Bacterial meningitis differential diagnosis: Difference between revisions
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==Overview== | ==Overview== | ||
==Differential diagnosis== | ==Differential diagnosis== | ||
Bacterial meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:<ref name="pmid20582303">{{cite journal| author=Stern TA, Celano CM, Gross AF, Huffman JC, Freudenreich O, Kontos N et al.| title=The assessment and management of agitation and delirium in the general hospital. | journal=Prim Care Companion J Clin Psychiatry | year= 2010 | volume= 12 | issue= 1 | pages= PCC.09r00938 | pmid=20582303 | doi=10.4088/PCC.09r00938yel | pmc=2882819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20582303 }} </ref><ref name="pmid1278192">Soffer D (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1278192 Brain tumors simulating purulent meningitis.] ''Eur Neurol'' 14 (3):192-7. PMID: [http://pubmed.gov/1278192 1278192]</ref> | Bacterial meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:<ref name="pmid20582303">{{cite journal| author=Stern TA, Celano CM, Gross AF, Huffman JC, Freudenreich O, Kontos N et al.| title=The assessment and management of agitation and delirium in the general hospital. | journal=Prim Care Companion J Clin Psychiatry | year= 2010 | volume= 12 | issue= 1 | pages= PCC.09r00938 | pmid=20582303 | doi=10.4088/PCC.09r00938yel | pmc=2882819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20582303 }} </ref><ref name="pmid1278192">Soffer D (1976) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1278192 Brain tumors simulating purulent meningitis.] ''Eur Neurol'' 14 (3):192-7. PMID: [http://pubmed.gov/1278192 1278192]</ref><ref name="pmid3883130">Terheggen HG (1985) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3883130 [CNS tumors with the clinical picture of meningitis].] ''Monatsschr Kinderheilkd'' 133 (1):13-9. PMID: [http://pubmed.gov/3883130 3883130]</ref><ref name="pmid21371327">{{cite journal| author=Weston CL, Glantz MJ, Connor JR| title=Detection of cancer cells in the cerebrospinal fluid: current methods and future directions. | journal=Fluids Barriers CNS | year= 2011 | volume= 8 | issue= 1 | pages= 14 | pmid=21371327 | doi=10.1186/2045-8118-8-14 | pmc=3059292 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21371327 }}</ref><ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628 }}</ref><ref name="pmid23177603">{{cite journal| author=Han JH, Wilber ST| title=Altered mental status in older patients in the emergency department. | journal=Clin Geriatr Med | year= 2013 | volume= 29 | issue= 1 | pages= 101-36 | pmid=23177603 | doi=10.1016/j.cger.2012.09.005 | pmc=3614410 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23177603 }} </ref><ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755 }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345 }}</ref><ref name="pmid7105615">{{cite journal| author=Stein MT, Trauner D| title=The child with a stiff neck. | journal=Clin Pediatr (Phila) | year= 1982 | volume= 21 | issue= 9 | pages= 559-63 | pmid=7105615 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7105615 }} </ref><ref name="pmid17968200">{{cite journal| author=De Cauwer HG, Eykens L, Hellinckx J, Mortelmans LJ| title=Differential diagnosis between viral and bacterial meningitis in children. | journal=Eur J Emerg Med | year= 2007 | volume= 14 | issue= 6 | pages= 343-7 | pmid=17968200 | doi=10.1097/MEJ.0b013e328270366b | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17968200 }} </ref><ref name="pmid2810603">{{cite journal| author=Spanos A, Harrell FE, Durack DT| title=Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations. | journal=JAMA | year= 1989 | volume= 262 | issue= 19 | pages= 2700-7 | pmid=2810603 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2810603 }} </ref><ref name="pmid3137038">{{cite journal| author=Lindquist L, Linné T, Hansson LO, Kalin M, Axelsson G| title=Value of cerebrospinal fluid analysis in the differential diagnosis of meningitis: a study in 710 patients with suspected central nervous system infection. | journal=Eur J Clin Microbiol Infect Dis | year= 1988 | volume= 7 | issue= 3 | pages= 374-80 | pmid=3137038 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3137038 }} </ref><ref name="pmid18984423">{{cite journal| author=Naganuma M, Fujioka S, Inatomi Y, Yonehara T, Hashimoto Y, Hirano T et al.