIC MENINGOENCEPHALITIS: CLINICAL
FEATURES

 Incubation period: 1-2 days to 2 weeks after exposure.

 Clinical course is acute and fulminant
 The initial symptoms include changes in the taste and
smell, headache, anorexia, nausea, vomiting, high fever.
 SIGNS & SYMPTOMS

 Kernigs sign: Positive

 Secondary symptoms include confusion, hallucinations,
lack of attention, ataxia, and seizures
 The mortality rate is nearly 98%. Death occurs within 7-
14 days after exposure.
LABORATORY DIAGNOSIS

 CSF analysis:
a) Purulent
b) pus cells >20,000/μL
c) elevated protein
d) reduced sugar level
e) Microscopy :Reveals
trophozoites in CSF
STAINING
Histopathology:
 Hematoxylin and eosin

 Giemsa stain
CULTURE:

 Non-nutrient agar (Page’s

saline and 1.5% agar):(Trail
sign)
 Enflagellation test:-amoeboid
form undergoes
transformation to a pear
shaped flagellate form
OTHER TESTS
 Isoenzyme analysis
 Molecular methods
 Imaging methods
TREATMENT

 No effective treatment is available for PAM .

 Amphotericin B
 Other drugs like rifampicin, and antifungals like miconazole,fluconazole are
also found to be effective.
ACANTHAMOEBA

 Ubiquitous
 A. astronyxis, A. castellanii (type
species), A. culbertsoni and A.
polyphaga
 Acanthamoeba may harbor
bacterial pathogens such as
Legionella
LIFE CYCLE AND PATHOGENESIS
GRANULOMATOUS AMOEBIC ENCEPHALITIS
(GAE) : CLINICAL FEATURES

 Symptoms: Confusion, dizziness, nausea,

headache, stiff neck and some times seizure and
hemiplegia
 Epidemiology:
India, few cases were reported from Vellore,
Chandigarh, Puducherry, Hyderabad.
LABORATORY DIAGNOSIS

 CSF microscopy:
 Wet mount examination and
phase contrast microscopy
are performed.
STAINING
 PAS stain
 Calcofluor white
 Indirect fluorescent
antibody technique

a) PAS staining
b) Calcofluor white staining
CULTURE & OTHER METHODS
 Culture:
Inoculated onto non-nutrient agar with bacterial supplement, and
incubated at 30°C.
 Molecular methods
 Imaging method
TREATMENT

 Combination therapy - pentamidine, an azole, sulfonamide (e.g.

cotrimoxazole) and possibly flucytosine.
DIFFERENCES IN THE CHARACTERISTICS OF
NAEGLERIA AND ACANTHAMOEBA