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Bacterial Meningitis


Presentation

The onset of symptoms in acute bacterial meningitis is abrupt. Initially, there is headache, vomiting and fever. Pain and stiffness then start developing in the neck and the back.

In severe cases, there is altered level of consciousness and the patient may have confusion, delirium, lethargy and coma. If the meningitis is uncomplicated, these neurological signs do not develop and there is not much deterioration of consciousness. Presence of neurological signs indicates complications such as cerebral edema and hydrocephalus.

The classic signs of meningitis upon physical examination include neck stiffness, Kernig’s sign and Brudzinski’s sign. Inflammation of the meninges causes reflex spasm of the paravertebral muscles which causes the neck stiffness seen in meningitis. In Kernig’s sign, the patient’s hip is flexed to ninety degrees and then the knee is extended. If the patient feels pain due to spasm of the hamstring muscles, meningitis is indicated. In Brudzinski’s sign, there is spontaneous flexion of the knee and hip when neck flexion is attempted.

Kernig’s and Brudzinski’s signs are positive in around 50% of the patients of meningitis [4] [5]. 50% of the patients with meningococcal meningitis may also have purpuric or petechial rashes principally on the extremities.

In the elderly, the classic signs of meningitis often do not appear and there is an insidious onset with lethargy, variable symptoms and no fever. In neonates, neck rigidity and/or fever are absent as well and the presenting features include irritability, restlessness and refusal to feed.

