How to use clinical signs of meningitis

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Interpretations

How to use clinical signs of meningitis

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1. http://orcid.org/0000-0003-4109-3568Alexander Tracy1,
2. Thomas Waterfield2

1. ¹
   General Paediatrics, Birmingham Children’s Hospital, Birmingham, UK
   
2. ²
   School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
   

1. Correspondence to
   Dr Alexander Tracy, General Paediatrics, Birmingham Children’s Hospital, Birmingham B4 6NH, UK; alexander.tracy{at}nhs.net

Abstract

Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig’s sign and Brudzinski’s sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.

• infectious diseases
• general paediatrics
• statistics
• evidence-based medicine

http://dx. doi.org/10.1136/archdischild-2018-315428

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• infectious diseases
• general paediatrics
• statistics
• evidence-based medicine

Background

Meningitis describes inflammation of the meninges, which can be subclassified by aetiology (box 1). The most critical diagnosis to identify is bacterial meningitis as this has a poor prognosis when unrecognised.

Box 1

Key definitions

• Meningitis—a disease characterised by inflammation of the meninges. Meningitis may be due to bacterial, tuberculous, viral or fungal infections, or may be aseptic. Causes of aseptic meningitis include partially treated infections, neoplastic disease, drug administration and systemic inflammatory diseases.

• Meningism—a clinical syndrome of signs and symptoms that are suggestive of meningeal irritation. Symptoms may include headache, photophobia, neck stiffness and seizures. Signs may include nuchal rigidity, Kernig’s sign, Brudzinski’s sign or jolt accentuation headache.

Definitive diagnosis of meningitis is made on examination of cerebrospinal fluid obtained at lumbar puncture (LP). Clinical assessment plays an important role in stratification of patients before LP according to pretest probability of meningitis. Traditionally, the identification of clinical signs on examination is used to assess likelihood of meningitis. Nuchal rigidity, Kernig’s sign and Brudzinski’s sign are classical signs that date from the early 20th century but are still used routinely in paediatric practice.1

The physiological principle underlying these tests is that meningeal irritation can be elicited by performing certain movements. In each test, the clinician aims to stretch the meninges and thus elicit features of meningeal irritation (box 2).

Box 2

How to test for clinical signs of meningitis

• Neck stiffness: Passively flex the patient’s neck. This test is positive if there is palpable resistance.

• Kernig’s sign: Position the patients supine with their hips flexed to 90°. This test is positive if there is pain on passive extension of the knee.

• Brudzinski’s sign: Position the patients supine and passively flex their neck. This test is positive if this manoeuvre causes reflex flexion of the hip and knee.

To test for nuchal rigidity, the examiner flexes the patient’s neck and the test is positive if there is palpable resistance to passive flexion. To test for Kernig’s sign, the patients are positioned supine with their hips flexed to 90°. Kernig’s sign is present if there is pain on passive knee extension. To elicit Brudzinski’s sign, the patients lie supine and their necks are passively flexed by the examining clinician. The test is positive if this causes reflex flexion of the hip and knee. Figure 1 and online supplementary figure 2 demonstrates how to test for Kernig’s sign and Brudzinski’s sign.

Figure 1

How to examine for clinical signs of meningism. (A) Kernig’s sign. (B) Brudzinski’s sign.

Scenarios

Case 1: In febrile children over the age of 1 year, can the absence of clinical signs of meningism rule out meningitis?

Studies reporting the diagnostic accuracy of clinical signs of meningitis are summarised in table 1. Of note, these studies were performed in different populations, using inconsistent reference standards across a range of healthcare contexts including high and low-resource settings (box 3).

Table 1

A summary of studies quantifying the diagnostic performance of clinical signs of meningitis

Box 3

Limitations of research on diagnostic value of clinical signs of meningitis

• Inconsistent diagnostic reference standard.

• Uncertain microbiology, which is sometimes confounded by pretreatment with antibiotics.

• Low patient numbers, often making it impossible to test the performance of each sign for identification of bacterial meningitis per se.

• Interobserver variability.

• Variability between study settings, for example, developed versus developing world.

Even with these variations in study design and setting, all studies demonstrated that the absence of clinical signs of meningism reduced the likelihood of meningitis, with a combined negative likelihood ratio of 0.41 (95% CI 0.3 to 0.57).2
Table 2 further summarises the performance of different signs in isolation.

