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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]
  • Cases without fever, with increased CSF gamma globulin and transient neurological signs and symptoms, have been reported.[emedicine.medscape.com]
  • Clinical manifestations include fever; nuchal rigidity; photophobia; seizures; hearing loss, sensorineural; coma; and cerebrovascular thrombosis.[icd9data.com]
High Fever
  • An infant presented to our hospital with high fever and irritability, as well as refusal to walk. Cerebrospinal fluid collected through lumbar puncture showed increased eosinophil count and third-stage Angiostrongylus cantonensis larvae.[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]
  • 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]
  • The usual range of incubation for most organisms causing meningitis is 2 days to 2 weeks. 4.2 Symptoms Common symptoms in patients over the age of 2 years are high fever, headache and neck stiffness.[flexikon.doccheck.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 Upset stomach and diarrhea Fatigue Bacterial meningitis is an emergency. You will need immediate treatment in a hospital.[nlm.nih.gov]
  • Common side-effects are minor and include fever; pain or redness around the injection site; fatigue and malaise; irritability. Very rarely, an allergic response to the vaccine may occur, leading to anaphylaxis or a rash.[victoria.ac.nz]
  • In the chronic form ( 1 year from onset), a chronic fatigue syndrome–like picture with depression and arthritis is typical.[emedicine.medscape.com]
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]
  • Common side-effects are minor and include fever; pain or redness around the injection site; fatigue and malaise; irritability. Very rarely, an allergic response to the vaccine may occur, leading to anaphylaxis or a rash.[victoria.ac.nz]
  • 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]
  • Incubation period The average incubation period is 4 days, ranging between 2 and 10 days Signs and Symptoms High fever Severe headache, Vomiting or Nausea with Headache Generalised malaise, Confusion Seizures Sleepiness or Difficulty waking up Stiff neck[kznhealth.gov.za]
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]
  • Other symptoms include photophobia, nausea, vomiting, lethargy and confusion. In newborns the typical symptoms are hard to detect. They usually present with inactivity, irritability, vomiting and poor feeding.[flexikon.doccheck.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]
  • 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]
Nausea
  • Other symptoms include photophobia, nausea, vomiting, lethargy and confusion. In newborns the typical symptoms are hard to detect. They usually present with inactivity, irritability, vomiting and poor feeding.[flexikon.doccheck.com]
  • 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%]).[oadoi.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]
  • Symptoms can include fatigue, nausea, loss of appetite, and yellowing of the skin.[carthage.edu]
  • 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]
Tachycardia
  • 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[symptoma.com]
  • 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]
Petechiae
  • Fever Irritability Listless, less responsive Loss 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[meningitis.com.au]
  • When a patient presents with fever and petechiae, WFS must be considered, even when the patient has a non-toxic appearance.[ncbi.nlm.nih.gov]
  • Next, they invade the blood, introducing toxic substances into the circulation and causing fever; if the infection is caused by N. meningitidis, a rash may appear and develop into hemorrhagic spots ( petechiae and purpura ) in severe cases.[britannica.com]
  • Twenty six patients had cerebrospinal fluid pleocytosis plus positive meningococcal blood cultures or petechiae, and 14 children who did not undergo lumbar puncture had meningism and evidence of meningococcal disease.[dx.doi.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]
  • Whenever possible, brainstem responses were also measured earlier to confirm hearing impairments detected by OAEs.[dx.doi.org]
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]
  • These long term issues can include hearing problems (due to damage to the acoustic nerves), seizures or epilepsy, hydrocephalus (a build-up of CSF in and around the brain), memory problems, changes in personality and behaviour, speech problems, and weakness[brainandspine.org.uk]
  • 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]
Photophobia
  • Other symptoms include photophobia, nausea, vomiting, lethargy and confusion. In newborns the typical symptoms are hard to detect. They usually present with inactivity, irritability, vomiting and poor feeding.[flexikon.doccheck.com]
  • 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]
  • Patient 2 A 32 year old woman presented with a three day history of headache, fever, and photophobia. She had perianal tenderness, and her boyfriend had noticed a rash. On examination, unilateral herpetic lesions were seen (fig 2 ).[ncbi.nlm.nih.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]
  • 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]
  • 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.[healthy.kaiserpermanente.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]
  • 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[stanfordchildrens.org]
  • 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
  • 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]
Meningism
  • Meningitis " search on:[curlie.org]
  • 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]
  • Diagnostic accuracy of meningeal signs in patients with more-severe meningiti.[doi.org]
Headache
  • […] the first description of post-LP headache. 6 Headache and backache are the most frequently reported adverse events associated with LP.[doi.org]
  • 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[oadoi.org]
Seizure
  • We report a rare case of large frontal sinus osteoma with intracranial extension, associated with meningitis and the development of seizures.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • Other symptoms include photophobia, nausea, vomiting, lethargy and confusion. In newborns the typical symptoms are hard to detect. They usually present with inactivity, irritability, vomiting and poor feeding.[flexikon.doccheck.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]
  • 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]
Irritability
  • An infant presented to our hospital with high fever and irritability, as well as refusal to walk. Cerebrospinal fluid collected through lumbar puncture showed increased eosinophil count and third-stage Angiostrongylus cantonensis larvae.[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]
  • Meningitis may also be caused by: Chemical irritation Drug allergies Fungi Parasites Tumors Many types of viruses can cause meningitis: Enteroviruses: These are viruses that also can cause intestinal illness.[nlm.nih.gov]

Workup

Laboratory tests

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:

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:

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:

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: 2019-07-11 22:33