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Meningitis

Meningitides

Meningitis is an inflammation of the meninges. The most common causes in adults are bacterial infections with Streptococcus pneumoniae, Neisseria meningitidis or Haemophilus influenzae. Aseptic meningitis may be caused by drugs (eg. NSAIDs, metronidazole and IV immunoglobulin), neoplasms or viruses. Typical signs and symptoms include severe headache, nuchal rigidity, fever, altered mental status, photophobia, phonophobia or vomiting.


Presentation

Most patients present with multiple symptoms. The most common symptoms of meningitis are fever, headache, neck stiffness and altered mental status. Other symptoms include nausea, vomiting, photophobia, confusion and irritability (exhibited by uncontrolled cry in children).

Signs elicited include bulging anterior fontanelle in children less than 18 months. Signs of meningeal irritation, focal neurological signs and some systemic findings are also present.

Fever
  • , fever, neck stiffness, and altered mental status.[ncbi.nlm.nih.gov]
  • We compared data from neonates with fever (temperature  38.0 C) and/or elevated C-reactive protein (CRP) levels (  5 mg/l) (possible sepsis) with data from neonates without fever or CRP elevation.[ncbi.nlm.nih.gov]
  • LESSONS: This case indicated that EGM could also occur in neonate and fever could be the only obvious manifestation.[ncbi.nlm.nih.gov]
  • Clinical manifestations include fever; nuchal rigidity; photophobia; seizures; hearing loss, sensorineural; coma; and cerebrovascular thrombosis.[icd9data.com]
  • The manifestation of intermittent headache and mild fever could be potential signs of fatal infection, and prompt appropriate measures should be taken timely.[ncbi.nlm.nih.gov]
High Fever
  • PATIENT CONCERNS: An infant presented to our hospital with high fever and irritability, as well as refusal to walk.[ncbi.nlm.nih.gov]
  • You should get medical care right away if you have A sudden high fever A severe headache A stiff neck Nausea or vomiting Early treatment can help prevent serious problems, including death.[medlineplus.gov]
  • Read the Taking Care of Your Child's Fever article Stiff neck that sometimes makes it hard to touch your chin to your chest Headache , which can be severe High fever Confusion Nausea or vomiting Discomfort from bright lights Sleepiness Seizures Rash Sometimes[webmd.com]
  • You want to watch for high fever , headaches , and an inability to lower your chin to your chest due to stiffness in the neck. In older children and adults, you may see confusion, irritability, increasing drowsiness. Seizures and stroke may occur.[my.clevelandclinic.org]
Fatigue
  • Symptoms may include: Headache Sensitivity to light ( photophobia ) Slight fever Fatigue Bacterial meningitis is an emergency. You will need immediate treatment in a hospital.[medlineplus.gov]
  • In the chronic form ( 1 year from onset), a chronic fatigue syndrome–like picture with depression and arthritis is typical.[emedicine.medscape.com]
  • Pregnant women with listeriosis typically experience only fever and other flu-like symptoms, such as fatigue and aches.[cdc.gov]
Malaise
  • […] or a more severe usually life-threatening illness caused by a bacterium (especially the meningococcus , Neisseria meningitides , or the serotype designated B of Haemophilus influenzae ) Note: Meningitis is often marked by fever, headache, vomiting, malaise[merriam-webster.com]
  • In the acute form, brucellosis takes the form of a flulike illness, with fever, sweats, malaise, anorexia, headache, myalgia, and back pain.[emedicine.medscape.com]
  • The initial presenting complaints for patients with the WFS usually include a diversity of nonspecific, vague symptoms such as cough, dizziness, headache, sore throat, chills, rigors, weakness, malaise, restlessness, apprehension, myalgias, arthralgias[ncbi.nlm.nih.gov]
  • Patients usually present with headache, fever, malaise and altered mental status over several weeks.[dx.doi.org]
Vomiting
  • After 2 months of the illness, he was admitted to our hospital with a persistent headache, vomiting and altered sensorium. CSF for cytospin confirmed myeloid blasts. He was still in haematological remission.[ncbi.nlm.nih.gov]
