Reactions 1680, p232 - 2 Dec 2017 Granulomatous meningitis: case report A 48-year-old man developed granulomatous meningitis during treatment with microfibrillar collagen haemostat [Avitene; dosage, route and time to reaction onset not stated]. The man was diagnosed with a sphenoid and cavernous- based WHO grade II meningioma. Two months prior to presentation, he underwent an uncomplicated debulking of his tumour. Three weeks prior to his presentation, he experienced a rapidly progressive fever, tremulousness, confusion and hiccups. A brain MRI revealed a superficial pial enhancement both near and remote from the operative site and temporal lobe oedema. A CSF evaluation revealed increased opening pressure with elevated protein and mixed monocytic/ lymphocytic pleocytosis. Out of concern for an infectious process, the man was started on broad-spectrum antibiotics and antivirals initially. Three days later, a repeat CSF evaluation was performed, which revealed a worsening CSF profile. Seven days after the initial CSF sample was collected, the consequent CSF samples continued to demonstrate mixed monocytic/lymphocytic pleocytosis and elevated protein. Cultures did not identify any organisms. A continuous EEG ruled out ongoing seizure. Following ineffective treatment with broad spectrum antibiotics and eventual ventricular shunting, he underwent a wound exploration procedure. The brain appeared to be inflamed without gross purulence on a gross inspection. Temporal lobe and meningeal biopsies revealed chronic inflammation with abundant amorphous eosinophilic material. A granulomatous-type reaction was noted encompassing the acellular material with palisading macrophages and foreign body giant cells. Additionally, a significant eosinophilic inflammatory infiltrate was present, which was suggestive of an allergic-type response to the microfibrillar collagen haemostat. Considering an inflammatory rather than an infectious process, the man started receiving treatment with IV corticosteroids. A significant initial improvement was noted in his mental status. But his subsequent clinical course fluctuated due to other complications. Repeat CSF analyses four days and 17 days following corticosteroid administration revealed resolution of the CSF pleocytosis. The radiographic findings of meningeal enhancement near and far from the operation site, his systemic symptomatology and an abnormal CSF, favoured a diffuse meningeal reaction. Author comment: "We report a case of Avitene-induced granulomatous inflammation presenting as meningitis after neurosurgery for WHO grade II atypical meningioma." "Granulomatous meningitis secondary to Avitene [microfibrillar collagen haemostat]." "Rarely, intracranial Avitene may provoke an inflammatory reaction leading to granulomatous meningitis." Renati S, et al. Granulomatous meningitis secondary to Avitene (microfibrillar collagen). Neurology: Clinical Practice 7: 384-386, No. 5, Oct 2017. Available from: URL: http://doi.org/10.1212/CPJ.0000000000000305 - USA 803284864 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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