Table 2

Negative predictive values and likelihood ratios for clinical signs of meningitis

As with all diagnostic tests, it is necessary to consider the pretest probability when applying the test to clinical practice. A recent prospective study of 5517 paediatric hospital attendances with acute illness (excluding trauma, intoxication and exacerbation of chronic conditions) found that only 0. 308% of children were diagnosed with meningitis.3 Using this as a pretest probability, the risk of meningitis in a child presenting with an acute illness withoutsigns ofmeningism is 0.1% (table 4).

Table 4

Pretest and post-test probabilities of meningitis

In summary, absence of clinical signs of meningitis suggests a very low risk of meningitis assuming a low pretest probability. The absence of clinical signs is reassuring in low-risk children, but meningitis can occur without clinical signs of meningism.

Case 2: In febrile children over the age of 1 year, does the presence of clinical signs of meningism confirm the diagnosis of meningitis?

As summarised in table 3, the positive predictive values for each clinical sign vary between 0.39 and 0.81.4 5 The likelihood ratios for positive results range from 1.39 to 13.3.2 6 7 These data demonstrate that the presence of clinical signs of meningism increases the likelihood of meningitis.

Table 3

Positive predictive values and likelihood ratios for clinical signs of meningitis

However, as shown in table 4, the risk of meningitis remains under 1% even in the presence of signs of meningitis. This is due to the low prevalence of meningitis in febrile children. Although the overall risk remains low in children aged over 1 year, the presence of clinical signs of meningism confers an increased risk of meningitis. In this situation, further investigation including LP is likely to be required.

Case 3: Are clinical signs of meningism useful in children under the age of 1 year?

Children below the age of 2 months were not included in any study that quantified the performance of clinical signs of meningitis (table 1). Consensus opinion is that these examination findings are unreliable in infants.8

Furthermore, the risks of meningitis are much higher in young infants than in older children. For example, a prospective study of infants under the age of 90 days who presented with fever without source found the prevalence of bacterial meningitis to be 0.458%.9 Therefore, it is necessary to maintain a higher index of suspicion for meningitis when infants present with fever.

For this reason, the National Institute for Health and Care Excellence guidelines recommend LP in febrile infants under the age of 1 month, and in febrile infants aged 1–3 monthswho appear unwell.10

Clinical bottom line

• Bacterial meningitis is uncommon in children over the age of 1 year.

• Meningitis can be difficult to detect clinically.

• The absence of Kernig’s sign, Brudzinski’s sign and nuchal rigidity is reassuring in low-risk settings but cannot fully exclude meningitis.

• The presence of Kernig’s sign, Brudzinski’s sign and nuchal rigidity confers enough risk to justify further investigation.

References

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   2010;126:952–60.doi:10.1542/peds.2010-0277
   

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   . Point-of-care C reactive protein to identify serious infection in acutely ill children presenting to hospital: prospective cohort study. Arch Dis Child
   2018;103:420–6.doi:10.1136/archdischild-2016-312384
   

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   . Aetiology and clinical signs of bacterial meningitis in children admitted to Goroka Base Hospital, Papua New Guinea, 1989-1992. Ann Trop Paediatr
   1999;19:21–32.doi:10.1080/02724939992608
   

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   . Diagnostic accuracy of clinical symptoms and signs in children with meningitis. Pediatr Emerg Care
   2011;27:196–9.doi:10.1097/PEC.0b013e31820d6543
   

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   . Indicators of acute bacterial meningitis in children at a rural Kenyan district hospital. Pediatrics
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   . The diagnostic accuracy of the ’classic meningeal signs’ in children with suspected bacterial meningitis. Eur J Emerg Med
   2013;20:361–3.doi:10.1097/MEJ.0b013e3283585f20
   

8. ↵

   Nice. ‘National Institute for Health and care excellence’. meningitis and meningococcal septicaemia in under 16s: recognition, diagnosis and management. 2015:1–5
   https://www.nice.org.uk/guidance/cg102?unlid=501397575201621231125 (accessed 9 Aug 2018).

9. ↵
   2. Gomez
      B
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   3. Mintegi
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   4. Bressan
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      , et al

   . Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics
   2016;138:e20154381.doi:10.1542/peds.2015-4381
   

10. ↵

    National Institute for Health and Care. Fever in under 5s: assessment and initial management. https://www.nice.org.uk/guidance/cg160 (accessed 9 Aug 2018).

