Meningitis: Difference between revisions

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{| class="infobox" style="float:right;"
|-
| [[File:Siren.gif|30px|link=Meningitis resident survival guide]]|| <br> || <br>
| [[Meningitis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{DiseaseDisorder infobox
{{DiseaseDisorder infobox
  | Name          = Meningitis
  | Name          = Meningitis
  | Image          = Illu_meninges.jpg
  | Image          = Illu_meninges.jpg
  | Caption        = Meninges of the central nervous system: dura mater, arachnoid, and pia mater.
  | Caption        = Meninges of the central nervous system: dura mater, arachnoid, and pia mater.
| DiseasesDB    = 22543
| ICD10          = {{ICD10|G|00||g|00}}-{{ICD10|G|03||g|00}}
| ICD9          =  {{ICD9|320}}-{{ICD9|322}}
| MedlinePlus    = 000680
| MeshID = D008581
  }}
  }}
{{Meningitis}}
{{Meningitis}}
'''For patient information click [[Meningitis (patient information)|here]].'''


'''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
{{CMG}}; {{AE}} {{NE}}{{MehdiP}}<br>
{{SK}} Leptomeningitis, Inflammation of meninges
==Overview==
The '''meninges''' (singular '''meninx''') is the system of [[Mesothelium|membrane]]s which envelop the [[central nervous system]]. The meninges consist  of three layers: the [[dura mater]], the [[arachnoid mater]], and the [[pia mater]]. The primary function of the meninges and of the cerebrospinal fluid is to protect the [[central nervous system]]. '''Meningitis''' is the [[inflammation]] of these protective membranes.<br> Meningitis may have been described in the Middle Ages, but it was first accurately identified by the Swiss Vieusseux (a scientific-literary association) during an outbreak in Geneva, Switzerland in 1805. In 1661, Thomas Willis first described the inflammation of meninges and an epidemic of meningitis. In the 17th century, Robert Whytt provided a detailed explanation of tuberculous meningitis and its stages. This was further elaborated by John Cheyne in the same century. Meningococcal meningitis was than described by Gaspard Vieusseux, Andre Matthey in Geneva and Elisa North in Massachussetes. <br>Meningitis may develop in response to a number of causes, including infectious agents ([[bacteria]], [[viruses]], [[fungi]], or other organisms) or non-infectious causes, such as systemic illnesses that may involve [[CNS]] (e.g. [[neoplasms]] or [[connective tissue diseases]], such as [[sarcoidosis]], [[systemic lupus erythematosus]] (SLE), and [[Granulomatosis with polyangiitis|wegener's]]) or certain drugs (e.g. [[nonsteroidal antiinflammatory drugs]], [[intravenous immunoglobulin]], intrathecal agents, and [[Sulfamethoxazole-Trimethoprim|trimethoprim-sulfamethoxazole]]). While some forms of meningitis are mild and resolve spontaneously (e.g. viral meningitis), meningitis is a potentially serious condition owing to the proximity of the [[inflammation]] to the [[brain]] and [[spinal cord]]. The potential for serious neurologic damage or even death necessitates prompt medical attention and evaluation. The common presenting features of meningitis are, [[fever]], [[neck stiffness]] and [[headache]]. Other symptoms include, [[photophobia]] (inability to tolerate bright light), [[phonophobia]] (inability to tolerate loud noises), [[irritability]], [[altered mental status]] (in small children), and [[seizure]]. Physical examination of meningitis may vary in adults and infants. In adults, physical examination findings may include [[bradycardia]], [[disorientation]], [[papilledema]], [[neck stiffness]], positive [[Brudzinski's Sign|brudzinski's]] and [[kernig's sign]]. However, [[petechial rash]], bulging [[fontanelle]], [[neck stiffness]], [[jaundice]], and [[convulsions]] are physical examination findings in infants. Diagnosis is based on clinical findings and [[CSF analysis]]. Treatment options are based on etiology and varies from supportive care and observing the patient (viral meningitis) to antibiotic therapy for bacterial meningitis or chemotherapy and/or irradiation for neoplastic meningitis.<ref name="pmid10411200">{{cite journal| author=Attia J, Hatala R, Cook DJ, Wong JG| title=The rational clinical examination. Does this adult patient have acute meningitis? | journal=JAMA | year= 1999 | volume= 282 | issue= 2 | pages= 175-81 | pmid=10411200 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10411200  }} </ref><ref name="abc">https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0047163/ Accessed on Jan 9th, 2017</ref><ref name="pmid20610819">{{cite journal| author=Brouwer MC, Tunkel AR, van de Beek D| title=Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. | journal=Clin Microbiol Rev | year= 2010 | volume= 23 | issue= 3 | pages= 467-92 | pmid=20610819 | doi=10.1128/CMR.00070-09 | pmc=2901656 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610819  }} </ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268  }} </ref><ref name="pmid15509818">{{cite journal| author=van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M| title=Clinical features and prognostic factors in adults with bacterial meningitis. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 18 | pages= 1849-59 | pmid=15509818 | doi=10.1056/NEJMoa040845 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15509818  }} </ref><ref>{{cite journal |author=van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M |title=Clinical features and prognostic factors in adults with bacterial meningitis |journal=N. Engl. J. Med. |volume=351 |issue=18 |pages=1849-59 |year=2004 |pmid=15509818 |doi=10.1056/NEJMoa040845}}</ref><ref name="pmid8416268">{{cite journal| author=Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS et al.| title=Acute bacterial meningitis in adults. A review of 493 episodes. | journal=N Engl J Med | year= 1993 | volume= 328 | issue= 1 | pages= 21-8 | pmid=8416268 | doi=10.1056/NEJM199301073280104 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8416268  }} </ref><ref name="pmid3403999">{{cite journal| author=Domingo P, Mancebo J, Blanch L, Net A, Nolla J| title=Fever in adult patients with acute bacterial meningitis. | journal=J Infect Dis | year= 1988 | volume= 158 | issue= 2 | pages= 496 | pmid=3403999 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3403999  }} </ref><ref name="pmid12060874">{{cite journal| author=Thomas KE, Hasbun R, Jekel J, Quagliarello VJ| title=The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. | journal=Clin Infect Dis | year= 2002 | volume= 35 | issue= 1 | pages= 46-52 | pmid=12060874 | doi=10.1086/340979 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12060874  }} </ref>


