Meningitis

Commonly Asked Questions

Stephen J. Gluckman, M.D.

What are normal CSF findings?

Protein
0.45 gm/L
Elevated with Diabetes
Elevated with neuropathies of any cause
Elevated with increasing age
Elevated by bleeding into the CSF (SAH or
traumatic)
0.01 gm/L for every 1000 RBCs

What are normal CSF findings?

Glucose
60 % of blood glucose
In persons with hyperglycemia it takes several
hours for CFS and blood glucose to equilibrate

Low CSF glucose

Bacterial infection
Tuberculosis, cryptococcosis, carcinomatous
SAH
Sarcoidosis
Occasional viral

What are normal CSF findings?

Cell count
<5 WBC (all mononuclear) and < 5 RBC
considered normal
Traumatic tap
WBC/RBC ratio = 1:1000

Pressure
<20
In patients with bacterial meningitis
wide range
40% >30, 10% < 14

Can the CSF reliably distinguish between a

bacterial and non-bacterial cause of
meningitis?

Usually
Look at the whole pattern!

Can the CSF reliably distinguish between a

bacterial and non-bacterial cause of
meningitis?
Glucose
<2.5 suggests bacterial
< 0.5 highly suggests bacterial

Protein
> 2.5 suggests bacterial

Cell count
>500 suggests bacterial
>1000 highly suggests bacterial

% polys
>50 suggests bacterial

Are there exceptions?

Early viral can have a predominance of
polys
Some viral can have low CFS glucose
Listeria can have predominance of
mononuclear cells rather than polys
TB can have predominance of polys

How much does prior administration of

antibiotics alter the CSF findings?

Not Much

How much does prior administration of

antibiotics alter the CSF findings?
48-72 hours of prior intravenous antibiotic
treatment has little effect on glucose,
protein and cell count
It will rarely change the CSF from a bacterial
to an aseptic formula

Prior antibiotic treatment will likely make

the cultures negative.

What is the typical clinical presentation

of bacterial meningitis?
History
Headache: 75-90%
Photophobia: uncommon

Examination
Fever: 95%
Stiff Neck: 85%
Altered mental status: 80%
All three: 40%
Any one of the three: 100%

How good are Kernig and

Brudzinski signs?
Originally related to severe, advanced TB
meningitis (not bacterial)
Not studied in a prospective study until
2002 (N=297)*
Sensitivity 5%
Specificity 95%

*Thomas KE et al. Clin Infect Dis. 2002;35:46-52

What are the common causes

of bacterial meningitis?
It depends upon age and risk factors
Age

Neonates: listeria, group B streptococci, E. coli

Children: H. influenza
10 to 21: meningococcal
21 onward: pneumococcal >meningococcal
Elderly: pneumococcal>listeria

Risk factors
Decreased CMI: listeria
S/P neurosurgery or opened head trauma: Staphylococcus,
Gram Negative Rods
Fracture of the cribiform plate: pneumococcal

What is the proper empirical antibiotic

regimen for presumed bacterial meningitis?

It depends upon the clinical situation

What is the proper empirical antibiotic

regimen for presumed bacterial meningitis?
Neonates
3rd generation cephalosporin and ampicillin

Children
3rd generation cephalosporin

Normal adult
3rd generation cephalosporin and vancomycin (if resistant
pneumococci)

Problems with cell mediated immunity (AIDS, steroids,

elderly)
Add coverage for listeria with ampicillin or co-trimoxazole

S/P CNS trauma or neurosurgery

Coverage for staphylococcus and gram negative rods with
antipseudomonal beta-lactam and vancomycin

How important is the speed of initiating

antibiotics in bacterial meningitis?

It is important
But it is not the critical prognostic factor

How important is the speed of initiating

antibiotics in bacterial meningitis?
The clinical outcome is primarily
influenced by the severity of the illness at
the time antibiotics are initiated
Severity based on
Altered mental status
Hypotension
Seizures

How important is the speed of initiating

antibiotics in bacterial meningitis?
No factors
9% with adverse outcome

One factor
33% with adverse outcome

Two or three factors

56% with adverse outcome

Therefore, though treatment should be

administered ASAP, the impact of antibiotic
delay is a function of the severity of disease at
the time that treatment is initiated

Steroids or no Steroids?