11. 2. Offringa
       M
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    3. Beishuizen
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    4. Derksen-Lubsen
       G
       , et al

    . Seizures and fever: can we rule out meningitis on clinical grounds alone?
    Clin Pediatr
    1992;31:514–22.doi:10.1177/000992289203100901
    

Footnotes

• Contributors AT conceived the work and contributed to the interpretation of data, drafting the manuscript and revising for intellectual content. TW contributed to the interpretation of data, drafting the manuscript and revising for intellectual content, and designed the figures.

• Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

• Competing interests None declared.

• Patient consent Parental/guardian consent obtained.

• Provenance and peer review Commissioned; externally peer reviewed.

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How Best to Rule Out Bacterial Meningitis? Neurologists Weig… : Neurology Today

• For Your Patients

February 6, 2007

ARTICLE IN BRIEF

• ✓ A new study reports that the Bacterial Meningitis Score is still helpful for helping to diagnose and distinguish children with bacterial versus viral meningitis. But some neurologists say better and quicker diagnostic methods will make this methodology obsolete.

Although most children in the US today are vaccinated against some bacteria that cause a possibly deadly form of meningitis, guidelines to determine which children have less serious viral infections work just as well, according to a study published in the Journal of the American Medical Association (2007;297:52–60). But some neurologists who specialize in neuroinfectious disease believe the guidelines could soon be obsolete.

The Bacterial Meningitis Score, as the guidelines are called, was devised to help physicians diagnose those children with viral meningitis, so they could avoid unnecessary hospital admission and a round of antibiotics, which would be ineffective against the disease and expose them to possible adverse reactions.

Lise E. Nigrovic, MD, MPH, of the division of emergency medicine at Children’s Hospital in Boston and Harvard Medical School, and two colleagues, Nathan Kupperman, MD, MPH, and Richard Malley, MD, developed the Bacterial Meningitis Score in 2002. The score was developed to help assess children with CSF pleocytosis (Pediatrics 2002;110:712–719). These children usually have flu-like symptoms — fever, anorexia, headache, and stiff neck. The symptoms tend to be similar in both bacterial and the far less serious viral meningitis, but only about 1 case in 25 is bacterial or fungal.

Culturing the CSF to detect bacteria provides a definite diagnosis, but results take two to three days. Waiting that long to begin treatment could be catastrophic, so physicians often hospitalize the children immediately and administer broad-spectrum antibiotics, either by injection or intravenous drip, just to be safe.

“I started as a resident in pediatrics, and I was admitting a lot of kids for meningitis and giving them antibiotics, but I realized most cases were viral, not bacterial, so the antibiotics were ineffective,” Dr. Nigrovic told 0″>Neurology Today. “I wondered if I could identify which cases were which to avoid admitting low-risk patients.”

The Bacterial Meningitis Score she developed classifies patients at very low risk of bacterial meningitis if they lack all of the following criteria:

• A CSF Gram stain for bacteria;
• CSF absolute neutrophil count (ANC) of at least 1,000 cells/ÌL;
• CSF protein of at least 80 mg/dL;
• Peripheral blood ANC of at least 10,000 cells/ÌL;
• A history of seizure before or at the time the patient is seen.

In the original study, none of the 144 patients classified as very low risk had bacterial meningitis. Since 2000, however, the heptavalent pneumococcal conjugate vaccine has been recommended for children under 2. Subsequently, the incidence of bacterial meningitis in children dropped, so Dr. Nigrovic and her colleagues set out to validate the Bacterial Meningitis Score to see if the widespread vaccination would alter the results.

“In the past, about two-thirds of (bacterial meningitis) cases were caused by pneumococcus,” Dr. Nigrovic said. “Now it’s only about 40 percent. So the bacteria haven’t gone away. Also there are many types of pneumococcal bacteria, and the vaccine covers only seven of them.”

Dr. Lise E. Nigrovic: “I started as a resident in pediatrics, and I was admitting a lot of kids for meningitis and giving them antibiotics, but I realized most cases were viral, not bacterial, so the antibiotics were ineffective. I wondered if I could identify which cases were which to avoid admitting low-risk patients.”