{{CMG}}; '''Associate Editor(s)-In-Chief:'''  {{CZ}}, [[User: Prashanthsaddala|Prashanth Saddala M.B.B.S]]


==[[Meningitis overview|Overview]]==


==[[Meningitis historical perspective|Historical Perspective]]==
==Causes==
<br>
{| align=center
|-
|
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
!align="center" style="background:#4479BA; color: #FFFFFF;" |Etiology
!align="center" style="background:#4479BA; color: #FFFFFF;" |Common causes
!align="center" style="background:#4479BA; color: #FFFFFF;" |Less common causes
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Bacterial
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Streptococcus pneumoniae]]
* [[Neisseria meningitis]]
* [[Haemophilus influenzae|Hemophilus influenza]]
* [[Group B streptococcus]]
* [[Listeria monocytogenes]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Staphylococcus aureus]]
* [[Klebsiella]]
* [[Pseudomonas]]
* [[Escherichia coli|E. coli]]
* [[Kingella|Kingella Kingae]]
* [[Mycobacterium tuberculosis]]
* [[Corynebacterium|Diphtheroids]]
* [[Propionibacterium acnes]]
* [[Serratia marcescens]]
* [[Salmonella|Salmonella species]]
* [[Brucella|Brucella sp]]
* [[Nocardia]]
* [[Francisella tularensis]]
* [[Streptococcus suis]]
* [[Ehrlichia|Ehrlichia chaffeensis]]


