Approach Considerations

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 central nervous system (CNS) infection is present in those with
suspected subacute or chronic meningitis

Identifying the causative organism

Bacterial meningitis must be the first and foremost consideration in the differential diagnosis of patients with
headache, neck stiffness, fever, and altered mental status. Acute bacterial meningitis is a medical emergency,
and delays in instituting effective antimicrobial therapy result in increased morbidity and mortality.
In general, whenever the diagnosis of meningitis is strongly considered, a lumbar puncture should be promptly
performed. Examination of the cerebrospinal fluid (CSF) is the cornerstone of the diagnosis. The diagnosis of
bacterial meningitis is made by culture of the CSF sample. The opening pressure should be measured and the
fluid sent for cell count (and differential count), chemistry (ie, CSF glucose and protein), and microbiology (ie,
Gram stain and cultures).
A concern regarding LP is that the lowering of CSF pressure from withdrawal of CSF could precipitate
herniation of the brain. Herniation can sometimes occur in acute bacterial meningitis and other CNS infections
as the consequence of severe cerebral edema or acute hydrocephalus. Clinically, this is manifested by an
altered state of consciousness, abnormalities in pupil reflexes, and decerebrate or decorticate posturing. The
incidence of herniation after LP, even in patients with papilledema, is approximately 1%.
A screening computed tomography (CT) scan of the head may be performed before LP to determine the risk of
herniation. A prospective study involving 301 adults with suspected meningitis found that the following baseline
patient characteristics were associated with an abnormal finding on head CT [16] :

Age 60 years
Immunocompromise (ie, HIV infection/AIDS, immunosuppressive therapy, or transplantation)
A history of CNS disease
A history of seizure within 1 week before presentation
Any abnormality on neurologic examination
These factors have been included in the Infectious Diseases Society of America guidelines to decide who
should undergo CT before LP.[17]
The decision to obtain a brain CT scan before LP should not delay the institution of antibiotic therapy; such
delay can increase mortality. It should be also noted that herniation can occur in patients with bacterial
meningitis who have a normal brain CT scan. The most reliable clinical signs that indicate the risk of herniation
include deteriorating level of consciousness, brainstem signs, and a very recent seizure.
Other laboratory tests, which may include blood cultures, are needed to complement the CSF culture. These
bacterial cultures are used for identification of the offending bacteria and occasionally its serogroup, as well as
for determination of the organisms susceptibility to antibiotics. Special studies, such as serology and nucleic
acid amplification, may also be performed, depending on clinical suspicion of an offending organism.
As many as 50% of patients with pneumococcal meningitis also have evidence of pneumonia on initial chest
radiography. This association occurs in fewer than 10% of patients with meningitis caused by H influenzae or N
meningitidis and in approximately 20% of patients with meningitis caused by other organisms. (See Imaging in
Bacterial Meningitis.)