Fever
  • In the elderly, the classic signs of meningitis often do not appear and there is an insidious onset with lethargy, variable symptoms and no fever.[symptoma.com]
  • High MELD and Child-Pugh scores were related to the mortality risk (p CONCLUSIONS: Bacterial meningitis should be considered in cirrhotics presenting with fever and altered conscience status. MELD and Child-Pugh scores predicted prognosis.[ncbi.nlm.nih.gov]
High Fever
  • […] are symptoms to look for in children: Irritability Vomiting from a high fever Frequent crying Swelling of the head Lack of appetite Seizures (sometimes also seen in adults if the meningitis is advanced) Symptoms typically come on quickly, in as little[columbianeurology.org]
  • The most common symptoms of bacterial meningitis are: Painful, stiff neck with limited range of motion Headaches High fever Feeling confused or sleepy Bruising easily all over the body A rash on the skin Sensitivity to light These are symptoms to look[hopkinsmedicine.org]
  • Symptoms in newborns and infants may include: Inactivity Unexplained high fever or any form of temperature instability, including a low body temperature Irritability Vomiting Yellowing of the skin or eyes Feeding poorly or refusing to eat Tightness or[cancercarewny.com]
  • High fever. Nausea. Sensitivity to light. Confusion Headaches. Vomiting. More severe symptoms can include brain damage, hearing loss and death. Who is at risk? People of any age are at risk for bacterial meningitis.[denverpublichealth.org]
Chills
  • A 39-year-old man was admitted with fever, chills, headache and photophobia. Escherichia coli was isolated from cerebrospinal fluid culture.[ncbi.nlm.nih.gov]
  • Bacterial meningitis typically begins with headache, nausea and vomiting, stiff neck (nuchal rigidity), and chills and fever.[medical-dictionary.thefreedictionary.com]
  • Chills (due to venular constriction) b. Fever c. Malaise d. Headache (cephalgia) e. Myalgia 2. Increased intracranial pressure, manifestations of which are: a. Headache b. Vomiting c. Eye effects d. Papilledema (late) e.[atsu.edu]
  • Other symptoms may include chills, sweating, weakness, loss of appetite, or inability to tolerate bright light (photophobia).[rarediseases.org]
  • Symptoms usually come on quickly, and may include: Fever and chills, especially in newborns and children Mental status changes Nausea and vomiting Sensitivity to light Severe headache Stiff neck Other symptoms that can occur with this disease: Agitation[medlineplus.gov]
Malaise
  • Malaise d. Headache (cephalgia) e. Myalgia 2. Increased intracranial pressure, manifestations of which are: a. Headache b. Vomiting c. Eye effects d. Papilledema (late) e.[atsu.edu]
  • […] renal failure) immunosuppression (e.g. functional asplenia, splenectomy, hypogammaglobulinemia, complement deficiency, steroids, diabetes mellitus) malnutrition low socioeconomic status and overcrowding exposure to epidemic CLINICAL FEATURES History malaise[lifeinthefastlane.com]
  • It usually has a short uncomplicated course characterized by malaise, fever, headache, stiffness of neck and back, and nausea.[medical-dictionary.thefreedictionary.com]
Fatigue
  • Pregnant women with listeriosis typically experience only fever and other flu-like symptoms, such as fatigue and aches.[cdc.gov]
  • Symptoms may include: Headache Sensitivity to light ( photophobia ) Slight fever Upset stomach and diarrhea Fatigue Bacterial meningitis is an emergency. You will need immediate treatment in a hospital.[medlineplus.gov]
Vomiting
  • The patients experience fever, vomiting, headache, stiffness of the neck and diminishing of consciousness. Bacterial meningitis is fatal unless diagnosed and treated early with antibiotics.[symptoma.com]
  • A 52-year-old woman with a 6-month history of prednisolone treatment for suspected diagnosis of myositis presented 3 months after withdrawal of steroids with headache, nuchal rigidity, fever, nausea, and vomiting.[ncbi.nlm.nih.gov]
  • Symptoms include nausea, fever, stiff neck, vomiting and sensitivity to light. The CDC’s website says the illness is “very serious and can be deadly.” The bacteria is spread through airborne droplets.[sacbee.com]
Nausea
  • A 52-year-old woman with a 6-month history of prednisolone treatment for suspected diagnosis of myositis presented 3 months after withdrawal of steroids with headache, nuchal rigidity, fever, nausea, and vomiting.[ncbi.nlm.nih.gov]
  • Symptoms include nausea, fever, stiff neck, vomiting and sensitivity to light. The CDC’s website says the illness is “very serious and can be deadly.” The bacteria is spread through airborne droplets.[sacbee.com]
  • Symptoms can develop around two to 10 days after exposure to the affected person and can include, according to the city’s Department of Health: Confusion, sleepiness nausea and/or vomiting headache stiffness in neck, shoulder and/or back The university[wtop.com]
Tachycardia
  • Shock: signs of shock include tachycardia and/or hypotension, respiratory distress, altered mental state and poor urine output. Kernig's sign (pain and resistance on passive knee extension with hips fully flexed).[patient.info]
  • ., low CSF white blood cell count, tachycardia, positive blood cultures, abnormal neurologic examination, fever), alcoholism, and pneumococcal infection. 11 – 13, 16 Mortality is generally higher in pneumococcal meningitis (30%) than other types, especially[aafp.org]
Neck Pain
  • Any of the following may develop within hours or days: A severe headache, stiff neck, and a fever Neck pain Nausea or vomiting Red or purple rash Eye pain when your child looks into bright lights Sleepiness or confusion How is bacterial meningitis diagnosed[drugs.com]
Petechiae
  • From the first to the third day, at least one-third of patients with meningococcal meningitis develop petechiae, most prominently in areas subjected to pressure; for example, axillary folds and the belt line.[atsu.edu]
  • Most deaths occur within 24 hours of hospital admission in patients who have features associated with poor prognosis, such as the following: Hypotension Shock Neutropenia Extremes of age Petechiae and purpura of less than 12 hours’ duration Disseminated[emedicine.medscape.com]
Photophobia
  • The patient presented with back pain and urinary retention and this was followed by the development of headache, photophobia and a left VIth nerve palsy. The patient was not diabetic or immunocompromised.[ncbi.nlm.nih.gov]
  • Fever Severe headache Very stiff neck Vomiting Sensitivity to bright lights (Photophobia) Skin rash or purple patches Confusion and sleepiness Nausea Lethargy Seizures Symptoms can appear quickly, or over a period of days.[weber.edu]
  • Photophobia and a general hyperesthesia to all forms of stimuli are present. Venous congestion of the ocular fundi is common.[atsu.edu]
  • Stiff neck (generally not present in children under the age of one year or in patients with altered mental state), back rigidity, bulging fontanelle (in infants), photophobia, opisthotonus (if severe).[patient.info]
Diplopia
  • Diplopia I. Papilledema 6. Mentation a. Delirium b. Drowsiness c. Stupor d. Coma The infant with meningitis may have signs of infection but more commonly is simply fretful and refuses food.[atsu.edu]
Meningism
  • The classic signs of meningitis upon physical examination include neck stiffness, Kernig’s sign and Brudzinski’s sign. Inflammation of the meninges causes reflex spasm of the paravertebral muscles which causes the neck stiffness seen in meningitis.[symptoma.com]
  • There was a peak of meningitis cases in 1995-1996.[ncbi.nlm.nih.gov]
Headache
  • A 48 year-old healthy female visited our hospital with strong headache, fever, bilateral hyperemia, and blurred vision in both eyes.[ncbi.nlm.nih.gov]
  • The patients experience fever, vomiting, headache, stiffness of the neck and diminishing of consciousness. Bacterial meningitis is fatal unless diagnosed and treated early with antibiotics.[symptoma.com]
Seizure
  • However, their findings suggest that that the risk of bacterial meningitis in children presenting with simple febrile seizure is very low.[ncbi.nlm.nih.gov]
Confusion
  • Fever was the most common presenting sign/symptom, observed in 8 patients, followed by otalgia, neck stiffness, headache, and confusion. An opaque and bulging tympanic membrane was observed in 8 patients.[ncbi.nlm.nih.gov]
  • Symptoms: Viral meningitis - Fever, headache, stiff neck, sensitivity to light, drowsiness, confusion. Bacterial meningitis - High fever, severe headache, stiff neck, sensitivity to light, drowsiness, confusion.[childrenshospital.org]
  • Symptoms can develop around two to 10 days after exposure to the affected person and can include, according to the city’s Department of Health: Confusion, sleepiness nausea and/or vomiting headache stiffness in neck, shoulder and/or back The university[wtop.com]
  • No matter the type, it typically presents with a a combination of vague and common symptoms: fever, nausea, vomiting, increased sensitivity to light, confusion, and the hallmark sign, a stiff neck.[self.com]
  • Any of the following may develop within hours or days: A severe headache, stiff neck, and a fever Neck pain Nausea or vomiting Red or purple rash Eye pain when your child looks into bright lights Sleepiness or confusion How is bacterial meningitis diagnosed[drugs.com]
Irritability
  • Irritability and confusion occur early in the course of the disease, and convulsive seizures occur in about 25 per cent of patients.[medical-dictionary.thefreedictionary.com]
  • In older children and adults, you may see confusion, irritability, increasing drowsiness. Seizures and stroke may occur. In young children, the fever may cause vomiting and they may refuse to eat. Young children may become very irritable and cry.[my.clevelandclinic.org]
  • Infants may not develop a stiff neck but may seem generally unwell and have a high or low body temperature, feed poorly, or be irritable or drowsy.[merckmanuals.com]
  • In neonates, neck rigidity and/or fever are absent as well and the presenting features include irritability, restlessness and refusal to feed. The following investigations are helpful in establishing the diagnosis of meningitis.[symptoma.com]
  • […] stiff neck severe headache If you develop the disease, you may also experience: nausea vomiting sensitivity to bright light confusion a rash of purple discoloration Parents of babies and toddlers under the age of 2 should closely monitor any lingering irritability[healthline.com]

