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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]
  • 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]
  • A 6-year-old otherwise healthy girl who underwent radiofrequency diathermy for adenoid hypertrophy presented with fever on the same day and was diagnosed as having bacterial meningitis 2 days later.[ncbi.nlm.nih.gov]
  • 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]
  • The patient was hospitalized due to rapidly undulant fever and sore throat. Empirical antibiotic therapy was started, however, headache also occurred.[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]
  • […] sudden high fever sever, persistent headache neck stiffness nausea/vomiting discomfort in bright lights drowsiness/difficulty awakening joint pain confusion or other mental changes general poor feeling Please see the following websites for more general[slhn.org]
  • 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]
  • Signs and symptoms for any type of meningitis may include: Severe headache High fever and chills Stiff neck Sensitivity to light Nausea and vomiting Sleepiness Confusion Seizures Symptoms in infants and young children may be hard to detect and may only[southernnevadahealthdistrict.org]
  • Bacterial meningitis typically begins with headache, nausea and vomiting, stiff neck (nuchal rigidity), and chills and fever.[medical-dictionary.thefreedictionary.com]
  • The most common symptoms are high fever, chills, lethargy, and a rash. If meningitis is present, the symptoms will also include headache and neck stiffness (which may not be present in infants). Seizures may also occur.[ct.gov]
  • Other symptoms may include chills, sweating, weakness, loss of appetite, or inability to tolerate bright light (photophobia).[rarediseases.org]
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]
Epilepsy
  • Every day children and adults die from acute community-acquired bacterial meningitis, particularly in low-income countries, and survivors risk deafness, epilepsy and neurological disabilities.[ncbi.nlm.nih.gov]
  • After effects most likely to be caused by meningitis Memory loss/lack of concentration/difficulty retaining information Clumsiness/co-ordination problems Headaches Deafness/hearing problems/tinnitus/dizziness/loss of balance Epilepsy/seizures Weakness[meningitis.org]
Vomiting
  • 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]
  • 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 9-year-old boy presented with acute headache, fever and vomiting. He had recurrent meningitis episode one month earlier and a head trauma 6 months ago. Laboratory findings and lumbar puncture suggested an intracranial bacterial infection.[ncbi.nlm.nih.gov]
  • After the surgery, the patient displayed dizziness and vomiting. A CSF culture revealed Pseudomonas aeruginosa infection. The patient was diagnosed with postoperative BM. Antibiotic was administered intravenously depends on the organism isolated.[ncbi.nlm.nih.gov]
  • A 21-year-old man was admitted to our emergency department with headache and vomiting. Neurologic examination, hematologic workup, and cerebrospinal fluid examination confirmed a diagnosis of bacterial meningitis.[ncbi.nlm.nih.gov]
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]
  • A 35-year-old female with a one day history of bilateral swollen eyes, visual disturbance, headache, petechial skin rash, and nausea visited our clinic. She was diagnosed as having endogenous endophthalmitis associated with bacterial meningitis.[ncbi.nlm.nih.gov]
  • The evidence on nausea, vomiting and diarrhoea is uncertain (RR 1.09, 95% CI 0.81 to 1.47; 2 studies, 851 participants; very low-certainty evidence).[ncbi.nlm.nih.gov]
  • 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]
  • In addition to the headache, Jennifer was dealing with a sore neck and nausea. The symptoms didn't improve after she took pain relievers and got some rest—in fact, they got worse.[self.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]
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]
  • 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]
  • 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]
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 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]
  • 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]
  • Empirical antibiotic therapy was started, however, headache also occurred. Lumbar puncture disclosed polynuclear leukocyte-predominant pleocytosis indicating that the patient suffered from bacterial meningitis.[ncbi.nlm.nih.gov]
  • Four days later, the patient developed severe lower back pain, bilateral leg pain, persistent headache and fever. Bacterial meningitis was initially suspected and antibiotics started.[ncbi.nlm.nih.gov]
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]
  • For TLR9 rs352139, patients who carried genotype AA and minor allele A developed seizures less often than those without (OR   0.289, p   0.003 and OR   0.568, p   0.004, respectively).[ncbi.nlm.nih.gov]
  • The most frequent long-term sequelae were late seizures 9 vs 1%, neuropsychological impairment 1 vs 5%, and deafness 1 vs 3%.[ncbi.nlm.nih.gov]
  • Seizures are common in alcoholic patients and warrant caution of development of an alcohol withdrawal syndrome.[ncbi.nlm.nih.gov]
  • Overall, 26 (39%) infants had a poor outcome in terms of death or neurological complication; seizures at presentation was the only significant independent risk factor (OR, 7.9; 95% CI 2.3 to 207.0).[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]
Neck Stiffness
  • Absence of neck stiffness did not rule out CABM and special attention should be given to patients with pneumonia and the elderly. Late diagnosis was associated with incorrect patient management and increased mortality.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • Patients with bacterial meningitis using immunosuppressive medication were less likely to present with headache (P 0.02) or neck stiffness (P 0.005), as compared those not on immunosuppressive medication.[ncbi.nlm.nih.gov]
  • This article examines the case of a five-year-old child who was comatose when admitted to the hospital with unilateral dilated pupil, neck stiffness and fever (T 39 degrees C). The initial brain computed tomography scan was unremarkable.[ncbi.nlm.nih.gov]
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]
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.

  • Mannitol: Mannitol is given in the patients with raised intracranial pressure.
  • Glucocorticoids: Glucocorticoids are effective in reducing the incidence of hearing loss and neurological deficits in children [9] [10].
  • Anti-epileptics: If the patient develops seizures, diazepam or phenytoin may be given.

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: 2018-06-22 02:45