istory

Only about 44% of adults with bacterial meningitis exhibit the classic triad of fever, headache, and neck
stiffness.[12] These symptoms can develop over several hours or over 1-2 days. In a large prospective
study of 696 cases of adults with bacterial meningitis, van de Beek et al reported that 95% of the patients
had 2 out of the following 4 symptoms: fever, headache, stiff neck, and altered mental status. [12]
Other symptoms can include the following:

Nausea
Vomiting
Photalgia (photophobia) - Discomfort when the patient looks into bright lights
Sleepiness
Confusion
Irritability
Delirium
Coma
Approximately 25% of patients with bacterial meningitis present acutely, well within 24 hours of the onset
of symptoms. Occasionally, if a patient has been taking antibiotics for another infection, meningitis
symptoms may take longer to develop or may be less intense.
Approximately 25% of patients have concomitant sinusitis or otitis that could predispose to S
pneumoniae meningitis.[12] In contrast, patients with subacute bacterial meningitis and most patients with
viral meningitis present with neurologic symptoms developing over 1-7 days. Chronic symptoms lasting
longer than 1 week suggest the presence of meningitis caused by certain viruses or by tuberculosis,
syphilis, fungi (especially cryptococci), or carcinomatosis.
Patients with viral meningitis may have a history of preceding systemic symptoms (eg, myalgias, fatigue,
or anorexia). Patients with meningitis caused by the mumps virus usually present with the triad of fever,
vomiting, and headache. This follows the onset of parotitis (salivary gland enlargement occurs in 50% of
patients), which clinically resolves in 7-10 days.
As bacterial meningitis progresses, patients of any age may have seizures (30% of adults and children;
40% of newborns and infants). In patients who have previously been treated with oral antibiotics, seizures
may be the sole presenting symptom; fever and changes in level of alertness or mental status are less
common in partially treated meningitis than in untreated meningitis.
Atypical presentation may be observed in certain groups. Elderly individuals, especially those with
underlying comorbidities (eg, diabetes, renal and liver disease), may present with lethargy and an
absence of meningeal symptoms. Patients with neutropenia may present with subtle symptoms of
meningeal irritation.
Other immunocompromised hosts, including organ and tissue transplant recipients and patients with HIV
and AIDS, may also have an atypical presentation. Immunosuppressed patients may not show dramatic
signs of fever or meningeal inflammation.
A less dramatic presentationheadache, nausea, minimal fever, and malaisemay be found in patients
with low-grade ventriculitis associated with a ventriculoperitoneal shunt. Newborns and small infants also
may not present with the classic symptoms, or the symptoms may be difficult to detect. An infant may
appear only to be slow or inactive, or be irritable, vomiting, or feeding poorly. Other symptoms in this age
group include temperature instability, high-pitched crying, respiratory distress, and bulging fontanelles (a
late sign in one third of neonates).
Epidemiologic factors and predisposing risks should be assessed in detail. These may suggest the
specific etiologic agent.

Exposures

A history of exposure to a patient with a similar illness is an important diagnostic clue. It may point to the
presence of epidemic disease, such as viral or meningococcal meningitis.
Elicit any history of sexual contact or high-risk behavior from the patient. Herpes simplex virus (HSV)
meningitis is associated with primary genital HSV infection and HIV infection. A history of recurrent bouts
of benign aseptic meningitis suggests Mollaret syndrome, which is caused by HSV.
Animal contacts should be elicited. Patients with rabies could present atypically with aseptic meningitis;
rabies should be suspected in a patient with a history of animal bite (eg, from a skunk, raccoon, dog, fox,
or bat). Exposure to rodents suggests infection with lymphocytic choriomeningitis virus (LCM) virus
andLeptospira infection. Laboratory workers dealing with these animals also are at increased risk of
contracting LCM.
Brucellosis may be transmitted through contact with infected farm animals (eg, cows or pigs). The intake
of unpasteurized milk and cheese also predisposes to brucellosis, as well as to L
monocytogenes infection.

Previous medical treatment and existing conditions

A history of recent antibiotic use should be elicited. As many as 40% of patients who present with acute or
subacute bacterial meningitis have previously been treated with oral antibiotics (presumably because of
misdiagnosis at the time of initial presentation).
The presence of a ventriculoperitoneal shunt or a history of recent cranial surgery should be elicited.
Patients with low-grade ventriculitis associated with a ventriculoperitoneal shunt may have a less dramatic
presentation than those with acute bacterial meningitis, experiencing headache, nausea, minimal fever,
and malaise. The presence of cochlear implants with a positioner has been associated with a higher risk
of bacterial meningitis.
Alcoholism and cirrhosis are risk factors for meningitis. Unfortunately, the multiple etiologies of fever and
seizures in patients with alcoholism or cirrhosis make meningitis challenging to diagnose.

Location and travel

Geographic location and travel history are important in the evaluation of patients. Infection with H
capsulatum or B dermatitidis is considered in patients with exposure to endemic areas of the Mississippi
and Ohio River valleys; C immitis is considered in regions of the southwestern United States, Mexico, and
Central America. B burgdorferi is considered in regions of the northeastern and northern central United
States, if tick exposure is a possibility.

Season and temperature

The time of year is an important variable because many infections are seasonal. With enteroviruses
(which are found worldwide), infections occur during late summer and early fall in temperate climates and
year-round in tropical regions. In contrast, mumps, measles, and varicella-zoster virus (VZV) are more
common during winter and spring. Arthropod-borne viruses (eg, West Nile virus, St Louis encephalitis,
and California encephalitis virus) are more common during the warmer months.
Next Section: Physical Examination