Workup

The following investigations are helpful in establishing the diagnosis of meningitis.

  • Cerebrospinal fluid (CSF) examination: The cerebrospinal fluid is examined after lumbar puncture. In bacterial meningitis, there is an increased white cell count with more than 1000 cells per cubic millimeter of the fluid. Polymorph leukocytes are predominant. The protein concentration is also elevated above the normal concentration of 45 mg/dl. The concentration of glucose is low (less than 40 mg/dl in normal patients). In 60 to 90% of the cases, the etiological agent can be identified after gram stain. Cerebrospinal culture also reveals the etiological agent.
  • Blood tests: Neutrophilic leukocytosis is seen in the blood. Blood culture for the etiological agent may be positive even when the cerebrospinal fluid culture is negative.
  • Coagulation tests: Tests for coagulation such as prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrin degradation product (FDP) should be performed to rule out disseminated intravascular coagulation.
  • Renal tests: The urea, creatinine and electrolytes in the serum should be evaluated in order to check renal function. Hyponatremia, if present, indicates syndrome of inappropriate antidiuretic hormone secretion.
Hyponatremia
  • Hyponatremia, if present, indicates syndrome of inappropriate antidiuretic hormone secretion. Supportive therapy The supportive treatment of bacterial meningitis includes bed rest and ensuring airway patency.[symptoma.com]
Pseudomonas
  • The other common Gram-negative pathogens were Pseudomonas species and Acinetobacter species, accounting for 10.3% (15/145) and 7.6% (11/145), respectively.[ncbi.nlm.nih.gov]
  • Immunocompromised children can develop meningitis caused by Pseudomonas, Serratia, Proteus, and diphtheroids.[emedicine.medscape.com]
  • Patients having spinal procedures (eg, spinal anaesthetics) are at increased risk and Pseudomonas spp. may then be the cause.[patient.info]
Brain Edema
  • Early signs of increased intracranial pressure from brain edema are reported promptly so that measures to reduce pressure can be taken as soon as possible.[medical-dictionary.thefreedictionary.com]
  • CT is widely available and is useful for rapid assessment of hydrocephalus, mass lesions, hemorrhage, or acute brain edema before LP. In contrast, MRI is required to detect more subtle findings.[clinicaladvisor.com]

Treatment

Supportive therapy

The supportive treatment of bacterial meningitis includes bed rest and ensuring airway patency. Intravenous fluids are given if there is danger of developing dehydration. If seizures develop, fluid intake is restricted.

