Practice Essentials

Meningitis is a clinical syndrome characterized by inflammation of the meninges. The image below depicts
acute bacterial meningitis.

Acute bacterial meningitis. This axial nonenhanced

computed tomography scan shows mild ventriculomegaly and sulcal effacement.

Signs and symptoms

The classic triad of bacterial meningitis consists of the following:

Fever
Headache
Neck stiffness
Other symptoms can include nausea, vomiting, photalgia (photophobia), sleepiness, confusion, irritability,
delirium, and coma. Patients with viral meningitis may have a history of preceding systemic symptoms (eg,
myalgias, fatigue, or anorexia).
The history should also address the following:

Epidemiologic factors and predisposing risks

Exposure to a patients or animals with a similar illness
Previous medical treatment and existing conditions
Geographic location and travel history
Season and temperature
Acute bacterial meningitis in otherwise healthy patients who are not at the extremes of age presents in a
clinically obvious fashion; however, subacute bacterial meningitis often poses a diagnostic challenge.
General physical findings in viral meningitis are common to all causative agents. Enteroviral infection is
suggested by the following:

Exanthemas
Symptoms of pericarditis, myocarditis, or conjunctivitis
Syndromes of pleurodynia, herpangina, and hand-foot-and-mouth disease

Infants may have the following:

Bulging fontanelle (if euvolemic)

Paradoxic irritability (ie, remaining quiet when stationary and crying when held)
High-pitched cry
Hypotonia
The examination should evaluate the following:

Focal neurologic signs

Signs of meningeal irritation
Systemic and extracranial findings
Chronic meningitis
In chronic meningitis, it is essential to perform careful general, systemic, and neurologic examinations, looking
especially for the following:

Lymphadenopathy
Papilledema and tuberculomas during funduscopy
Meningismus
Cranial nerve palsies
Patients with aseptic meningitis syndrome usually appear clinically nontoxic, with no vascular instability. They
characteristically have an acute onset of meningeal symptoms, fever, and CSF pleocytosis that is usually
prominently lymphocytic.
See Clinical Presentation for more detail.

Diagnosis
The diagnostic challenges in patients with clinical findings of meningitis are as follows:

Early identification and treatment of patients with acute bacterial meningitis

Assessing whether a treatable CNS infection is present in those with suspected subacute or chronic
meningitis

Identifying the causative organism

Blood studies that may be useful include the following:

Complete blood count (CBC) with differential

Serum electrolytes
Serum glucose (which is compared with the CSF glucose)
Blood urea nitrogen (BUN) or creatinine and liver profile
In addition, the following tests may be ordered:

Blood, nasopharynx, respiratory secretion, urine or skin lesion cultures

Syphilis testing
Serum procalcitonin testing
Lumbar puncture and CSF analysis
Neuroimaging (CT of the head and MRI of the brain)
See Workup for more detail.

Management
Initial measures include the following:

Shock or hypotension Crystalloids

Altered mental status Seizure precautions and treatment (if necessary), along with airway protection
(if warranted)

Stable with normal vital signs Oxygen, IV access, and rapid transport to the emergency department
(ED)
Treatment of bacterial meningitis includes the following:

Prompt initiation of empiric antibacterial therapy as appropriate for patient age and condition
After identification of the pathogen and determination of susceptibilities, targeted antibiotic therapy as
appropriate for patient age and condition

Steroid (typically, dexamethasone) therapy

In patients with nosocomial meningitis, intrathecal antibiotics

The following systemic complications of acute bacterial meningitis must be treated:

Hypotension or shock
Hypoxemia
Hyponatremia
Cardiac arrhythmias and ischemia
Stroke
Exacerbation of chronic diseases
Most cases of viral meningitis are benign and self-limited, but in certain instances, specific antiviral therapy may
be indicated, if available.
Other types of meningitis are treated with specific therapy as appropriate for the causative pathogen, as
follows:

Fungal meningitis - Cryptococcal (amphotericin B, flucytosine, fluconazole, itraconazole), Coccidioides

immitis (fluconazole, intrathecal amphoytericin B, itraconazole), Histoplasma capsulatum (liposomal
amphotericin B, itraconazole), or Candida (IM or aqueous penicillin G, probenecid)
Tuberculous meningitis (isoniazid, rifampin, pyrazinamide, ethambutol, streptomycin)
Parasitic meningitis Amebic (amphotericin B, miconazole, rifampin) or helminthic (largely supportive)
Lyme meningitis (ceftriaxone; alternatively, penicillin G, doxycycline, chloramphenicol)