STUDY PROTOCOLS

Dr. Nigrovic and her colleagues included 3,295 children ranging in age from 29 days to 19 years who appeared at emergency departments at 20 US academic medical centers with CSF pleocytosis between January 2001 and June 2004. Of these patients, 121, or 3.7 percent, had bacterial meningitis, while 3,174 had aseptic, or nonbacterial, meningitis. Of the 1,714 patients categorized as very low risk according to the Bacterial Meningitis Score, only 2 had bacterial meningitis. Both were younger than 2 months, and both had E. coli meningitis and urinary tract infections, but the urinalysis in each case came back negative. As a result, the authors warn that the Bacterial Meningitis Score for infants younger than 2 months may be less accurate.

Of 1,189 patients categorized as not very low risk according to the Bacterial Meningitis Score, 119, or 10 percent, actually had bacterial meningitis.

Dr. Nigrovic and her colleagues attempted to refine the Bacterial Meningitis Score by emphasizing three variables in the following order: CSF protein level of 80 mg/dL, positive CSF Gram stain for bacteria, and peripheral ANC of at least 10,000 cells/ÌL. However, of the 1,786 patients who had none of these variables, 3, or 0.2 percent, actually had bacterial meningitis (the two infants plus another child). Therefore, the authors concluded that the original Bacterial Meningitis Score rather than the proposed refinement is better for identifying children with CSF pleocytosis who are at very low risk for bacterial meningitis. They also suggest hospital admission and immediate antibiotics for patients who have at least one risk factor, or who are younger than two months.

“Our low-risk model does not say that kids should go without antibiotics,” Dr. Nigrovic said, “just that physicians might consider outpatient management with strong consideration of a long-acting antibiotic such as ceftriaxone.”

NEW TESTS ON THE HORIZON

Some neurologists, who were not involved in the current study, doubt that the guidelines will be of much use, however. “Neurologists are not going to be comfortable with this Bacterial Meningitis Score,” said Karen Roos, MD, John and Nancy Nelson professor of neurology and professor of neurosurgery at the University of Indiana School of Medicine. “They’re not going to change their standard of care. I think it might be important for the pediatric emergency medicine group, but not for neurologists because bacterial meningitis is an emergency, and if you miss the diagnosis, the child could die. ”

Dr. Roos — who wrote Neurologic Infectious Diseases, and Meningitis: 100 Maxims in Neurology—predicted that the Bacterial Meningitis Score would soon be obsolete because new tests, such as the polymerase chain reaction (PCR) test, can identify bacterial meningitis quickly and reliably.

“The routine availability of newer technology will change clinical decision making,” she said. “In the next few months the laboratory here will be able to give me the results of a PCR for bacterial nucleic acid on blood in under 30 minutes. This, combined with CSF Gram stain, culture and bacterial PCR, and CSF enteroviral PCR, all readily available now, will guide the management of children with suspected meningitis. Bacterial meningitis is a neurological emergency. We do not want to ‘predict’ its presence or absence.”

Dr. Roos takes a dim view of clinical predictors of disease. “They’ve been around for a century,” she said. “The idea is if you can predict the likelihood of the absence of disease, you can actually streamline treatment and make it less expensive.”

But the dangers posed by bacterial meningitis, in her opinion, are so great that the risks outweigh the benefits of saving on antibiotic costs or avoiding unnecessary hospitalization.

“If patients survive bacterial meningitis, they may have neurological sequelae, and antibiotics are no problem,” she said. “We routinely order neuroimaging when patients don’t need it at a cost of $10,000 or so. It might cost $500 to give antibiotics.”

HOSPITALS LACK TOOLS FOR QUICK DETECTION

Larry E. Davis, MD, neurology service chief at the New Mexico VA Health Care System in Albuquerque, NM, agreed that costs of the various diagnostic tests can exceed the cost of routine antibiotics. But he noted that the antibiotics are almost always given intravenously. “Thus, you have to hospitalize the patient, and the hospital costs rapidly exceed the costs of the diagnostic tests,” he said.

He also noted that the ability to detect viral meningitis quickly might be a more effective way to quickly rule out bacterial meningitis. But, he added, many hospitals currently do not have rapid laboratory methods to detect bacteria or viral nucleic acid.

Dr. Karen Roos: “In the next few months the laboratory here will be able to give me the results of a PCR for bacterial nucleic acid on blood in under 30 minutes. This, combined with CSF Gram stain, culture and bacterial PCR, and CSF enteroviral PCR, all readily available now, will guide the management of children with suspected meningitis. Bacterial meningitis is a neurological emergency. We do not want to ‘predict’ its presence or absence.”