  • Typical signs and symptoms include severe headache, nuchal rigidity, fever, altered mental status, photophobia, phonophobia or vomiting. Most patients present with multiple symptoms.[symptoma.com]
  • We present a case of a 23-year-old woman with a 2-week history nocturnal fever, vertigo, headache and projectile vomiting. She had nystagmus, scanning speech, bilateral papilloedema and ataxia. Cranial imaging showed a 10 mm tonsillar herniation.[ncbi.nlm.nih.gov]
  • CASE SUMMARY: We discuss the case of a 56-year-old white man with a history of rheumatoid arthritis and hypertension who became confused, nauseated, and began to vomit within 2 hours of the ingestion of ibuprofen.[ncbi.nlm.nih.gov]
  • Abstract Background There are several etiologies of meningitis and encephalitis which must be considered in any patient presenting with fever, headache, neck stiffness and vomiting.[ncbi.nlm.nih.gov]
Nausea
  • Fourteen days later, the patient presented to the emergency department with fever and nausea. HIV test was negative. Ruxolitinib was suspended. Symptoms progressed with neck stiffness, cognitive impairment, and motor aphasia.[ncbi.nlm.nih.gov]
  • Other symptoms are nausea, vomiting, inability to look bright lights, confusion, irritability and confusion. In babies, there will be a characteristic high-pitched cry.[symptoma.com]
  • DATA SYNTHESIS: Individual items of the clinical history have low accuracy for the diagnosis of meningitis in adults (pooled sensitivity for headache, 50% [95% confidence interval [CI], 32%-68%]; for nausea/vomiting, 30% [95% CI, 22%-38%]).[ncbi.nlm.nih.gov]
  • Data Synthesis Individual items of the clinical history have low accuracy for the diagnosis of meningitis in adults (pooled sensitivity for headache, 50% [95% confidence interval {CI}, 32%-68%]; for nausea/vomiting, 30% [95% CI, 22%-38%]).[doi.org]
Loss of Appetite
  • […] of appetite, refusing food (infants) Muscle, leg or joint pain Neck retraction with arching of the back (infants) Pale or blotchy skin Rash or spots that don’t fade with pressure (also called purpure or petechiae )* Rapid breathing Seizures, fits or[meningitis.com.au]
  • The most common symptoms of meningitis are fever , headache , vomiting , loss of appetite, tiredness, drowsiness or altered consciousness, irritability, stiff neck and sensitivity to light. Some people with meningitis can have seizures .[healthdirect.gov.au]
  • Other symptoms that can occur include the following: Photophobia (sensitivity to light) Nausea and vomiting Fatigue Rash (not all cases) Loss of appetite Diarrhea Muscleaches Altered level of consciousness Seizures As the illness progresses, symptoms[web.archive.org]
Eruptions
  • Migration in subcutaneous tissues induces a linear dermatitis with light to moderate pruritus, usually localized to the abdomen and later in multiple skin areas, known as creeping eruption or CLM.[doi.org]
Hearing Impairment
  • Our findings suggest that S. suis infection should be considered when hearing impairment is present in a patient with bacterial infection and that MRI can help detect ventriculitis, which can necessitate a prolonged treatment duration.[ncbi.nlm.nih.gov]
  • Otoacoustic emissions as a screening test for hearing impairment in children. Arch Dis Child. 1995 Apr; 72 (4):294–297. [ PMC free article ] [ PubMed ] [ Google Scholar ] Orchik DJ, Dunn JW, McNutt L.[ncbi.nlm.nih.gov]
  • Whenever possible, brainstem responses were also measured earlier to confirm hearing impairments detected by OAEs.[adc.bmj.com]
Hearing Problem
  • There are some possible after-effects of meningitis, which may include: general tiredness frequent headaches difficulty in concentration and short-term memory lapses clumsiness or problems with balance hearing problems mood swings.[rch.org.au]
  • Steroid medication has been shown in some studies to reduce the risk of developing hearing problems and other complications. Viral meningitis Antibiotics may be given at first when the cause of the meningitis is not known.[patient.info]
