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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
  • Spots/rash See the Glass Test Severe headache Stiff neck Dislike bright lights Convulsions/seizures Early symptoms can include: Fever, headache, vomiting, muscle pain and fever with cold hands and feet.[meningitisnow.org]
  • Older adults and people with other medical problems may have only a slight headache and fever. Treatment depends on the cause. Bacterial meningitis can be deadly if not treated right away.[vch.ca]
  • , headache, vomiting, muscle pain and fever with cold hands and feet.[mirror.co.uk]
  • The symptoms of meningitis in babies and young children include: fever, food refusal, fretfulness, drowsiness, purple-red skin rash or bruising, high moaning cry, light sensitivity and pale or blotchy skin.[healthdirect.gov.au]
  • They also may have a fever or bulging fontanelle (soft spot on head).[kidshealth.org]
High Fever
  • 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]
  • Be on the lookout for these signs in you or your family: 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[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]
  • Although the signs and symptoms of meningitis are dependant on the agent and the age of the patient, most cases manifest with high fever, headaches, and a stiff neck.[ehagroup.com]
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.[mountsinai.org]
  • Pregnant women with listeriosis typically experience only fever and other flu-like symptoms, such as fatigue and aches.[cdc.gov]
  • Physical after-effects that may be experienced by both children and adults include: Fatigue Headaches Sore, stiff joints Eyesight problems Short-term memory loss Balance problems. These resolve with time, and rest.[southerncross.co.nz]
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]
Vomiting
  • Common signs & symptoms of meningitis and septicaemia Fever, cold hands and feet Vomiting Drowsy, difficult to wake Confusion and irritability Severe muscle pain Pale, blotchy skin.[meningitisnow.org]
  • The first symptoms are usually fever, vomiting, headache and feeling unwell. Young people and students are the next most at-risk group. Don’t assume an illness is a hangover or a touch of flu.[meningitis.org]
  • The main symptoms to look out for are fever, vomiting, headache, stiff neck, sensitivity to light, and drowsiness or altered consciousness. The signs and symptoms do not appear in a definite order and some may not appear at all.[meningitis.com.au]
  • 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]
  • ‘I had a stiff neck, I ached, I was vomiting and felt generally unwell,’ Jemma said. ‘Literally the minute she finished work, Mum drove straight up to collect me.[metro.co.uk]
Nausea
  • 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]
  • 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]
  • Symptoms Symptoms include an intense headache, fever, nausea and stiff neck, sometimes accompanied by a rash; delirium and coma can occur in severe cases.[dhhs.nh.gov]
  • Be on the lookout for these signs in you or your family: 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[webmd.com]
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]
Hearing Problem
  • The possible after-effects of meningitis 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]
Hearing Impairment
  • Potential long-term complications of meningitis may include: hearing impairment; and brain damage, which can result in seizures, learning difficulties and/or physical impairment.[mydr.com.au]
  • Four months later, he complained of headache, diplopia and severe hearing impairment in the left ear. There was no evidence for bacterial, fungal, tuberculous infection or neoplastic infiltration.[science.gov]
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 Diagnosing Neck Pain The spinal tap’s lab results for potential bacterial or viral cultures can take a few days for enough growth to be analyzed, which is why an official meningitis diagnosis cannot typically be made the same day.[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, and rash can all be signs of meningitis. Changes in behavior such as confusion, sleepiness, and trouble waking up can also be important symptoms.[mass.gov]
  • pain Back pain Headache Sleepiness Confusion Irritability Fever Refusing to eat Reduced level of consciousness Seizures Eyes sensitive to light (photophobia) Nausea and vomiting Neck stiffness A purple-red splotchy rash The symptoms of meningitis can[lifespan.org]
Low Back Pain
  • In 2012, fungal meningitis was linked to a contamination in a specific steroid product, methylprednisolone , manufactured in a single pharmacy and injected in the spine of people suffering from low back pain .[emedicinehealth.com]
  • 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
  • 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]
  • Some cases will also present with meningitis , which will typically manifest as nuchal rigidity, headache and photophobia. Meningitis is the most common presentation in humans. In 1944, penicillin was first reported to be effective in meningitis .[dictionary.cambridge.org]
  • 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]
  • Photophobia – this means that light hurts your eyes. Meningitis will cause someone to refuse to look into light, especially the bright sunlight.[askdrsears.com]