| title=Clinical characteristics of subarachnoid hemorrhage with or without headache. | journal=J Stroke Cerebrovasc Dis | year= 2008 | volume= 17 | issue= 6 | pages= 334-9 | pmid=18984423 | doi=10.1016/j.jstrokecerebrovasdis.2008.04.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18984423 }} </ref><ref name="pmid10916131">{{cite journal| author=Rajnik M, Ottolini MG| title=Serious infections of the central nervous system: encephalitis, meningitis, and brain abscess. | journal=Adolesc Med | year= 2000 | volume= 11 | issue= 2 | pages= 401-25 | pmid=10916131 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10916131 }} </ref> | ||
===Differentiating bacterial meningitis from other diseases=== | ===Differentiating bacterial meningitis from other diseases=== | ||
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Revision as of 16:50, 11 January 2017
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Bacterial meningitis Microchapters |
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Diagnosis |
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Treatment |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]
Overview
Differential diagnosis
Bacterial meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
Differentiating bacterial meningitis from other diseases
| Diseases | Diagnostic tests | Physical Examination | Symptoms | Past medical history | Other Findings | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Na+, K+, Ca2+ | CT /MRI | CSF Findings | Gold standard test | Neck stiffness | Motor or Sensory deficit | Papilledema | Bulging fontanelle | Cranial nerves | Headache | Fever | Altered mental status | |||
| Brain tumour[2] Determination of creatine kinase BB and carcinoembryonic antigenhelps in differentiating.[3] | ✔ | Cancer cells[4] | MRI | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Cachexia, gradual progression of symptoms | ||||
| Delerium Tremens | ✔ | Clinical diagnosis | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Alcohal intake, sudden witdrawl or reduction in consumption | Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, tachypnea | ||||
| Subarachnoid hemorrhage[15] | ✔ | Xanthochromia[5] | CT scan without contrast[7][8] | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Trauma/fall | Confusion, dizziness, nausea, vomiting | |
| Stroke | ✔ | Normal | CT scan without contrast | ✔ | ✔ | ✔ | ✔ | ✔ | TIAs, hypertension, diabetes mellitus | Speech difficulty, gait abnormality | ||||
| Neurosyphilis[16][17] | ✔ | ↑ Leukocytes and protein | CSF VDRL-specifc
CSF FTA-Ab -sensitive[18] |
✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Unprotected sexual intercourse, STIs | Blindness, confusion, depression,
Abnormal gait | |||
| Viral encephalitis | ✔ | Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose | Clinical assesment | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Tick bite/mosquito bite/ viral prodome for several days | Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes | ||
| Herpes simplex encephalitis | ✔ | Clinical assesment | ✔ | ✔ | ✔ | ✔ | ✔ | History of hypertension | Delirium, cortical blindness, cerebral edema, seizure | |||||
| Wernicke’s encephalopathy | Normal | ✔ | ✔ | ✔ | History of alcohal abuse | Ophthalmoplegia, confusion | ||||||||
| CNS abscess | ✔ | ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ red blood cells, lactic acid >500mg | Contrast enhanced MRI is more sensitive and specific,
Histopathological examination of brain tissue |
✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | History of drug abuse, endocarditis, ↓ immune status | High grade fever, fatigue,nausea, vomiting | ||