  • The osmotic therapy, glycerol, has an unclear effect on mortality but may decrease hearing problems.[en.wikipedia.org]
  • The malformation may be unilateral, and hearing problems, particularly in younger children, may go unnoticed. In addition, the hearing impairment might be misinterpreted as resulting from preceding episodes of meningitis ( 154 ).[doi.org]
Myalgia
  • In the acute form, brucellosis takes the form of a flulike illness, with fever, sweats, malaise, anorexia, headache, myalgia, and back pain.[emedicine.medscape.com]
  • The initial presenting complaints for patients with the WFS usually include a diversity of nonspecific, vague symptoms such as cough, dizziness, headache, sore throat, chills, rigors, weakness, malaise, restlessness, apprehension, myalgias, arthralgias[ncbi.nlm.nih.gov]
  • Other findings less frequently reported included rash, arthralgias, myalgias, facial edema, and lymph node or liver test abnormalities, which can also occur in infectious meningitis, mainly of viral origin, with variable frequency.[dx.doi.org]
Neck Pain
  • The key to meningitis is the neck pain and stiffness. So if your child has severe neck pain and stiffness, and one or more of the other four symptoms, call your doctor to be seen right away, or page the doctor after hours.[askdrsears.com]
  • See How Neck Pain and Headache Can Occur Together Stiff neck. This symptom most commonly involves a reduced ability to flex the neck forward, also called nuchal rigidity.[spine-health.com]
  • METHODS :A 43-year-old male patient presented with 'neck pain for 15 days, exacerbated accompanying motor and sensory dysfunction of lower limbs with bowel and bladder dysfunction for 4 days' was admitted to our department.[paper.medlive.cn]
  • Fever, severe and constant headache, stiff neck or neck pain, nausea and vomiting, sensitivity to light, and rash can all be signs of meningitis.[mass.gov]
Low Back Pain
  • Herein, we report a 62-year-old man with a 4-wk history of progressive low back pain with radiation to bilateral lower legs, dysphagia and body weight loss.[science.gov]
Photophobia
  • Clinical manifestations include fever; nuchal rigidity; photophobia; seizures; hearing loss, sensorineural; coma; and cerebrovascular thrombosis.[icd9data.com]
  • Typical signs and symptoms include severe headache, nuchal rigidity, fever, altered mental status, photophobia, phonophobia or vomiting. Most patients present with multiple symptoms.[symptoma.com]
  • Regardless of the particular type of bacteria causing the meningitis, the classical features of the disease include headache, neck stiffness, photophobia (aversion to light), vomiting and fever. Joint pain and drowsiness may also occur.[irishtimes.com]
  • Symptoms may include: Headache Sensitivity to light ( photophobia ) Slight fever Fatigue Bacterial meningitis is an emergency. You will need immediate treatment in a hospital.[medlineplus.gov]
Diplopia
  • ,et al, 2018 A 56-year-old woman with acute vertigo and diplopia Neurol 90:748-752, Sharma, R.,et al, 2018 A 30-year-old man with headache and sleep disturbance Neurol 90:e1535-e1540, English, S.W.[neudle.com]
  • These episodes resolve spontaneously and are followed by symptom-free periods of weeks to months Transient neurological abnormalities, including seizures, diplopia, pathologic reflexes, cranial nerve pareses, hallucinations, and coma, occur in as many[emedicine.medscape.com]
  • Approximately one-half of patients have transient neurological manifestations, including seizures, hallucinations, diplopia, cranial nerve palsies, or altered levels of consciousness.[web.archive.org]
Eye Pain
  • Symptoms of meningitis Meningitis is commonly manifested by: severe headache vomiting high fever stiffness of the neck sensitivity and eye pain on exposure to light skin rash Symptoms can differ in young children and babies.[news-medical.net]
  • Eye sensitivity and eye pain from bright lights. Dark purple and blotchy skin rash. Dizzy spells. Babies, young children, older adults, and people with other medical conditions may not have the usual symptoms of meningitis.[healthlinkbc.ca]
Meningism
