Table 2

Differential diagnoses for meningitis associated with cranial neuropathy

DiagnosisClinical featuresConfirmatory tests
InfectiousViral
  • Varicella zoster virus

  • Enterovirus

  • Herpes simplex virus

Acute meningitisCSF Viral PCR
Fungal
  • Cryptococcus neoformans and Cryptococcus gatti

  • Histoplasma Capsulatum

  • Coccidioides immitis

  • Blastomyces dermatitidis

Subacute/chronic meningitis
Sinusitis, pulmonary involvement (±multiorgan)
Focal neurological deficits (CNS abscess, granuloma, cryptococcoma)
hydrocephalus
CSF India Ink Stain, Gram Stain, Periodic Acid Schiff Stain
CSF Fungal Culture
CSF Cryptococcal antigen
Mycobacterial
  • Mycobacterium tuberculosis

Subacute/chronic meningitis
Pulmonary involvement
Systemic symptoms (night sweats, loss of weight, lymphadenopathy)
Hydrocephalus
Focal neurological deficits (tuberculoma)
CSF Acid Fast Bacilli
CSF TB PCR
CSF TB culture
Spirochete
  • Treponema pallidum

  • Borrelia burgdorferi

Subacute/chronic meningitis
Tabes dorsalis
Neuropsychiatric
Fever, genital ulcers, lymphadenopathy
Multiorgan involvement
Fever, rash, myalgia
Carditis
Polyradiculitis
Serum TPPA, RPR.
CSF TPPA, VDRL.
CSF Treponema pallidum PCR.
Serum and CSF Borrelia-Specific IgM, IgG
AutoimmuneSarcoidosisSubacute/chronic meningitis
Anterior uveitis
Pulmonary (interstitial lung disease, hilar lymphadenopathy)
±multisystem involvement
Hypercalcaemia
Nil-specific CSF test
Raised CSF ACE supportive.
Non-necrotising granuloma on biopsy
Behcet’s diseaseSubacute/chronic meningitis
Neurological symptoms associated with systemic flare
Recurrent oral and genital ulceration
Pan uveitis, skin lesions, arthropathy
Nil specific.
Skin pathergy test supportive.
Systemic lupus erythematosusSubacute/chronic meningitis
Malar rash, photosensitivity
psychosis, seizures
arthritis, serositis (pericarditis, pleuritis)
Interstitial lung disease
Antiphospholipid syndrome lupus nephritis
ANA, dsDNA, anti-Sm, C3, C4 levels
MalignantLeptomeningeal carcinomatosisSubacute/chronic meningitis
Evidence of systemic malignancy
Breast, lung, gastrointestinal and melanoma more common
Malignant cells on CSF cytology.
LymphomaSubacute/chronic meningitis
Higher risk with high grade lymphomas, more extensive extranodal disease
Lymphadenopathy, hepatosplenomegaly
Lymphoma cells on CSF flow cytometry.
  • ANA, antinuclear antibody; CNS, central nervous system; CSF, cerebrospinal fluid; dsDNA, anti double stranded DNA antibodies; RPR, rapid plasma reagin; TB, Tuberculosis; TPPA, treponema pallidum particle agglutination assay; VDRL, venereal disease research laboratory test.