Meningitis
This page is for adult meningitis. See Meningitis (peds) for the pediatric page.
Background
Microbiology
- Bacterial meningitis:
- Pneumococcus (60%), meningococcus (15%), group B streptococcus (15%), H flu (7%), listeria (2%)
- Viral meningitis
- Echovirus, coxsackies, enterovirus (85%)
- HSV, CMV, Herpes B virus
Pathophysiology
- Hematogenous spread via respiratory tract
- Contiguous spread (otitis media, sinusitis, brain abscess)
Risk Factors
- Otitis Media
- Sinusitis
- Immunosuppression/splenectomy
- Alcoholism
- Pneumonia
- Diabetes Mellitus
- CSF leak
- Endocarditis
- Neurosurgical procedure / head injury
- Indwelling neurosurgical device / cochlear implant
- Malignancy
- Drug induced aseptic meningitis
- NSAIDs
- Antimicrobials, see above page for list
Classification
- Acute (<24hr)
- Usually bacterial in origin (25%)
- Subacute (1-7d)
- Viral or bacterial
- Chronic (>7d)
Clinical Features
Almost all adults present with at least 2 of the following:[1]
- Headache
- Fever
- Neck stiffness
- Altered Mental Status
Other nonspecific symptoms include:
- Photophobia
- Vomiting
- Prodromal URI
- Focal neuro symptoms (e.g. CN deficit)
- Seizures
- Rash
- Approximately 2/3 of patients with meningococcemia develop rash.[2]
- Can include erythematous, morbilliform, or urticarial macules and papules[3]
- Most common hallmark is purpuric lesions with jagged edges. [4]
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Mild traumatic brain injury
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Altered mental status and fever
- Infectious
- Sepsis
- Meningitis
- Encephalitis
- Cerebral malaria
- Brain abscess
- Other
Evaluation
Physical Exam
Finding | Description | Sensitivity | Specificity |
Nuchal rigidity |
|
13%[5] | 80% [5] |
Kernig's sign |
|
2%[5] | 97%[5] |
Brudzinski's sign |
|
2%[5] | 98%[5] |
Jolt Test |
|
100%?^ |
^Although a 1991 study[6] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity.[7][8] Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% sensitive.
Work-Up
- CBC
- Chem
- Blood culture
- ?CT head: See CT Before Lumbar Puncture
- CXR (50% of patients with pneumoccocal meningitis have evidence of pneumonia on CXR)
- Lumbar Puncture
Lumbar Puncture Diagnosis
Measure | Normal | Bacterial | Aseptic (Viral) | Fungal | Tuberculosis | Subarachnoid hemorrhage | Neoplastic |
Appearance | Clear | Clear, cloudy, or purulent | Clear | Clear or opaque | Clear or opaque | Xanthochromia, bloody, or clear | Clear or opaque |
Opening Pressure (cm H2O) | 10-20 | >25 | Normal or elevated | >25 | >25 | >25 | Normal or elevated |
WBC Count^ (cells/µL) | 0-5^ | >100^ | 5-1000 | <500 | 50-500 | 0-5 (see correction section) | <500 |
% PMNs | >80-90% | 1-50%^^ | 1-50% | Early PMN then lymph | 1-50% | ||
Glucose | >60% of serum glucose | Low | Normal | Low | Low | Normal | Normal |
Protein^^^ (mg/dL) | < 45 | Elevated | Elevated | Elevated | Elevated | Elevated | >200 |
Gram Stain | Neg | Pos | Neg | India ink | Tb stain | Blood |
- ^Normal or lower WBC results may be found in immunocompromised, early, or partially treated (e.g. with oral antibiotics) bacterial menintigis, and those with tuberculosis meningitis
- ^^Lymph predominance may be found in patients with early bacterial meningitis or those that have been partially treated (e.g. with oral antibiotics)
- ^^^For unexplained elevations of protein, consider encephalitis, MS, Guillian Barre
Corrections
- WBC correction (for bloody tap)
- Simplified version (if peripheral WBC and RBC counts are within normal limits):
- Subtract 1 WBC for every 750 RBC in CSF
- Complex version (WBC and/or RBC not within normal limits):
- "WBCs added" = WBC(blood) x [RBC(CSF) / RBC(blood)]
- WBC counted/resulted - "WBCs added" = actual WBC
- Simplified version (if peripheral WBC and RBC counts are within normal limits):
- Protein correction (for bloody tap)
- For each 1000 RBC decrease protein value by 1mg/dl
Delay in LP
- CSF cultures become sterile in 2 hrs after parenteral antibiotics in meningococcal meningitis and 6 hrs in pneumococcal meningitis[9][10]
- 12 hrs after antibiotics: CSF glucose levels increase and protein levels decrease. CSF WBC and neutrophils are not affected[11]
Antibiotics
- Give as soon as possible (if LP performed within 2hr of antibiotics, CSF culture will not be affected)
Neonates (up to 1 month of age)[12]
MRSA is uncommon in the neonate
- Ampicillin 75mg/kg IV q6hrs PLUS
- Cefotaxime 50mg/kg IV q6hrs OR Gentamicin 2.5mg/kg IV q8hrs
- Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[13]
- If suspecting S. pneumoniae or MRSA, add Vancomycin
- Consider acyclovir for HSV
> 1 month old[14]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Adult < 50 yr[15]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Adult > 50 yr and Immunocompromised[16]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily PLUS
- Ampicillin 2gm IV q4h (hourly if listeria suspected)[17]
Post Procedural (or penetrating trauma)[18]
- Vancomycin 15-20mg/kg IV BID daily PLUS
- Cefepime 2g (50mg/kg) IV q8 hours daily OR Ceftazidime 2g (50mg/kg) IV q8 hours daily OR Meropenem 2gm (40mg/kg) IV q8 hours daily
Cryptococcosis Meningitis
Options
- Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
- Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
Meningitis with severe PCN allergy
- Chloramphenicol 1g IV q6h + Vancomycin 15mg/kg q8-12hr
Meningitis with VP shunt
- Coverage for skin contaminants (S. epidermis, S. aureus)
- Vancomycin plus ceftriaxone plus shunt removal
Neisseria meningitidis Prophylaxis
- Ceftriaxone 250mg IM once (if less than 15yr then 125mg IM)
- Ciprofloxacin 500mg PO once
- Rifampin 600 mg PO BID x 2 days
- if < 1 month old then 5mg/kg PO BID x 2 days
- if ≥ 1 month old then 10mg/kg (max at 600mg) PO BID x 2 days
If patient has a cephalosporin allergy, you can replace the third generation cephalosporin with Meropenem or chloramphenicol.