  • Viral Meningitis Meningitis caused by viruses is serious but often is less severe than bacterial meningitis. People with normal immune systems who get viral meningitis usually get better on their own.[cdc.gov]
  • […] infection of the meninges—the tough layer of tissue that surrounds the brain and the spinal cord. eMedicine: Meningitis Dr.[curlie.org]
  • Meningitis is defined as inflammation of the meninges. The meninges are the three layers of membrane that enclose the brain and spinal cord. Meningitis is a disease of the membranes covering the brain.[symptoma.com]
  • Household members and others in close contact with people who have meningococcal meningitis should receive antibiotics to prevent becoming infected. Meningitis - bacterial; Meningitis - viral; Meningitis - fungal; Meningitis - vaccine Nath A.[medlineplus.gov]
Headache
  • Reinsertion of the stylet before needle removal decreased the risk of headache (ARR, 11.3%; 95% CI, 6.50%-16.2%).[ncbi.nlm.nih.gov]
  • Among patients with fever and headache, jolt accentuation of headache is a useful adjunctive maneuver, with a sensitivity of 100%, specificity of 54%, positive likelihood ratio of 2.2, and negative likelihood ratio of 0 for the diagnosis of meningitis[ncbi.nlm.nih.gov]
Seizure
  • Clinical manifestations include fever; nuchal rigidity; photophobia; seizures; hearing loss, sensorineural; coma; and cerebrovascular thrombosis.[icd9data.com]
  • Less frequent presentations of CNS tuberculosis include atypical febrile seizures in children, isolated cranial nerve palsies, bilateral papilledema, and acute confusional states.[emedicine.medscape.com]
  • CASE REPORT: A patient with a 30-year history of RA, well controlled with methotrexate therapy, presented with new-onset seizures. Magnetic resonance imaging showed leptomeningeal and pachymeningeal enhancement.[ncbi.nlm.nih.gov]
  • Two hours prior to admission, he developed epileptic seizures. DIAGNOSES: Brain computed tomography and magnetic resonance imaging showed intracerebral malacic lesions. Bacterial culture of cerebrospinal fluid revealed the presence of R. equi.[ncbi.nlm.nih.gov]
  • Seizures: occur more commonly during the acute stage of the disease.[patient.info]
Confusion
  • Other symptoms are nausea, vomiting, inability to look bright lights, confusion, irritability and confusion. In babies, there will be a characteristic high-pitched cry.[symptoma.com]
  • CASE SUMMARY: We discuss the case of a 56-year-old white man with a history of rheumatoid arthritis and hypertension who became confused, nauseated, and began to vomit within 2 hours of the ingestion of ibuprofen.[ncbi.nlm.nih.gov]
  • CASE REPORT A 49-year-old Asian male presented to the emergency department with complaints of a headache, fever greater than 37.8 C (100 F) and confusion, of approximately 3 days duration.[ncbi.nlm.nih.gov]
  • Confusion, psychosis, and seizures also have been reported. Diagnosis of Behçet syndrome A triad of uveitis, painful oral ulcers, and genital ulcers characterizes this disease. Other manifestations include arthritis and thrombophlebitis.[emedicine.medscape.com]
  • The disease should not be confused with encephalitis which is inflammation of the brain itself. How many types...[musa.org]
Neck Stiffness
  • , fever, neck stiffness, and altered mental status.[ncbi.nlm.nih.gov]
  • Abstract Background There are several etiologies of meningitis and encephalitis which must be considered in any patient presenting with fever, headache, neck stiffness and vomiting.[ncbi.nlm.nih.gov]
  • Neck stiffness Other causes of bacterial meningitis include invasive streptococcus pneumonia, haemophilus influenza, tuberculosis (TB) and listeria.[irishtimes.com]
  • Symptoms progressed with neck stiffness, cognitive impairment, and motor aphasia. CSF was positive for JC virus. MRI showed nonspecific abnormal findings. Five days after the clinical debut, the patient died.[ncbi.nlm.nih.gov]
  • The most common symptoms of meningitis are fever, headache, neck stiffness and altered mental status. Other symptoms include nausea, vomiting, photophobia, confusion and irritability (exhibited by uncontrolled cry in children).[symptoma.com]

