![]() Once bacteria invades the meninges and disrupts the blood-brain barrier, it rapidly replicates in the subarachnoid space ( van de Beek et al., 2016a). ![]() Presentation clinically varies according to the age of the patient, the causative agents, and the presence of underlying conditions ( Hasbun et al., 2018). The presentation of meningitis can be classified as acute (symptoms for less than 5 days), subacute (symptoms 6-30 days), or chronic (symptoms for more than 30 days) ( Sulaiman et al., 2017). Patients typically have abnormalities in the cerebrospinal fluid (CSF) such as elevated white blood cells (WBC), elevated protein (due to alterations in the blood brain barrier), and low glucose in some cases. Meningitis can be caused by bacteria, viruses, fungus, amebic, parasites, mycobacteria or due to noninfectious causes. Meningitis is characterized by inflammation of the subarachnoid space (space between two membranes (i.e., meninges) that surrounds the brain and spinal cord). Pathophysiology for Use of Adjunctive Steroids in Meningitis In this review, we will review the available data for the use of adjunctive steroids in the most common CNS infections and make clear recommendations for its use or not. In contrast, in some CNS infections, the use of steroids has no clear beneficial effects or is detrimental with worse outcomes ( Fitch and van de Beek, 2008). Adjunctive steroids can ameliorate the host’s inflammatory response to the infection that account for the neurological morbidity associated with the CNS infection. Of all the adjunctive therapies that have been evaluated to date only adjunctive steroids have shown benefit in some CNS infections. Despite the use of antimicrobial therapies neurological morbidity and mortality remains high for certain pathogens such as Streptococcus pneumoniae ( Steel et al., 2013). Precision in diagnosis, however, is essential to treatment, which varies across CNS infection. Various bacteria, fungi, viruses, and parasites can be the source of CNS infection, which often presents nonspecifically with headache, fever, altered mental status, and behavioral changes ( Dorsett and Liang, 2016). CNS infections can either originate by hematogenous spread (e.g., bacteremia, viremia), by retrograde neuronal invasion (e.g., viral infection through axonal transport such as rabies, Naegleria fowleri) or by contiguous spread of microorganisms (e.g., post cranial trauma or surgery, implementation of medical hardware into the brain or spine, or by parameningeal spread from a focus such as sinusitis or mastoiditis) ( Archibald and Quisling, 2013 Koyuncu et al., 2013). CNS infection broadly can be categorized as encephalitis, meningitis, or intracranial suppurative complications (e.g., brain abscess), with a broad range of causal organisms and clinical presentations. We highlight areas of consistent and proven findings and those which need more evidence for supported beneficial clinical use of adjunctive steroid therapy.Ĭentral nervous system (CNS) infections involve the brain, spine, and associated membranes, and are linked to significant neurological morbidity and mortality, with long term consequences in survivors that affect the quality of life and activity of daily living (ADLS) ( Erdem et al., 2017 Sulaiman et al., 2017). We describe that while steroid therapy is beneficial and supported in pathogens such as pneumococcal meningitis and tuberculosis, for other diseases, like Listeria monocytogenes and Cryptococcus neoformans they are associated with worse outcomes. We summarize the existing literature on the effects of adjunctive steroid therapy on outcome for a number of CNS infections, including bacterial meningitis, herpes simplex virus, West Nile virus, tuberculosis meningitis, cryptococcal meningitis, Angiostrongylus cantonensis, neurocysticercosis, autoimmune encephalitis, toxoplasmosis, and bacterial brain abscess. The data on benefits or harms of adjunctive steroid therapy is not consistent in outcome or density through CNS infections, and varies based on the disease diagnosis and pathogen. Steroid therapy can potentially improve clinical outcomes including reducing mortality rates, provide no significant benefit, or cause worsened outcomes, based on the causative agent of infection. Adjunctive steroid therapy has been employed clinically to reduce inflammation in the treatment of CNS infections across various causative pathogens. 2Department of Internal Medicine, UT Health McGovern Medical School, Houston, TX, United StatesĬentral nervous system (CNS) infections continue to be associated with significant neurological morbidity and mortality despite various existing therapies.1Cornell University, Ithaca, NY, United States.Shalini Gundamraj 1 and Rodrigo Hasbun 2*
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