Steroids
- Dexamethasone in adults
- Only give 15 min prior to or with first dose of antibiotics
- 10mg IV q6hr x4d
- Overall, steroids only decreased mortality in patients with meningitis caused by Streptococcus pneumoniae[19]
- Steroids did decrease rates of any hearing loss, severe hearing loss, and any neurological sequelae in meningitis caused by all species
- This benefit was present in high-income countries but not in low-income countries
- Dexamethasone in children and infants
- There has been no mortality benefit found with steroid use in children[20]
- Steroids decreased the rate of hearing loss in children with meningitis caused by Haemophilus influenzae[21]
- Hydrocortisone for adrenal failure (Waterhouse–Friderichsen syndrome, bilateral adrenal hemorrhage causing adrenal failure, seen in meningococcemia)
Antivirals
- Acyclovir
- Consider for patients with suspected viral meningitis who present with neurologic deficits
- 10mg/kg IV q8hr (Obese patients should be dosed using ideal body weight)
Other Considerations
- Inpatient team may consider MRI with MRV for further diagnostic considerations
- If there is concern for tick-borne illness, it may be prudent to add doxycycline before ID consult can occur
Prophylaxis
Only for meningococcus exposure
Indications
- Household contacts
- School or day care contacts in previous 7 days
- Direct exposure to patient's secretions (kissing, shared utensils or toothbrush)
- Intubation without facemark
Prophylaxis regimen
Either of the options are acceptable
- Rifampin 600mg PO BID x2d
- 5mg/kg PO if < 1 month old
- 10mg/kg PO ≥ 1 month old
- Ceftriaxone 250mg IM x1
- 125mg IM if ≤ 15 years old
- Ceftriaxone should be used for pregnant patients
- Azithromycin[22]
- Pediatric: 10 mg/kg (maximum 500 mg), po x 1
- Adult: 500 mg, po x 1
- Ciprofloxacin 500mg PO x1
Disposition
Bacterial meningitis
- Admit with droplet precautions
Viral meningitis
- Admit for empiric antibiotics until culture results return OR
- Discharge with 24hr follow up
See Also
References
- ↑ van de Beek D. et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. 2004 Oct 28. 351(18):1849-59.
- ↑ Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
- ↑ Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
- ↑ Sara Bode; Contagious Exanthematous Diseases. Quick References 2022; 10.1542/aap.ppcqr.396150
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Nakao JH, et al. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24-28.
- ↑ Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
- ↑ Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
- ↑ Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
- ↑ Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibotic pretreatment. Pediatrics2001;108:1169–74
- ↑ Michael B1, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J 2010;27:6 433-438. PMID 20360497
- ↑ Lise E. Nigrovic, Richard Malley, Charles G. Macias, John T. Kanegaye, Donna M. Moro-Sutherland, Robert D. Schremmer, Sandra H. Schwab, Dewesh Agrawal, Karim M. Mansour, Jonathan E. Bennett, Yiannis L. Katsogridakis, Michael M. Mohseni, Blake Bulloch, Dale W. Steele, Ron L. Kaplan, Martin I. Herman, Subhankar Bandyopadhyay, Peter Dayan, Uyen T. Truong, Vince J. Wang, Bema K. Bonsu, Jennifer L. Chapman, Nathan Kuppermann. Effect of Antibiotic Pretreatment on Cerebrospinal Fluid Profiles of Children With Bacterial Meningitis. Pediatrics Oct 2008, 122 (4) 726-730. PMID 18829794
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ [Guideline] Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul. 15(7):649-59.
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.
- ↑ Mongelluzzo J, Mohamad Z, Ten Have TR, et al. Corticosteroids and mortality in children with bacterial meningitis. JAMA. 2008. 299(17):2048-2055.
- ↑ Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D. Corticosteroids for Acute Bacterial Meningitis. Cochrane Database of Systematic Reviews 2010, Issue 9.
- ↑ https://www.cdph.ca.gov/Programs/OPA/Pages/CAHAN/ca-discontinuation-of-ciprofloxacin-for-invasive-meningococcal-disease-pep.aspx
- ↑ https://www.cdph.ca.gov/Programs/OPA/Pages/CAHAN/ca-discontinuation-of-ciprofloxacin-for-invasive-meningococcal-disease-pep.aspx
- ↑ https://www.cdc.gov/mmwr/volumes/73/wr/mm7322e1.htm