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Overview of Meningitis

By John E. Greenlee, MD

Last full review/revision November 2015 by John E. Greenlee, MD

Meningitis is inflammation of the meninges and subarachnoid space. It may result from
infections, other disorders, or reactions to drugs. Severity and acuity vary. Findings typically
include headache, fever, and nuchal rigidity, Diagnosis is by CSF analysis. Treatment
includes antimicrobial drugs as indicated plus adjunctive measures.

Meningitis may be classified as acute, subacute, chronic, or recurrent. It may also be
classified by its cause: bacteria, viruses, fungi, protozoa, or, occasionally, noninfectious
conditions. But the most clinically useful categories of meningitis are

 Acute bacterial meningitis
 Viral meningitis

 Noninfectious meningitis

 Recurrent meningitis

 Subacute and chronic meningitis

Acute bacterial meningitis is particularly serious and rapidly progressive. Viral and
noninfectious meningitides are usually self-limited. Subacute and chronic meningitides
usually follow a more indolent course than other meningitides, but determining the cause can
be difficult.

Aseptic meningitis, an older term, is sometimes used synonymously with viral meningitis;
however, it usually refers to acute meningitis caused by anything other than the bacteria that
typically cause acute bacterial meningitis. Thus, aseptic meningitis can be caused by viruses,
noninfectious conditions (eg, drugs, disorders), or, occasionally, other organisms (eg,
Borrelia burgdorferi in Lyme disease, Treponema pallidum in syphilis).

Symptoms and Signs

Symptoms and signs of the different types of meningitis may vary, particularly in severity and
acuity. However, all types tend to cause the following (except in infants):

 Headache
 Fever

 Nuchal rigidity (meningismus)

Patients may appear lethargic or obtunded.

from least to most sensitive. CSF Findings in Meningitis Condition Predominant Cell Protein* Glucose* Specific Tests Type* Condition Predominant Cell Protein* Glucose* Specific Tests Type* Normal CSF All lymphocytes‡ < 40 > 50 % of None . lumbar puncture can be done. If the skin over the needle insertion site is infected or if a subcutaneous or parameningeal lumbar infection is suspected. Clinical tests for it. lumbar puncture should usually be done if there is any suspicion of meningitis. neuroimaging—typically.Nuchal rigidity. a key indicator of meningeal irritation. In contrast. are  Kernig sign (resistance to passive knee extension)  Brudzinski sign (full or partial flexion of the hips and knees when the neck is flexed)  Difficulty touching the chin to the chest with the mouth closed  Difficulty touching the forehead or chin to the knee Nuchal rigidity can be distinguished from neck stiffness due to cervical spine osteoarthritis or influenza with severe myalgia: in these disorders. neck movement in all directions is usually affected. followed immediately by empiric treatment with antibiotics. Because meningitis can be serious and lumbar puncture is a safe procedure. blood cultures should be obtained. lumbar puncture is not done until the bleeding disorder is excluded or controlled. If patients have signs suggesting increased intracranial pressure (ICP) or a mass effect (eg. the neck can usually be rotated but cannot be flexed. CSF findings tend to differ by the type of meningitis but can overlap. thus. nuchal rigidity due to meningeal irritation affects mostly neck flexion. When lumbar puncture is deferred. In such patients. contrast- enhanced CT or MRI—is done before lumbar puncture. Diagnosis  CSF analysis Diagnosis is mainly by CSF analysis. lumbar puncture may cause brain herniation. deterioration in consciousness. focal neurologic deficits. the needle is inserted at a different site. especially if patients have HIV infection or are immunocompromised). Also. is resistance to passive or volitional neck flexion. After ICP has been lowered and if no mass is detected. seizures. papilledema. Nuchal rigidity may take time to develop. if a bleeding disorder is suspected.

or West Nile virus) during the first 24– 48 h) IgM (to check for West Nile virus or other arboviruses) Acid-fast staining † Tuberculous PMNs and Elevated < 50% of meningitis lymphocytes blood PCR (usually mixed glucose pleocytosis) (may be Mycobacterial culture extremely (ideally using a CSF low) sample of ≥ 30 mL) Interferon-γ tests of serum and (if available) CSF Cryptococcal antigen test Fungal Usually Elevated < 50% of meningitis lymphocytes blood Serologic tests for glucose Coccidioides immitisor (may be Histoplasma sp antigen extremely especially if patients have low) recently spent time in an endemic area Fungal culture (ideally using a CSF sample of ≥ 30 mL) India ink (for Cryptococcussp) *Changes in cell count. herpes and lymphocytes zoster. Positive CSF interferon-γ tests indicate . blood forming units of bacteria/ often greatly glucose mL are present) increased (may be extremely Bacterial culture low) PCR if available Sometimes PCR (to check Viral Lymphocytes (may Elevated Usually for enteroviruses or meningitis be mixed. and protein may be minimal in severely immunocompromised patients. and culture requires up to 8 wk. (0–5 cells/μL) mg/dL blood glucose Gram staining (yield is Bacterial Leukocytes Elevated < 50% of high if 105 colony- meningitis (usually PMNs). PMNs normal herpes simplex. sensitivity of PCR is only about 50%. glucose. CSF acid-fast staining can be insensitive. † In tuberculous meningitis.

and if it is strongly suspected. ‡ A small number of cells may be present normally in neonates or after a seizure. confirming a diagnosis of tuberculous meningitis is difficult. corticosteroids . Adjunctive treatments for meningitis can include  Supportive measures  Treatment of complications or of associated disorders  Removal of causative drugs  For bacterial meningitis. PMNs = polymorphonuclear neutrophils. Treatment  Antimicrobial therapy as indicated  Adjunctive treatments Infectious meningitis is treated with antimicrobial therapy as indicated clinically. even if not confirmed. PCR = polymerase chain reaction. but serum interferon-γ tests may only indicate prior infection. Thus. it is treated presumptively. tuberculous meningitis.