  • Symptoms of Meningitis When infected people begin to show symptoms, they often experience sudden and intense headaches, fever, nausea, vomiting, photophobia (a low tolerance to light), and stiffness of the neck.[doctorswithoutborders.org]
Diplopia
  • ,et al, 2017 A 22-year-old Man with Diplopia Neurol 89:e45-e49, Meyer, C.,et al, 2017 Cerebral Amyloid Angiopathy-Related Inflammation Presenting with Isolated Leptomeningitis Neurol 89:e66-e67, Kang, P.[neudle.com]
  • Four months later, he complained of headache, diplopia and severe hearing impairment in the left ear. There was no evidence for bacterial, fungal, tuberculous infection or neoplastic infiltration.[science.gov]
  • Diplopia With Dural Fibrotic Thickening . Seminars in Pediatric Neurology, Vol. 26, Issue. , p. 83.[cambridge.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]
  • The classic signs and symptoms of meningitis are headache , fever, and stiff neck (in adults and older children), and eyes painful sensitivity to light ( photophobia ).[medicinenet.com]
  • 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
  • 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]
  • Meningitis Meninges of the central nervous system : dura mater , arachnoid mater , and pia mater .[en.wikipedia.org]
  • Meningitis is an infection of the meninges that are membranes that cover the brain and the spinal cord. What are meninges? Meninges are 3 connective tissue layers.[news-medical.net]
  • Meningitis occurs when the lining of the brain and spinal cord (the “meninges”) is inflamed or infected. There are two main types of meningitis: viral meningitis and bacterial meningitis.[rush.edu]
Headache
  • Spots/rash See the Glass Test Severe headache Stiff neck Dislike bright lights Convulsions/seizures Early symptoms can include: Fever, headache, vomiting, muscle pain and fever with cold hands and feet.[meningitisnow.org]
  • So if your child has a headache, but no fever (and no neck stiffness), then you can be reassured it is not meningitis. In fact, headache, fever and vomiting, without neck pain or stiffness, is probably the just a bad flu virus.[askdrsears.com]
  • The first symptoms are usually fever, vomiting, headache and feeling unwell. Young people and students are the next most at-risk group. Don’t assume an illness is a hangover or a touch of flu.[meningitis.org]
  • The main symptoms to look out for are fever, vomiting, headache, stiff neck, sensitivity to light, and drowsiness or altered consciousness. The signs and symptoms do not appear in a definite order and some may not appear at all.[meningitis.com.au]
  • In newborns and infants under the age of 2 the symptoms of fever, headache and stiff neck may be absent or difficult to detect. The infant may experience irritability, poor feeding and vomiting.[simcoemuskokahealth.org]
Seizure
  • Under antiepileptic medications, focal seizures remained persistent but progression to secondary generalized seizures became rare.[paperity.org]
  • In severe cases, it can cause prolonged fever and seizures. Bacterial meningitis - Bacterial meningitis is not as common, but it is very serious. It needs to be treated right away to prevent brain damage and death.[vch.ca]
  • 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. There may be seizures.[my.clevelandclinic.org]
  • A 52-year-old man presented with refractory generalized tonic-clonic seizure. Magnetic resonance imaging revealed thickening of the meninges with enhancement near the superior sagittal sinus; skull bone defect was also noted.[wwe.eurekamag.com]
  • Seizures along with a fever may be the first signs of meningitis, although most brief, generalized (so-called tonic-clonic) convulsions turn out to be simple febrile seizures , not meningitis. A rash also may be a symptom of this condition.[healthychildren.org]
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]
  • The disease should not be confused with encephalitis which is inflammation of the brain itself. How many types...[musa.org]
  • Limb pain, pale skin, and cold hands and feet often appear earlier than the rash, neck stiffness, dislike of bright lights and confusion. Septicaemia can occur with or without meningitis.[meningitis.org]
  • […] especially the meningococcus , Neisseria meningitides , or the serotype designated B of Haemophilus influenzae ) Note: Meningitis is often marked by fever, headache, vomiting, malaise, and stiff neck, and if left untreated in bacterial forms, may progress to confusion[merriam-webster.com]
  • Common signs & symptoms of meningitis and septicaemia Fever, cold hands and feet Vomiting Drowsy, difficult to wake Confusion and irritability Severe muscle pain Pale, blotchy skin.[meningitisnow.org]
Irritability
  • 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]
  • 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]
  • Common symptoms include: fever lack of energy irritability headache sensitivity to light stiff neck skin rashes Meningitis in Infants Infants with meningitis might have different symptoms.[kidshealth.org]
  • These primary symptoms can be accompanied by nausea, vomiting, photophobia, confusion and irritability. Some of these classic signs and symptoms cannot be detected in an infant in whom lethargy and irritability are important signs.[ehagroup.com]
  • Other causes may include: cancer chemical irritation fungi drug allergies Viral and bacterial meningitis are contagious. They can be transmitted by coughing , sneezing , or close contact.[healthline.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.

Symptoms

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