| Drug toxicity | ✔ | ✔ | Lithium, Sedatives, phenytoin, carbamazepine | |||||||||||
| Conversion disorder | Diagnosis of exclusion | ✔ | ✔ | ✔ | ✔ | ✔ | Tremors, blindness, difficulty swallowing | |||||||
| Electrolyte disturbance | ↓ or ↑ | Depends on the cause | ✔ | ✔ | Confusion, seizures | |||||||||
| Febrile seizures | Not performed in first simple febrile seizures | Clinical diagnosis and EEG | ✔ | ✔ | ✔ | ✔ | Family history of febrile seizures, viral illness or gastroenteritis | Age > 1 month, | ||||||
| Subdural empyema | ✔ | Clinical assesment and MRI | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | History of relapses and remissions | Blurry vision, urinary incontinence, fatigue | ||||
| Hypoglycemia | ↓ or ↑ | Serum blood glucose | ✔ | ✔ | ✔ | History of diabetes | Palpitations, sweating, dizziness, low serum, glucose | |||||||
Differentiating bacterial meningitis from other causes of meningitis
| Cerebrospinal Fluid | |||||
| Normal Levels | Acute Bacterial M. | Acute Viral M. | TB M. | Neuroborreliosis | |
| Cells/ul | < 5 | In the 1000s | In the 100s | In the 100s | Some 100 |
| Cells | Lymph:Monos 7:3 | Gran. > Lymph. | Lymph. > Gran. | Various leukos | Lymph. monocytic |
| Total Protein (mg/dl) | 45-60 | Typically 100-500 | Typically normal | Typically 100-200 | Typically up to 350 |
| Glucose Ratio (CSF/plasma) | Typically > 0.5 | < 0.3 | > 0.6 | < 0.5 | Normal |
| Lactate (mmol/l) | < 2.1 | > 2.1 | < 2.1 | > 2.1 | - |
| Others | ICP: 6-22 (cm H2O) | PCR of HSV-DNA | PCR of TBC-DNA | IgG/IgM CSF/Serum Ratio |
References
- ↑ Stern TA, Celano CM, Gross AF, Huffman JC, Freudenreich O, Kontos N; et al. (2010). "The assessment and management of agitation and delirium in the general hospital". Prim Care Companion J Clin Psychiatry. 12 (1): PCC.09r00938. doi:10.4088/PCC.09r00938yel. PMC 2882819. PMID 20582303.
- ↑ 2.0 2.1 Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
- ↑ 3.0 3.1 Terheggen HG (1985) [CNS tumors with the clinical picture of meningitis.] Monatsschr Kinderheilkd 133 (1):13-9. PMID: 3883130
- ↑ 4.0 4.1 Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
- ↑ 5.0 5.1 Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
- ↑ Han JH, Wilber ST (2013). "Altered mental status in older patients in the emergency department". Clin Geriatr Med. 29 (1): 101–36. doi:10.1016/j.cger.2012.09.005. PMC 3614410. PMID 23177603.
- ↑ 7.0 7.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
- ↑ 8.0 8.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
- ↑ Stein MT, Trauner D (1982). "The child with a stiff neck". Clin Pediatr (Phila). 21 (9): 559–63. PMID 7105615.
- ↑ De Cauwer HG, Eykens L, Hellinckx J, Mortelmans LJ (2007). "Differential diagnosis between viral and bacterial meningitis in children". Eur J Emerg Med. 14 (6): 343–7. doi:10.1097/MEJ.0b013e328270366b. PMID 17968200.
- ↑ Spanos A, Harrell FE, Durack DT (1989). "Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations". JAMA. 262 (19): 2700–7. PMID 2810603.
- ↑ Lindquist L, Linné T, Hansson LO, Kalin M, Axelsson G (1988). "Value of cerebrospinal fluid analysis in the differential diagnosis of meningitis: a study in 710 patients with suspected central nervous system infection". Eur J Clin Microbiol Infect Dis. 7 (3): 374–80. PMID 3137038.
- ↑ Naganuma M, Fujioka S, Inatomi Y, Yonehara T, Hashimoto Y, Hirano T; et al. (2008). "Clinical characteristics of subarachnoid hemorrhage with or without headache". J Stroke Cerebrovasc Dis. 17 (6): 334–9. doi:10.1016/j.jstrokecerebrovasdis.2008.04.009. PMID 18984423.
- ↑ Rajnik M, Ottolini MG (2000). "Serious infections of the central nervous system: encephalitis, meningitis, and brain abscess". Adolesc Med. 11 (2): 401–25. PMID 10916131.
- ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
- ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
- ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
- ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.