Meningitis

Meningitis is inflammation of the meninges and subarachnoid space. It may

result from infections, other disorders, or reactions to drugs. Severity and
acuity vary. Findings typically include headache, fever, and nuchal rigidity,
Diagnosis is by cerebrospinal fluid (CSF) analysis. Treatment includes
antimicrobial drugs as indicated plus adjunctive measures.

Meningitis may be classified as acute, subacute, chronic, or recurrent. It may

also be classified by its cause: bacteria, viruses, fungi, protozoa, or, occasionally, noninfectious
conditions. But the most clinically useful categories of meningitis are

● Acute bacterial meningitis

● Viral meningitis
● Noninfectious meningitis
● Recurrent meningitis
● Subacute and chronic meningitis
● Meningeal inflammation as an atypical reaction to anti-inflammatory,
immunosuppressive, or other drugs
Acute bacterial meningitis is particularly serious and rapidly progressive. Viral and noninfectious
meningitides are usually self-limited. Subacute and chronic meningitides usually follow a more
indolent course than other meningitides, but determining the cause can be difficult.

Aseptic meningitis, an older term, is sometimes used synonymously with viral meningitis;
however, it usually refers to acute meningitis caused by anything other than the bacteria that
typically cause acute bacterial meningitis. Thus, aseptic meningitis can be caused by

● Viruses
● Noninfectious conditions (eg, drugs, disorders)
● Occasionally, other organisms (eg, Borrelia burgdorferi in Lyme disease,
Treponema pallidum in syphilis)
Symptoms and Signs of Meningitis
Symptoms and signs of the different types of meningitis may vary, particularly in severity and
acuity. However, all types tend to cause the following (except in infants and sometimes in the
very old and in immunosuppressed patients): Headache, Fever, Nuchal rigidity (meningismus)
Patients may appear lethargic or obtunded.
Nuchal rigidity, a key indicator of meningeal irritation, is resistance to passive or volitional neck
flexion. Nuchal rigidity may take time to develop. Clinical tests for it, from least to most sensitive,
are, Kernig sign (resistance to passive knee extension)
Brudzinski sign (full or partial flexion of the hips and knees when the neck is flexed)
Difficulty touching the chin to the chest with the mouth closed
Difficulty touching the forehead or chin to the knee
Nuchal rigidity can be distinguished from neck stiffness due to cervical spine osteoarthritis or
influenza with severe myalgia; in these disorders, neck movement in all directions is usually
affected. In contrast, nuchal rigidity due to meningeal irritation affects mostly neck flexion; thus,
the neck can usually be rotated but cannot be flexed.
Diagnosis of Meningitis
Cerebrospinal fluid (CSF) analysis
Meningitis is diagnosed mainly by CSF analysis. Because meningitis can be serious and lumbar
puncture is a safe procedure, lumbar puncture should usually be done if there is any suspicion
of meningitis. CSF findings differ by the type of meningitis but can overlap.

If patients have signs suggesting increased intracranial pressure or a mass effect (eg, focal
neurologic deficits, papilledema, deterioration in consciousness, seizures, especially if patients
have HIV infection or are immunocompromised), neuroimaging—typically, contrast-enhanced
CT or MRI—is done before lumbar puncture. In patients with increased intracranial pressure,
lumbar puncture may cause brain herniation, usually within hours of the procedure.

Also, if a bleeding disorder is suspected, lumbar puncture is not done until the bleeding disorder
is excluded or controlled.

When lumbar puncture is deferred, blood cultures should be obtained, followed immediately by
empiric treatment with antibiotics. After intracranial pressure has been lowered and if no mass is
detected, lumbar puncture can be done.

If the skin over the needle insertion site is infected or if a subcutaneous or parameningeal
lumbar infection is suspected, the needle is inserted at a different site, usually into the cisterna
magna or the upper cervical spine at C2 using radiologic guidance.
Treatment of Meningitis
Antimicrobial therapy as indicated
Adjunctive treatments
Infectious meningitis is treated with antimicrobial therapy as indicated clinically.
Adjunctive treatments for meningitis can include:
Supportive measures
Treatment of complications or of associated disorders
Removal of causative drugs
For bacterial meningitis, corticosteroids
https://www.msdmanuals.com/professional/neurologic-disorders/meningitis/overview-of-meningit
is