“Simultaneous bacterial and viral meningitis is very rare,” he said. “Many hospital physicians test CSF for enterovirus and herpes simplex. If the CSF is positive for either virus, they know it’s very unlikely to be bacterial meningitis. Then you can discharge the patient back to the family with close follow-up. ”

Dr. Davis admired the way the creators of the Bacterial Meningitis Score reversed the algorithm — instead of seeking evidence indicating that patients probably have bacterial meningitis, they developed criteria to identify patients that probably don’t.

But he found it strange that the creators of the Score, after demonstrating that their criteria were highly effective in detecting the absence of bacterial meningitis, recommended giving a long-acting antibiotic anyway.

“They didn’t cite a single study that says one dose of a long-acting antibiotic will kill a broad enough spectrum of bacteria sufficient to always cure the patient with bacterial meningitis,” he said. “Anytime a doctor discharges a patient with any form of meningitis, it is important that a responsible individual caring for the patient be present who could return that patient to the hospital if he or she worsens. Sending the patient home with one dose of an antibiotic could lead to a false sense of security. ”

Dr. Davis also noted that the study excluded many patients at higher risk for misclassification when they have symptoms of meningitis, and these exclusions should be taken into consideration by anyone using the Bacteria Meningitis Score with patients in the ER.

“While the Bacterial Meningitis Score has some value as a screening tool,” he said, “I doubt that its use will prevent most of the aseptic meningitis patients from being admitted to the hospital for at least observation and likely antibiotic coverage until the CSF culture report returns.”

The Bacterial Meningitis Score should always be used cautiously, Dr. Nigrovic emphasized. “This rule was derived and validated with kids who were not looking critically ill,” she said. “They didn’t have low blood pressure; they had no difficulty breathing; they did not have neurosurgical problems or suppressed immune systems. None of the patients had been pretreated with antibiotics prior to lumbar puncture. This was a population of kids who might very well have been sent home. We don’t think every low-risk patient will go home, but in the low-risk group, the risk is extremely low.”

Immunosuppressed children were excluded from the study, “but they aren’t candidates for going home,” she said.

In short, Dr. Nigrovic retains her confidence in the Bacterial Meningitis Score. “We were wondering how the performance of this decision-making tool would be now that vaccines are used,” she said. “The epidemiology has changed, but the rule performed just as well.”

REFERENCES

• Nigrovic LE, Kuppermann N, Malley R, et al. for the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA 2007;297:52–60.

symptoms, diagnostics, prices for treatment and appointments

Any disturbance in the functioning of the brain is dangerous for health and life in general. All often doctors are faced with a disease such as meningitis. It is an inflammatory process involving the membranes of the brain and spinal cord. If treatment is not started on time, the disease can lead to an extremely serious condition and complications.

What is meningitis?

Meningitis is an acute inflammatory process in the pia, arachnoid or dura mater. The soft shell is most commonly affected. Pathology is extremely dangerous, proceeds with severe headache, fever to high rates, excessive tone of the occipital muscles. It is more difficult to diagnose pathology in children. In them, the disease can be manifested by drowsiness, loss of appetite, irritability. The occurrence of an inflammatory process may be associated with the ingress of viruses, bacteria or protozoa.

Due to the fact that the focus of inflammation is located especially close to important organs, you should consult a doctor at the first sign. After the diagnosis of meningitis, treatment will be prescribed taking into account the identified flora. If you ignore the condition, the risk of developing dropsy of the brain, deafness, impaired individual brain functions, up to impaired mental development in a child, increases. In an adult, paresis, paralysis and death are possible.

Causes of meningitis

Most often inflammation is caused by enteroviruses, streptococci, neisseria. Often, meningitis develops as a complication of another infection in an acute or chronic form. The pathogen can enter the membranes of the brain with the flow of blood or lymph. It is not excluded infection of the child through the placenta. In more rare cases, infection occurs by contact during the outflow of cerebrospinal fluid

There are factors that increase the risk of developing pathology:

• Traumatic brain injury.
• Acute respiratory infections.
• Infections of the oral cavity, including diseased teeth and gums.
• Violation of the integrity of the bones with the outflow of cerebrospinal fluid.
• Infections of the sinuses of the skull.
• Operations on the brain or spinal cord.
• Pronounced decrease in the functions of the immune system.
• Chronic pathologies such as diabetes mellitus.
• Alcoholism.