==[[Meningitis classification|Classification]]==
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Viral
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Enteroviruses]]
* [[Herpes simplex]] [[viruses]] 1 and 2
* [[Arboviruses]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Influenza virus]]
* [[Herpes zoster]]
* [[HHV-6 encephalitis|Human Herpes Virus 6]]
* [[Epstein barr virus mononucleosis|Epstein barr virus]] (EBV)
* [[Lymphocytic choriomeningitis virus]]
* [[Mumps]]
* [[Cytomegalovirus|Cytomegalo virus]] (CMV)
* [[Human Immunodeficiency Virus (HIV)|Human immunodeficiency virus]] (HIV)
* [[West nile virus]]
* [[HTLV|Human T cell lymphotrophic virus]] I and II
* [[Varicella zoster virus]]
*[[SARS-CoV-2 virus]] ([[Coronavirus|corona virus]])
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Fungal
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Cryptococcus neoformans]]
*[[Aspergillus]] sp.
*[[Blastomyces dermatitidis]]
*[[Coccidioides immitis]]
*[[Candida]] spp.
*[[Histoplasma capsulatum]]
*[[Sporothrix schenckii|Sporothrix schencki]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*Xylohypha (formerly [[Cladosporium]]) trichoides and other dark-walled (demateaceous) fungi such as [[Curvularia]] and Drechslera
*[[Mucor]]
*Arthrographis kalrae
*[[Pneumocystis jirovecii]]<ref name="pmid9495679">{{cite journal| author=Villanueva JL, Cordero E, Caballero-Granado FJ, Regordan C, Becerril B, Pachón J| title=Pneumocystis carinii meningoradiculitis in a patient with AIDS. | journal=Eur J Clin Microbiol Infect Dis | year= 1997 | volume= 16 | issue= 12 | pages= 940-2 | pmid=9495679 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9495679  }}</ref><ref name="pmid9629775">{{cite journal| author=Baena Luna MR, Muñoz García J, Grancha Bertolín L, Sanz García M| title=[Presence of Pneumocystis carinii in cerebrospinal fluid]. | journal=An Med Interna | year= 1998 | volume= 15 | issue= 5 | pages= 265-6 | pmid=9629775 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9629775  }}</ref>
*[[Cryptococcus]] albidus<ref name="pmid7185917">{{cite journal| author=Melo JC, Srinivasan S, Scott ML, Raff MJ| title=Cryptococcus albidus meningitis. | journal=J Infect | year= 1980 | volume= 2 | issue= 1 | pages= 79-82 | pmid=7185917 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7185917  }}</ref>


==[[Meningitis pathophysiology|Pathophysiology]]==
*[[Alternaria]] spp<ref name="pmid13730495">{{cite journal| author=OHASHI Y| title=On a rare disease due to Alternaria tenuis Nees (alternariasis). | journal=Tohoku J Exp Med | year= 1960 | volume= 72 | issue=  | pages= 78-82 | pmid=13730495 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13730495  }}</ref>


==[[Meningitis causes|Causes]]==
*[[Rhodotorula]] spp <ref name="pmid18974495">{{cite journal| author=Shinde RS, Mantur BG, Patil G, Parande MV, Parande AM| title=Meningitis due to Rhodotorula glutinis in an HIV infected patient. | journal=Indian J Med Microbiol | year= 2008 | volume= 26 | issue= 4 | pages= 375-7 | pmid=18974495 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18974495  }}</ref>


==[[Meningitis epidemiology and demographics|Epidemiology & Demographics]]==
*[[Acremonium]] spp.<ref name="pmid1956281">{{cite journal| author=Fincher RM, Fisher JF, Lovell RD, Newman CL, Espinel-Ingroff A, Shadomy HJ| title=Infection due to the fungus Acremonium (cephalosporium). | journal=Medicine (Baltimore) | year= 1991 | volume= 70 | issue= 6 | pages= 398-409 | pmid=1956281 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1956281  }}</ref>


