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APPROACH TO MENINGITIS

Fever, nuchal rigidity and

headache

Brain
abscess
Meningitis
Associated with
seizures and focal
neurological
symptoms

Encephalitis
Neoplasm
Associated with
seizures and
altered mental
status

Associated with
seizures and focal
neurological
symptoms

Non infective
causes:
SLE
Associated with
other features of
SLE

Clinical features of Meningits

Features

Classical triad of bacterial meningitis

Fever
Nuchal rigidity
Altered mental status

Meningitis

Bacterial

-headache
-fever
-altered mental status
-ACUTE
-focal neurological
symptoms
-other symptoms like
SEPTICEMIA, JOINT
PAINS AND RASHES

Viral

-headache
-fever
-meningismus
-SELF LIMITING
-sub acute

Tuberculosis

-headache
-LOW GRADE
fever
-CHRONIC
-progresses to
altered
sensorium

Fungal

-headache
-fever
-IMMUNO
COMPROMISED

Signs of meningismus
Kernig and Brudzinski signs
The classic Brudzinski sign refers to
spontaneous flexion of the hips during
attempted passive flexion of the neck.

Kernigs sign
hip and knee are flexed to a right angle
knee is slowly extended
the appearance of resistance or pain during
extension of the patient's knees beyond 135
degrees constitutes a positive Kernig's sign

Mechanism
protective reaction to prevent the pain or
spasm of the hamstring muscles induced by
stretch of the inflamed and hypersensitive
nerve roots

Brudzinksis sign
one hand behind the patient's head and the
other on chest in order to prevent the patient
from rising
Reflex flexion of the patient's hips and knees
after passive flexion of the neck constitutes a
positive Brudzinski sign

Mechanism
passive flexion of the neck stretches the nerve
roots through the inflamed meninges, leading
to pain and flexion movements of lower
extremities.

Clinical use ?
are not very sensitive
when absent, should not be inferred as there
is no evidence of meningitis.
high specificity
if Kernig's or Brudzinski's sign is present, there
is a high likelihood for meningitis.

Did you know?

The symphyseal sign, in which pressure on the
pubic symphysis leads to abduction of the leg
and reflexive hip and knee flexion.
The cheek sign, in which pressure on the
cheek below the zygoma leads to rising and
flexion in the forearm.
Brudzinski's reflex, in which passive flexion of
one knee into the abdomen leads to
involuntary flexion in the opposite leg, and
stretching of a limb that was flexed leads to
contralateral extension

Meningitis
inflammatory disease of the leptomeninges, and is
defined by an abnormal number of white blood cells in
the cerebrospinal fluid (CSF).

infection of the arachnoid mater and the CSF in both the

subarachnoid space and the cerebral ventricles.

Risk factors
suppressed immune system
Not receiving mumps, Haemophilus influenzae type b, and
pneumococcal vaccines.
Age
Living and working with large groups of people (e.g., military
bases, child care facilities).
Contact with domestic animals (e.g., dairy farmers, ranchers)
and pregnant women acquire listeriosis.
Head injuries and brain surgery

Types of meningitis
Acute meningitis
Recurrent meningitis
Chronic meningitis

Causes
Bacteria
Community-acquired - S. pneumoniae, N. meningitidis, gp B streptococcus
Post-op or hospital acquired MRSA, Ps. Aeruginosa
H.influenzae common in children
In the very young and very old Listeria monocytogenes

Viruses

Enterovirus, coxsackie virus, echovirus, HSV-2, etc

TB
Fungi
cryptococcus

Pathology
Bacteria in nasopharynx
Cross the endothelium
Resistant to phagocytosis in blood
Enters choroid plexus
Enter CSF and resist phagocytosis
Inflammatory reaction

Recurrent meningitis

Leaking arachnoid cyst

Cryptogenic
Mollarets meningitis
Most common cause is HSV2
May respond to acyclovir

Complications
Septic shock, including disseminated intravascular
coagulation (DIC)
Coma with loss of protective airway reflexes
Seizures, which occur in 30-40% of children and
20-30% of adults
Cerebral edema

Thwaites scoring

Score <5=TBM, Score>4=BM

Lancet consensus score

MRC STAGING OF TB meningitis

Stage 1 Fully conscious, no paresis
Stage 2 Decreased level of consciousness,
localizing pain
Stage 3 Deeply comatose gross paresis

Prognosis
Systemic complications
Neurologic complications
impaired

In bacterial meningitis..
decreased level of consciousness on admission
onset of seizures within 24 h of admission,
signs of increased ICP,
young age (infancy) and age >50,
the presence of comorbid conditions including
shock and/or the need for mechanical ventilation,
delay in the initiation of treatment.
DecreasedCSF glucose concentration (<2.2
mmol/L [<40 mg/dL]) and markedly increased
CSF protein concentration (>3 g/L [> 300 mg/dL

Recap
Acute meningitis is commonly caused by
viruses and bacteria
Chronic meningitis - TB most commonly in
India
In HIV patients-Cryptococcus
Recurrent meningitis Mallorets

As in the case of
57 year old woman presented with history of high grade fever
for 2 months, intermittent holocranial headache for 2 months
and non projectile non bilious vomiting 5-10 minutes after
food for the past 2 months.
No h/o dizziness/blurring of vision/diplopia
No h/o seizure/stroke/syncope
O/E: concious, oriented, febrile
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, pedal
edema
Neck stiffness present

Resuscitate and stabilise the patient.