In addition to the above, there is a high risk of meningitis in patients who are not vaccinated against meningococcal disease. This is especially true for people whose work is associated with constant contact with people of low social status and the sick.

Clinic pathology directly depends on what exactly provoked inflammation. Separate forms proceed with specific signs. So, meningococcal infection is always manifested by small rashes on the skin.

Symptoms of meningitis

Signs of meningitis directly depend on the age of the patient. Also important is the type of pathogen and the condition of the patient. All symptoms of pathology can be divided into non-specific, for example, weakness, fever, drowsiness, as well as symptoms of damage to the nervous system. These include a painful reaction to light, stiff neck, and hand tremors. In children and elderly patients, only a decrease in mood and weakness is possible.

Each case of infection is individual and the set of symptoms may vary significantly. In addition to the above, the following conditions may be signs of meningitis:

• Severe headache localized in the back of the head and along the back of the neck.
• Nausea and vomiting not related to eating.
• Increased heart rate.
• Pupil dilation.
• Convulsions, especially in children.
• Disturbance of consciousness.
• Daytime sleepiness.
• Great thirst.
• Skin eruptions.
• Aggravation of pains from a sharp sound or light.

Seek immediate medical attention if any of these symptoms occur. In a serious condition, an ambulance should be called. Not always the existing signs turn out to be meningitis, but in any case, the diagnosis of the pathology is extremely important. In children, a doctor should be called in case of weakness, drowsiness, mild soreness on the back of the neck, refusal to eat. At them the clinic of meningitis can be erased.

Diagnosis

Diagnosis of the disease is based on identifying the characteristic signs of pathology and performing a laboratory test. The neurologist conducts an examination, assesses the patient’s condition, identifies factors and risks of developing the disease. During the examination, it is possible to identify stiff neck, skin rash, pain on palpation of the base of the skull. After examination, the doctor prescribes laboratory tests and instrumental diagnostic methods. This allows you to determine the degree of damage and identify the pathogen.

The most commonly used methods for diagnosing meningitis are:

• Lumbar puncture. To do this, the doctor inserts a needle between the vertebrae in the lumbar region and collects 100-120 ml of cerebrospinal fluid. The procedure is safe, due to the use of anesthetics, it is not accompanied by severe pain. Immediately after taking the material, the patient is placed on his back. In this position, he should be within two hours.
• Blood tests. To conduct a study, a nurse takes blood from a vein to determine the general condition of the patient and identify bacterial or viral flora.
• CT or MRI are especially revealing. The methods are considered safe, they allow you to immediately obtain scan results and assess the patient’s condition. In addition, due to tomography, you can immediately exclude the likelihood of complications or prevent them.

Only after an examination can an accurate diagnosis be made.

Treatment of meningitis

Most cases of meningitis are treated in a hospital. Exceptions are situations when a person has a mild form. This situation can be observed in children, when there are no other signs besides weakness, runny nose, headache. In this case, the treatment is carried out on an outpatient basis under the supervision of a doctor. Babies under one year old are always hospitalized.

Therapy includes antibacterial agents, depending on the flora present, or antivirals. Also needed are analgesics for pain, antipyretic drugs, anti-inflammatory drugs. The course continues until the pathogenic flora is completely eliminated, which is confirmed by the analysis.

When a specific flora is identified, drugs active against it are prescribed. At the transition of the serous form to the purulent, corticosteroids are indicated.

Prevention

Prevention of meningitis includes the following recommendations:

• Vaccination against meningococcal infection.
• Timely treatment of chronic pathologies.
• Hardening of the body, physical activity.
• Avoid contact with sick people.

Inflammation of the meninges is extremely dangerous and often leads to complications. The sooner the manifestations are noticed and the fight against infection is started, the higher the chances of a person’s full recovery. If you suspect meningitis, you can contact the President-Med clinic. Our neurologists will conduct a complete examination, identify the cause of the disorder, and only then prescribe treatment. After its completion, a rehabilitation and prevention plan will be drawn up.

Fungal meningitis. What is fungal meningitis?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Fungal meningitis is a lesion of the pia and dura mater by a fungal infection with the development of inflammatory changes. The clinical picture is characterized by a subacute/chronic course with fever, headache, drowsiness, and mild meningeal symptoms. Diagnosis of fungal meningitis allows neurological examination, lumbar puncture, analysis of cerebrospinal fluid, identification of the pathogen in the blood and cerebrospinal fluid. The basis of treatment is antifungal pharmaceuticals used as monotherapy, combined and anti-relapse treatment.