Workup

Laboratory tests

  • Blood studies like serum electrolytes, serum glucose and blood urea nitrogen.
  • Cultures like blood and urine culture.
  • Lumbar puncture for CSF analysis [5] – Intracranial pressure should be checked before this procedure to avoid cerebral herniation. Focal neurological signs might suggest herniation.
  • Syphilis testing
  • HIV screening

Imaging

CT scan is not routinely done but may be required when then are signs of focal neurological deficit.

Treatment

This involves treating the active infection and managing complications. The medication used is dependent on the type of meningitis. Severe life threatening situations should be managed first by rehydrating patients who are in shock and are hypovolemic, managing seizures and securing the airway if unconscious. Medications that are used are dependent on a wide range of variable like causative organism, age of patient and complications. Such medication may include:

  • Antibiotics: Sulfonamides, tetracyclines, carbapenems, fluoroquinolones, penicilins, cephalosporins.
  • Antivirals
  • Antifungals
  • Antituberculosis agents
  • Corticosteroids [6]
  • Diuretics like osmotic and loop diuretics
  • Anticonvulsants like hydantoins and barbiturates

Prognosis

Meningitis is a medical emergency and if treated early, some patients can attain full remission. Some factors have however been identified that could worsen the prognosis and they include:

  • Advanced age
  • Low Glasgow Coma Scale
  • Tachycardia
  • Reduced CSF leucocyte count
  • Presence of gram-positive cocci on gram staining

Late intervention in bacterial meningitis could lead to permanent brain damage or death. 50% of survivors develop complications like deafness [3], blindness, cranial nerve palsy and hydrocephalus amongst others.

Etiology

Meningitis is caused by a number of agents including:

  • Bacteria: This is the commonest cause and agents include H. influenza, S. pneumonia and N. meningitidis.
  • Viruses: Some viruses that can cause meningitis are enterovirus and West Nile virus.
  • Parasites: This is a very rare cause of meningitis and is fatal in most cases [4].
  • Fungi: This is usually as a result of background immunosuppression and some of the organisms implicated are C. neoformans
  • Drugs: NSAIDs, IV immunoglobulin and metronidazole.

There are some risk factors that make an individual more susceptible to some particular pathogens, like age and immune status.

Epidemiology

The incidence of meningitis is higher in developing countries because of the poor health sectors which is highlighted by the limited availability of preventive measures like vaccination. The incidence is also dependent on the type of meningitis.

Most meningitis forms affects the extremes of age. Children are particular susceptible to many forms of meningitis [2]. Neonates have the highest risk. Individuals older than 60 years are also at increased risk for meningitis infection.

Sex distribution is equal for most forms of meningitis, although overall, it is slightly more common in males. Meningitis is more common in blacks than in Caucasians and Asians. A particular form, meningococcal meningitis, is endemic in tropical regions alike sub-Saharan Africa and India, and there have been recorded periodic outbreak of epidemics.

Sex distribution
Age distribution

Pathophysiology

Pathogens that cause meningitis can get to the meninges in three major ways:

  • Through the blood stream which is the most common route of spread for most pathogens.
  • Through a retrograde neuronal pathway.
  • Through local contiguous spread.