==[[Meningitis risk factors|Risk Factors]]==
*Dreschlera spp<ref name="pmid4739938">{{cite journal| author=Fuste FJ, Ajello L, Threlkeld R, Henry JE| title=Drechslera hawaiiensis: causative agent of a fatal fungal meningo-encephalitis. | journal=Sabouraudia | year= 1973 | volume= 11 | issue= 1 | pages= 59-63 | pmid=4739938 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4739938  }}</ref>


==[[Meningitis screening|Screening]]==
*[[Malassezia]] spp<ref name="pmid15255040">{{cite journal| author=Rosales CM, Jackson MA, Zwick D| title=Malassezia furfur meningitis associated with total parenteral nutrition subdural effusion. | journal=Pediatr Dev Pathol | year= 2004 | volume= 7 | issue= 1 | pages= 86-90 | pmid=15255040 | doi=10.1007/s10024-003-4030-5 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15255040  }}</ref>


==[[Meningitis differential diagnosis|Differentiating Meningitis from other Diseases]]==
*[[Scedosporium apiospermum|Scedosporium]] spp<ref name="pmid16678041">{{cite journal| author=Symoens F, Knoop C, Schrooyen M, Denis O, Estenne M, Nolard N et al.| title=Disseminated Scedosporium apiospermum infection in a cystic fibrosis patient after double-lung transplantation. | journal=J Heart Lung Transplant | year= 2006 | volume= 25 | issue= 5 | pages= 603-7 | pmid=16678041 | doi=10.1016/j.healun.2005.12.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16678041  }}</ref>
 
*Arthrographis spp<ref name="pmid11158158">{{cite journal| author=Chin-Hong PV, Sutton DA, Roemer M, Jacobson MA, Aberg JA| title=Invasive fungal sinusitis and meningitis due to Arthrographis kalrae in a patient with AIDS. | journal=J Clin Microbiol | year= 2001 | volume= 39 | issue= 2 | pages= 804-7 | pmid=11158158 | doi=10.1128/JCM.39.2.804-807.2001 | pmc=87827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11158158  }}</ref>
 
*Blastoschizomyces<ref name="pmid1810730">{{cite journal| author=Girmenia C, Micozzi A, Venditti M, Meloni G, Iori AP, Bastianello S et al.| title=Fluconazole treatment of Blastoschizomyces capitatus meningitis in an allogeneic bone marrow recipient. | journal=Eur J Clin Microbiol Infect Dis | year= 1991 | volume= 10 | issue= 9 | pages= 752-6 | pmid=1810730 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1810730  }}</ref><ref name="pmid2324536">{{cite journal| author=Naficy AB, Murray HW| title=Isolated meningitis caused by Blastoschizomyces capitatus. | journal=J Infect Dis | year= 1990 | volume= 161 | issue= 5 | pages= 1041-2 | pmid=2324536 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2324536  }}</ref>
 
*[[Paecilomyces]]<ref name="pmid12588483">{{cite journal| author=Kantarcioğlu AS, Hatemi G, Yücel A, De Hoog GS, Mandel NM| title=Paecilomyces variotii central nervous system infection in a patient with cancer. | journal=Mycoses | year= 2003 | volume= 46 | issue= 1-2 | pages= 45-50 | pmid=12588483 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12588483  }}</ref><ref name="pmid7192726">{{cite journal| author=Fagerburg R, Suh B, Buckley HR, Lorber B, Karian J| title=Cerebrospinal fluid shunt colonization and obstruction by Paecilomyces variotii. Case report. | journal=J Neurosurg | year= 1981 | volume= 54 | issue= 2 | pages= 257-60 | pmid=7192726 | doi=10.3171/jns.1981.54.2.0257 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7192726  }}</ref>
 
*[[Aureobasidium]]<ref name="pmid22504065">{{cite journal| author=Kutleša M, Mlinarić-Missoni E, Hatvani L, Voncina D, Simon S, Lepur D et al.| title=Chronic fungal meningitis caused by Aureobasidium proteae. | journal=Diagn Microbiol Infect Dis | year= 2012 | volume= 73 | issue= 3 | pages= 271-2 | pmid=22504065 | doi=10.1016/j.diagmicrobio.2012.03.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22504065  }}</ref>
 