ICD-10

G02* B37.5† B38.4†

• Causes of fungal meningitis
• Pathogenesis
• Classification
• Symptoms of fungal meningitis
• Complications
• Diagnostics
• Treatment of fungal meningitis
• Prognosis and prevention
• Treatment prices

General

Fungal (mycotic) meningitis is a rare form of infectious lesions of the cerebral membranes. Pathology occurs everywhere, the incidence rate is the same for both sexes. Fungal meningitis mainly affects immunocompromised patients and people in endemic areas of pathogens. Among AIDS patients, fungal cryptococcal meningitis is diagnosed in 6-13% of cases. In endemic areas, a large number of those infected with the fungus are detected, but only 1% of the pathogen occurs, which in 35% of cases is accompanied by damage to the meninges.

Fungal meningitis

Causes of fungal meningitis

The causative agents of the disease are various pathogenic and conditionally pathogenic fungi. Penetration into the body is carried out by airborne droplets (when inhaling fungal spores), alimentary (when eating food, water contaminated with spores) ways. A sick person is not a source of infection for others. The most common causative agents of meningitis of fungal etiology are:

• Cryptococcus. The most common pathogen is C. neoformans. It is released into the environment with bird droppings, is present on vegetables, fruits, and in the soil. Infection occurs with food, by inhalation of dust particles with spores. The vast majority of cases are AIDS patients.
• Candida. They belong to the natural flora of the human body. They cause the development of infectious diseases only against the background of immunodeficiency. Caused by these fungi, meningitis accounts for 15% of all candidal lesions of the central nervous system.
• Coccidia. Among the causative agents of coccidiosis, C. Immitis is the most common. Mycosis is observed in endemic regions of the United States, South and Central America. Damage to the meninges occurs against the background of disseminated infection more often in the elderly, pregnant women, patients with immune suppression.

The risk group for the development of mycotic meningitis of any etiology includes persons with immunodeficiency states: newborns, patients with HIV infection, who underwent cytostatic therapy for organ transplantation, oncological diseases, patients with chronic renal failure, diabetes mellitus, alcoholism, blood diseases, people over 60 years old.

Pathogenesis

Once in the body, the pathogen encounters a reaction of protective immunological factors that prevent the development of infection. Against the background of a reduced immune response, fungal spores are not destroyed, they are carried by blood flow to various organs and tissues, where the pathogen develops. The introduction of spores into the membranes of the brain becomes possible due to the increased permeability of the blood-brain barrier, which normally protects brain tissues from the penetration of large molecules circulating in the blood, including various infectious agents.

Fungal meningitis is accompanied by a serous inflammatory process. There is a thickening, clouding of the shell tissues, their surface acquires a finely bumpy character. Petechial hemorrhages are noted. The inflammatory process can move to the cerebral substance with the development of encephalitis, to the membranes of the spinal cord.

Classification

In practical neurology, the division of mycotic lesions of the membranes is used, depending on its specified etiology, the characteristics of the clinical course. In accordance with the type of pathogen, cryptococcal, candidal, coccidiosis, histoplasmic, aspergillus meningitis are distinguished. According to the course of the disease, fungal meningitis is classified into:

• Acute – characterized by sudden onset, rapid development of symptoms. It is rare, mainly with candidal etiology.
• Subacute – characterized by a delayed onset with a gradually progressive increase in symptoms. The most common option. Subsequently, it can become chronic.
• Chronic – symptoms persist for more than 4 weeks. The severity of clinical manifestations is moderate.

Symptoms of fungal meningitis

The onset of the disease is usually subacute (rarely acute), the subsequent course is chronic. The main symptoms are intense headache (cephalgia), vomiting, fever, anorexia, drowsiness. In a number of patients, cephalalgia occurs with repeated vomiting that does not bring relief. Body temperature is kept at the level of 37.2-37.9 degrees, sometimes reaches febrile values. There is a loss of appetite, perhaps an aversion to food. The patient is lethargic, sleeps a lot, gets tired quickly, looks inhibited. There is increased sensitivity to light. Convulsive paroxysms, anxiety, disorders of consciousness, focal symptoms are possible.

