Meningitis
The classic triad of meningitis has been described as fever, neck stiffness, and altered mental status. All three of these are present together in less than half of adult patients with bacterial meningitis, but the absence of all three makes the diagnosis of meningitis unlikely - Michael T. Fitch MD PhD.
image by: Mikael Häggström
HWN Suggests
Meningitis: Clinical Pearls and Pitfalls
In medical school we were all taught the infamous Kernig and Brudzinski signs, and were practiced ad nauseam in our clinical medicine classes. The Kernig and Brudzinski signs have been shown to offer little to no help in diagnosing meningitis. Although there is a reported 95% specificity, the sensitivity is as low as 5%.9 These tests are antiquated, take up valuable time, and should have no real place in the evaluation of meningitis. The “jolt test” is a slightly more sensitive physical exam tool. This test is considered positive if the headache is accentuated by horizontal rotation of the head at a frequency of two to three times per second. But, studies of the jolt test produced variable…
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Meningitis in the ED Patient
The clinical presentation of both viral and bacterial meningitis is often indistinguishable. However, alterations in level of consciousness are absent in viral meningitis, which should trigger concern for either bacterial meningitis or encephalitis.
Articles of Interest
Emergency Department Management of Adults With Infectious Meningitis and Encephalitis
Infectious meningitis and encephalitis are often life-threatening illnesses, though prompt workup and targeted treatment can greatly reduce morbidity and mortality. Although presentation of central nervous system infection can sometimes be subtle, this issue focuses on evidence-based strategies for identifying combinations of signs and symptoms to narrow the diagnosis. Identifying meningitis versus encephalitis; bacterial versus viral, fungal, or iatrogenic causes; and providing prompt empiric antimicrobials and appropriate diagnostic testing are key to management.
Management of acute meningitis
Acute meningitis remains a devastating disease. Clinicians need a low threshold for suspecting meningitis, to undertake appropriate investigations and provide treatment in a timely manner, to minimise the risk of poor outcome in bacterial disease, while limiting unnecessary treatment in viral meningitis.
Meningitis – Diagnosis
In adults with community-acquired acute bacterial meningitis, the sensitivity of the classic triad of fever, neck stiffness, and altered mental status is low (44%), but almost all (95%) present with at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status (van de Beek et al., 2004; n= 696 patients).
Progress and challenges in bacterial meningitis
Bacterial meningitis is a devastating disease that is associated with substantial mortality and morbidity. The major causative bacteria are Streptococcus pneumoniae and Neisseria meningitis , with case-fatality rates of 30% and 7%, respectively, in high-income countries. In resource-poor countries, fatality rates can be as high as 50%.
Steroids for Adult Bacterial Meningitis
In adults, dexamethasone (10mg IV q6 hours for 4-days) in acute bacterial meningitis save lives (NNT=10) and prevent long-term neurological sequelae whether administered before or after antibiotics. Except for low-income countries, steroids in children reduced hearing loss (NNT=23) regardless of the causative organism.
Resources
Meningitis & Encephalitis
initial empiric therapy prior to LP: 2 grams ceftriaxone IV, 10 mg dexamethasone IV, 10 mg/kg acyclovir IV, (Subsequently adjust antibiotics based on LP results.).