*Clavispora<ref name="pmid10030550">{{cite journal| author=Krcmery V, Mateicka F, Grausova S, Kunova A, Hanzen J| title=Invasive infections due to Clavispora lusitaniae. | journal=FEMS Immunol Med Microbiol | year= 1999 | volume= 23 | issue= 1 | pages= 75-8 | pmid=10030550 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10030550  }}</ref>
 
*[[Ustilago]]<ref name="pmid20991975">{{cite journal| author=MOORE M, RUSSELL WO, SACHS E| title=Chronic leptomeningitis and ependymitis caused by Ustilago, probably U. zeae (corn smut). | journal=Am J Pathol | year= 1946 | volume= 22 | issue=  | pages= 761-77 | pmid=20991975 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20991975  }}</ref>
 
*[[Exophiala]] (Wangiella)<ref name="pmid12530707">{{cite journal| author=Centers for Disease Control and Prevention (CDC)| title=Exophiala infection from contaminated injectable steroids prepared by a compounding pharmacy--United States, July-November 2002. | journal=MMWR Morb Mortal Wkly Rep | year= 2002 | volume= 51 | issue= 49 | pages= 1109-12 | pmid=12530707 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12530707  }}</ref>
 
*Exserohilum<ref name="pmid23465119">{{cite journal| author=Pettit AC, Pugh ME| title=Index case for the fungal meningitis outbreak, United States. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 10 | pages= 970 | pmid=23465119 | doi=10.1056/NEJMc1300630 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23465119  }}</ref>
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Spirochetal
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Treponema pallidum]]
* [[Borrelia burgdorferi|Borrelia burgdoferi]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" | --
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Protozoal and Helminthic
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Amebas (''[[Naegleria]], [[Acanthamoeba]],'' and ''[[Balamuthia mandrillaris|Balamuthia]])''
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Angiostrongylus cantonensis]]
* [[Gnathostoma Infection|Gnathostoma species]]
* [[Baylisascaris|Baylisascaris procyonis]]
* [[Toxocara|Toxocara species]]
* [[Taenia solium]]
|-
|style="padding: 5px 5px; background: #DCDCDC;" align="center" |Noninfectious conditions
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Neoplastic]]
* [[Sarcoidosis]]
* [[Systemic lupus erythematosus]]
* [[Granulomatosis with polyangiitis]] (Wegener's)
* [[Behçet's disease]]
|style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Fabry's disease|Fabry disease]]
* Central nervous system [[vasculitis]]
* [[Vogt-Koyanagi-Harada syndrome|Vogt-Koyanagi-Harada disease]]
* Chemical or drug-induced meningitis
** [[Nonsteroidal antiinflammatory drugs]]
** [[Intravenous immunoglobulin]]
** [[Intrathecal]] agents
** Certain antibiotics (eg, [[Sulfamethoxazole-Trimethoprim|trimethoprim-sulfamethoxazole]])
|}
<br>
|}
 
==Classification==
Meningitis could be classified to two main groups based on etiology:
*Infectious
*Non-infectious
===Infectious meningitis===
Infectious meningitis may be classified as the following algorithm based on chronicity of symptoms.<br><br>
{{familytree/start}}
{{familytree | | | | | | | | | | | | | | | A01 |A01='''Infectious Meningitis'''}}
{{familytree | | | | | |,|-|-|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | }}
{{familytree | | | | | B01 | | | | | | | | B02 | | | | | | | | | | | | | B03 | |B01=[[Viral meningitis|Viral]]|B02=[[Bacterial meningitis|Bacterial]]|B03=[[Fungal meningitis|Fungal]]}}
{{familytree | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | |,|-|-|-|v|-|^|-|v|-|-|-|.|}}
{{familytree | | | | | | | | | | | C01 | | C02 | | C03 | | | C04 | | C05 | | C06 | | |C07 |C01=Acute|C02=Chronic|C03=Recurrent|C04=Acute|C05=Subacute|C06=Chronic|C07=Recurrent|}}
{{familytree/end}}<br>
 
===Non-infectious meningitis===
Systemic illnesses, such as malignancies and connective tissue diseases (e.g. [[sarcoidosis]], [[SLE]], and [[Granulomatosis with polyangiitis|wegener's]]) may involve meninges in their course and present as chronic meningitis.
 