A distinctive feature is the weak severity of meningeal syndrome, sometimes – its complete absence. The meningeal symptom complex is a typical symptom of meningeal lesions and includes tension (rigidity) of the muscles of the neck, a specific posture of the patient, general hyperesthesia, and tonic phenomena detected during the examination. In subacute and chronic course, fungal meningitis may not be accompanied by meningeal symptoms, which greatly complicates the diagnosis.

Complications

In 40% of cases, fungal meningitis occurs with intracranial hypertension, which exacerbates cephalalgia and causes nausea and vomiting. When the infectious process spreads to the spinal membranes, a radicular syndrome occurs, signs of damage to the spinal cord: peripheral and central paresis, sensitivity disorders. The transition of the infectious-inflammatory process to cerebral tissues is accompanied by the development of focal symptoms, severe impairment of consciousness. Fungal encephalitis is dangerous due to the occurrence of cerebral edema, coma, and the death of the disease.

Diagnostics

Diagnostic difficulties are due to the erased symptoms, the absence of a pronounced meningeal syndrome, the presence of immunosuppression, which complicates the immunological diagnosis of the disease. The diagnosis is made using the following studies:

• Neurological examination. The neurologist pays attention to the presence and severity of meningeal symptoms, assesses the level of consciousness, reveals focal neurological deficit, signs of spinal cord injury (if any).
• Lumbar puncture. Allows you to determine the cerebrospinal fluid pressure, evaluate the color, degree of transparency of the cerebrospinal fluid. Subsequent examination of the cerebrospinal fluid confirms lymphocytic pleocytosis, the level of which depends on the type of pathogen, the stage of the disease. Microscopy of smears reveals the presence of fungal filaments in 50% of cases.
• MRI of the brain. It is necessary to exclude concomitant cerebral lesions: tuberculosis, toxoplasmosis. Mixed fungal-bacterial, protozoal-fungal infection occurs in immunocompromised patients.
• Laboratory tests. Aimed at verification of the pathogen, determination of its sensitivity to antimycotic drugs. Blood culture for sterility, microbiological examination of cerebrospinal fluid make it possible to exclude bacterial etiology, to detect the growth of fungal colonies. Enzyme immunoassay of cerebrospinal fluid for the presence of antimycotic antibodies in its specificity approaches 100%, however, in immunodeficient states it can give false negative results.

Differential diagnosis is carried out with bacterial meningitis, tuberculous meningitis, viral lesions of the membranes. In some cases, differentiation with meningioma, brain abscess, and cerebral tumor is required.

Treatment of fungal meningitis

The basis of therapy is the use of antimycotic pharmaceuticals. Prior to receiving the results of the determination of sensitivity, treatment is carried out empirically, then – taking into account the data obtained. The following therapy options are used:

• Monotherapy. It is carried out by slow intravenous drip. In cryptococcal etiology, life-threatening candidal meningitis, amphotericin B is indicated until data on the sensitivity of coccidia are obtained. In other cases, fluconazole has proven itself well. In the presence of indications, intrathecal administration of the drug is possible through a lumbar or ventricular puncture. Pharmacotherapy is carried out for a long time (1.5-2.5 months) until the cerebrospinal fluid is completely sanitized.
• Combination treatment. It is carried out with amphotericin in combination with fluconazole, flucytosine. This type of therapy is considered effective in patients with cryptococcal infection without concomitant HIV clinic. The optimal combination of drugs has not yet been found.
• Anti-relapse therapy. It is necessary to prevent the recurrence of the disease, even in the case of complete sanitation of the cerebrospinal fluid from the pathogen. Fluconazole is the drug of choice.

In parallel, symptomatic therapy is carried out. Relief of vomiting is achieved by the use of antiemetics, intracranial pressure is reduced by diuretics, and convulsive syndrome is treated with anticonvulsants.

Prognosis and prevention

Before the introduction of amphotericin into medical practice, fungal meningitis was 100% fatal. Now timely started, properly selected therapy allows you to save the patient’s life, to achieve his recovery. The prognosis of the disease depends on age, the state of the immune system, the timeliness of therapy, the speed of sanitation of the cerebrospinal fluid in response to the treatment. Recurrent fungal meningitis occurs in 40% of cases. In case of recovery, residual effects are possible in the form of a persistent increase in intracranial pressure, epilepsy, and cognitive impairment.