Anti-microbial therapy

Bacterial meningitis is treated initially with empirical intravenous antibiotic therapy [6]. Once the cerebrospinal fluid or blood culture results are available, specific antibiotic therapy is initiated [7] [8]. Usually, benzyl penicillin is given for meningococcal meningitis and ceftriaxone is used as an alternative in the patients who can not tolerate penicillin. In the patients suffering from pneumococcal meningitis, ceftriaxone is given. Vancomycin or rifampin may be added if the pathogen is resistant to beta lactam. Hemophilus meningitis is also treated by ceftriaxone. Chloramphenicol may be used as an alternative. Listeria meningitis is treated by ampicillin or gentamycin and cotrimoxazole may be used as an alternative.

Adjunctive therapy

Adjunctive therapy of meningitis consists of the following drugs.

Prognosis

The mortality rate in the patients suffering from bacterial meningitis is 19 to 37% [3]. Mortality increases when the disease is not diagnosed or treated early.

Several complications may develop in the patients suffering from bacterial meningitis. These include septicemia, disseminated intravascular coagulation, shock, septic arthritis, syndrome of inappropriate antidiuretic hormone secretion (SIADH) and neurological disturbances.

Etiology

The common causal agents of bacterial meningitis are the following [1].

Epidemiology

In the developed countries, the incidence of bacterial meningitis is 3 to 5 in 100,000 people. The incidence is higher in undeveloped countries.

Sex distribution
Age distribution

Pathophysiology

Bacterial infection causes an acute inflammatory response of the pia mater and arachnoid mater which become congested and infiltrated with inflammatory cells. A thin layer of pus forms which may later organize to form adhesions which may cause obstruction in the free flow of the cerebrospinal fluid. Cranial nerve damage may also occur at the base of the brain.

Prevention

Family members and close contacts of the patients of meningococcal meningitis should receive prophylactic antibiotic therapy for two days. For this purpose, ciprofloxacin or rifampin may be used in suitable doses.
Vaccination is also available for prevention of disease caused by group A and C meningococci. Vaccination against group B meningococci is not available.

Summary

Bacterial meningitis is the inflammation of the meninges commonly caused by bacteria such as Neisseria meningitides, Streptococcus pneumonia, Hemophilus influenza and Listeria monocytogenes. It is an acute medical condition and may prove fatal if not diagnosed and treated early. The typical features include fever, headache and vomiting followed by neck stiffness and neurological disturbances. The mainstay of treatment is antibiotic therapy along with supportive care.

Patient Information

Bacterial meningitis is the swelling of the membranous sheet that covers the brain in response to infection with bacteria. The patients experience fever, vomiting, headache, stiffness of the neck and diminishing of consciousness. Bacterial meningitis is fatal unless diagnosed and treated early with antibiotics.

References

Article

  1. Christensen AC, Frederiksen W. [Etiology of bacterial meningitis]. Ugeskrift for laeger. Mar 14 1988;150(11):655-657.
  2. Vincent J, Sainaba MK, Rajagopalan KC. Bacterial etiology of meningitis with special reference to staphylococci. Indian pediatrics. Feb 1987;24(2):145-151.
  3. van de Beek D, de Gans J, Tunkel AR, Wijdicks EF. Community-acquired bacterial meningitis in adults. The New England journal of medicine. Jan 5 2006;354(1):44-53.
  4. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jul 1 2002;35(1):46-52.
  5. van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. The New England journal of medicine. Oct 28 2004;351(18):1849-1859.
  6. van de Beek D, Brouwer MC, Thwaites GE, Tunkel AR. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-1702.
  7. Thys JP. Diagnosis and treatment of bacterial meningitis. Resuscitation. Mar 1984;11(3-4):243-248.
  8. Kains JP, Thys JP. Principles of treatment of bacterial meningitis. Acta clinica Belgica. 1985;40(5):304-313.
    Brouwer MC, Heckenberg SG, de Gans J, Spanjaard L, Reitsma JB, van de
  9. Beek D. Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis. Neurology. Oct 26 2010;75(17):1533-1539.
  10. van de Beek D, Farrar JJ, de Gans J, et al. Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual patient data. The Lancet. Neurology. Mar 2010;9(3):254-263.

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Last updated: 2019-07-11 21:08