Initial tests (blood culture, PCR,
throat swab)

Emperical antibiotics
Transfer to critical care facility

Drowsy? Focal signs?

(possible mass lesion, hydrocephalus
or cerebral edema)

NO

YES

No other contraindications
for lumbar puncture

LUMBAR
PUNCTURE

CT Brain

NO mass, hydrocephalus
or any contraindications
for lumbar puncture

Blood studies
A complete blood count (CBC) with differential
Serum electrolytes, to determine SIADH
Serum glucose (which is compared with the CSF
glucose)
Blood urea nitrogen (BUN), creatinine and liver
profile
coagulation profile and platelet count to suspected
DIC or any liver problems

Other methods used to diagnose

meningitis
Chest X ray to detect tuberculosis
Nasal swab and stool for virology
Whole blood real-time PCR testing (EDTA sample) for N.
meningitidis
CT scan or computed tomography scan and MRI scan to check
for brain tumors, abscesses and other pathologies.
Blood antigen tests for Cryptococcus and India ink and CSF
cryptococcal antigen
Blood tests for syphilis

Lumbar puncture
This is performed immediately providing there
are no signs of raised intracranial pressure.
Video

ContraIndications for LP
1. Immunocompromised state
2. History of CNS disease (eg, mass lesion, stroke,
or focal infection)
3. Seizure within 1 week of presentation
4. Papilledema
5. Abnormal level of consciousness
6. Focal neurologic deficit (eg, dilated nonreactive
pupil, gaze palsy, or arm or leg drift)

CSF sample Handling

Tube 1 Send to the chemistry laboratory for glucose
and protein
Tube 2 Send to the hematology laboratory for a cell
count with differential
Tube 3 Send to the microbiology and immunology
laboratory
Tube 4 Hold for a repeat cell count with differential, if
needed (or for other subsequent studies not initially
ordered)

Microbiology and immunology studies

Gram stain
Bacterial culture
Acid-fast bacillus (AFB) stain and tuberculosis
cultures
India ink stain
Fungal cultures, counterimmunoelectrophoresis,
VDRL, and cryptococcal antigen, if indicated

Results of LP for our patient

Opening pressure: 280 mmH2O
Tube 1: glucose <5 mg/dl
protein 150 mg/dl
Tube 2: total count 4cells/cu.mm (Lymphocytes)
RBC 3 cells/cu.mm

Gram stain

Direct microscopy

Neisseria
meningitidis

Haemophilus
influenzae

Streptococcus
pneumoniae

Cryptococcus
neoformans

 India ink stain

Ziehl neelson

Culture
The utility of cultures is most evident when LP is delayed until
head imaging can rule out the risk of brain herniation, in
which cases antimicrobial therapy is rightfully initiated
before CSF samples can be obtained.
These cultures include the following:
Blood - 50% positive in meningitis caused by H influenzae, S
pneumoniae, or N meningitidis
Nasopharynx
Respiratory secretions
Urine
Skin lesions

Streptococcus pneumoniae

Niesseria meningtidis

Glucose and maltose

positive. Sucrose and
lactose negative.

Haemophilus influenzae

Our case..

Cryptococcal antigen detection- Lateral flow

assay

Special tests
Latex agglutination or counter-immunoelectrophoresis (CIE) of blood, urine, and CSF
for specific bacterial antigens.
polymerase chain reaction [PCR] for the
diagnosis of herpes simplex virus (HSV)
meningitis.

CT

Acute bacterial meningitis. This contrastenhanced, axial T1-weighted magnetic

resonance image shows leptomeningeal
enhancement (arrows).

Acute bacterial meningitis. This axial

nonenhanced computed tomography scan
shows mild ventriculomegaly and sulcal
effacement.

Cerebritis and developing abscess formation in

a patient with bacterial meningitis. This
contrast-enhanced axial computed
tomography scan shows leptomeningitis and
parenchymal enhancement (cerebritis) with a
low-attenuating area (edema) in the left basal
ganglia.

Subdural empyema and diffuse cerebral

edema in a patient with bacterial
meningitis. This axial computed
tomography scan shows bilateral subdural
effusion (empyema) and parenchymal
low-attenuating areas.