Steroids
(today)

Steroids or no Steroids?
Reduces morbidity and mortality*
Give before or at the same time as the first
dose of antibiotics
Dose studied
Dexamethazone 10 mg Q6H x 4 days
*Only shown for pneumococcal meningitis in
adults and haemophilus meningitis in children

Do you need to do a CT scan

before an LP?

Usually not
A CT scan should never delay therapy
(obtain blood cultures)

Do you need to do a CT scan

before an LP?

Prospective studies*
N = 412
Predictors of CNS mass lesion
History
> 60 years old
Immunocompromised
Hx of prior CNS disease
Hx of seizure w/in 1 week prior to onset
Examination
Focal neurological findings
Altered mental status
Papilledema

*Gopal et al. Arch Intern Med. 1999;159:2681-5

Hasbun and Abrahams. N Engl J Med 2001:345:1727-33

How contagious is meningitis?

Are we at risk when we care for a patient?
Not really
The only bacterial meningitis that is
spread from person to person is
meningococcal
The risk is very low
Household contacts have about a 1% risk
Health care workers have not been shown to have
a risk
After 24 hours of treatment this is no risk

What is Aseptic meningitis?

It is a term used to mean non-pyogenic
bacterial meningitis
It describes a spinal fluid formula that
typically has:
A low number of WBC
A minimally elevated protein
A normal glucose

It has a much bigger differential diagnosis

than viral meningitis.

What are the

treatable causes of aseptic
meningitis/encephalitis syndrome?
Infectious

HSV 1 and 2
Syphilis
Listeria (occasionally)
Tuberculosis
Cryptococcus
Leptospirosis
Cerebral malaria
African tick typhus
Lyme disease

Non-Infectious

Carcinomatous
Sarcoidosis
Vasculitis
Dural venous sinus
thrombosis
Migraine
Drug
Co-trimoxazole
IVIG
NSAIDS

What are the important things to know about

AIDS- associated cryptococcal meningitis?
Generally advanced with CD4 < 100
Sub-acute onset: fever, headache
Stiff neck is rare

Mortality with treatment is about 15%!

Predictors of death
Altered Mental status, low CSF WBC count, high
CSF cryptococcal antigen titer

What are the important things to know about

AIDS- associated cryptococcal meningitis?
CSF findings
Elevated pressure is the usual (>70%)
Rest of CSF findings are often unimpressive

WBC <50
Glucose: normal or slightly low
Protein: normal or slightly elevated
25% have normal WBC, glucose and protein

CSF cryptococcal antigen: 95-100% sensitive

What are the important things to know about

AIDS- associated cryptococcal meningitis?
Treatment
Medical
Induction: amphotericin B 0.7mg/kg x 2/52
(flucytosine)

Consolidation: fluconazole 400 mg x 8/52

Maintenance: fluconazole 200 mg

Pressure
Daily LPs to keep opening pressure <20
If LPs are still needed after 1 month
shunt

Questions from the Audience?

Meningitis Who was awake?

Which of the following are true statements?
a. Early viral meningitis can have a
predominance of polys
b. Some viral meningitis can have low CSF
glucose
c. Listeria meningitis can have predominance of
mononuclear cells rather than polys
d. All of the above

Meningitis Who was awake?

Which of the following are true statements?
a. Early viral meningitis can have a
predominance of polys
b. Some viral meningitis can have low CSF
glucose
c. Listeria meningitis can have predominance of
mononuclear cells rather than polys
d. All of the above

Meningitis Who was awake?

To correct CSF protein concentrations for blood in
the CSF the proper ratio is approximately 0.01
gm/L of protein for every 100 RBCs
a. True
b. False

Meningitis Who was awake?

To correct CSF protein concentrations for blood in
the CSF the proper ratio is approximately 0.01
gm/L of protein for every 100 RBCs
a. True
b. False

Meningitis Who was awake?

Which of the following are true about
cryptococcal meningitis?
a. A normal CSF effectively rules out
cryptococcal meningitis
b. If the CSF pressure is elevated one should
not remove more than 10 ml at a time
c. Everyone with HIV infection is at increased
risk for cryptococcal meningitis.

Meningitis Who was awake?

Which of the following are true about
cryptococcal meningitis?
a. A normal CSF effectively rules out
cryptococcal meningitis
b. If the CSF pressure is elevated one should
not remove more than 10 ml at a time
c. Everyone with HIV infection is at increased
risk for cryptococcal meningitis.
None