The first event is invasion of the meninges by the pathogens. The exact method of how they cross the blood-brain barrier is poorly documented but it is usually preceded by an overwhelming sepsis. This triggers an inflammatory response and inflammatory cells cross the now porous blood-brain barrier to enter the brain. There is then predominance of lymphocytes or neutrophils based on the pathogen responsible. This process further worsens the condition as it leads to brain swelling and then ischemia of parts of the brain [1]. The inflammatory cells increased the membrane permeability and alter normal chemical contents of the cerebrospinal fluid like glucose and protein.

Prevention

The mainstay of prevention of meningitis is vaccination [7]. Vaccination should be given to individuals who are susceptible to H. influenza and S. pneumonia. Also, individuals who live in and those who travel to endemic areas should be vaccinated against N. meningitidis. Researchers who work with the bacteria should also be vaccinated against it.

Chemoprophylaxis is a second form of prevention and is usually reserved for individuals who have had prior exposure to H. influenza, S. pneumonia and N. meningitidis. Rifampin is the drug of choice. Ceftriaxone can also be used.

Summary

Meningitis is defined as inflammation of the meninges. The meninges are the three layers of membrane that enclose the brain and spinal cord. Meningitis is a disease of the membranes covering the brain. It is often an infectious disease with bacteria being the commonest cause. It manifests via a myriad of CNS symptoms and could result in permanent disability or death. Meningitis is a medical emergency.

Patient Information

Definition

Meningitis is an infection of the layers covering the brain.

Cause

The cause of meningitis are mainly microorganisms although some people at higher risk of meningitis, like very young children and people who are old. People who have an infection is areas close to the brain, like the ear and throat are also at increased risk of getting this disease.

Signs and symptoms

The common symptoms are fever, headache and neck stiffness. Other symptoms are nausea, vomiting, inability to look bright lights, confusion, irritability and confusion. In babies, there will be a characteristic high-pitched cry. Meningitis is an emergency and if any of this symptoms are noted, the individual should be taken to the hospital immediately.

Diagnosis

Diagnosis involves a series of blood tests to check the level of sugar and protein and also to check for infection of the blood. Part of the fluid surrounding the brain, the cerebrospinal fluid is also checked to know the cause of the meningitis. CT scan may also be required.

Treatment

Treatment of meningitis involves mainly, to treating the underlying cause of the disease. Other supportive therapies are instituted as well as treatment of complications that may arise.

References

Article

  1. Berkhout B. Infectious diseases of the nervous system: pathogenesis and worldwide impact. IDrugs. Nov 2008;11(11):791-5.
  2. Thigpen, M, Rosenstein, NE, Whitney, CG. Bacterial meningitis in the United States--1998-2003. Presented at the 43rd Annual Meeting of the Infectious Diseases Society of America, San Francisco, CA. October 2005;65.
  3. Worsøe L, Cayé-Thomasen P, Brandt CT, Thomsen J, Østergaard C. Factors associated with the occurrence of hearing loss after pneumococcal meningitis. Clin Infect Dis. Oct 15 2010;51(8):917-24.
  4. Ramirez-Avila L, Slome S, Schuster FL, Gavali S, Schantz PM, Sejvar J, et al. Eosinophilic meningitis due to Angiostrongylus and Gnathostoma species. Clin Infect Dis. Feb 1 2009;48(3):322-7.
  5. Seupaul RA. Evidence-based emergency medicine/rational clinical examination abstract. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?. Ann Emerg Med. Jul 2007;50(1):85-7.
  6. Brouwer MC, Heckenberg SG, de Gans J, Spanjaard L, Reitsma JB, van de Beek D. Nationwide implementation of adjunctive dexamethasone therapy for pneumococcal meningitis. Neurology. Oct 26 2010;75(17):1533-9.
  7. Advisory Committee on Immunization Practices (ACIP). Updated recommendations for use of meningococcal conjugate vaccines. MMWR Morb Mortal Wkly Rep. Jan 28 2011;60(3):72-6.

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Last updated: 2017-08-09 17:48