Certain drugs may cause meningeal irritation and resemble as meningitis including:
* [[Nonsteroidal antiinflammatory drugs]] (NSAIDs)
* [[Intravenous immunoglobulin]]
* [[Intrathecal]] agents
* Certain antibiotics (eg, [[Sulfamethoxazole-Trimethoprim|trimethoprim-sulfamethoxazole]])
==Differential diagnosis==
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |<small>Diseases</small>
! colspan="4" |<small>Symptoms
! colspan="5" |<small>Physical Examination</small>
! rowspan="2" |<small>Past medical history</small>
! colspan="3" |<small>Diagnostic tests</small>
! rowspan="2" |<small>Other Findings</small>
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!<small>Headache</small>
!↓<small>LOC</small>
!<small>Motor weakness</small>
!<small>Abnormal sensory</small>
!<small>Motor Deficit</small>
!<small>Sensory deficit</small>
!<small>Speech difficulty</small>
!<small>Gait abnormality</small>
!<small>Cranial nerves</small>
!<small>CT /MRI</small>
!<small>CSF Findings</small>
!<small>Gold standard test</small>
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Meningitis]]
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" |History of [[fever]] and [[malaise]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px; text-align:center" |'''↑''' [[Leukocytes]],
 
'''↑''' Protein
 
↓ Glucose
| style="background: #F5F5F5; padding: 5px;" |[[CSF analysis]]<ref name="pmid19398286">{{cite journal| author=Carbonnelle E| title=[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]. | journal=Med Mal Infect | year= 2009 | volume= 39 | issue= 7-8 | pages= 581-605 | pmid=19398286 | doi=10.1016/j.medmal.2009.02.017 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19398286  }}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Fever]], [[Neck rigidity|neck]]
[[Neck rigidity|rigidity]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Encephalitis]]
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" | +/-
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" |History of [[fever]] and [[malaise]]
| style="background: #F5F5F5; padding: 5px text-align:center" | +
| style="background: #F5F5F5; padding: 5px text-align:center" |'''↑''' [[Leukocytes]], ↓ Glucose
| style="background: #F5F5F5; padding: 5px text-align:center" |CSF [[PCR]]
| style="background: #F5F5F5; padding: 5px text-align:center" |[[Fever]], [[Seizure|seizures]], [[Focal neurologic signs|focal neurologic abnormalities]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Brain tumor]]<ref name="pmid10582668">{{cite journal| author=Morgenstern LB, Frankowski RF| title=Brain tumor masquerading as stroke. | journal=J Neurooncol | year= 1999 | volume= 44 | issue= 1 | pages= 47-52 | pmid=10582668 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10582668  }} </ref>
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Weight loss]], [[fatigue]]
|style="background: #F5F5F5; padding: 5px; text-align:center"| +
|style="background: #F5F5F5; padding: 5px text-align:center" |Cancer cells<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>
|style="background: #F5F5F5; padding: 5px;" |MRI
|style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hemorrhagic stroke]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Hypertension]]
|style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" |CT scan  without contrast<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>
|style="background: #F5F5F5; padding: 5px;" |[[Neck stiffness]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Subdural hematoma|Subdural hemorrhage]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Trauma]], fall
|style="background: #F5F5F5; padding: 5px; text-align:center" | +
|style="background: #F5F5F5; padding: 5px;" |Xanthochromia<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>
|style="background: #F5F5F5; padding: 5px;" |CT scan  without contrast<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>
|style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[dizziness]], [[nausea]], [[vomiting]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neurosyphilis]]<ref name="pmid22482824">{{cite journal| author=Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG et al.| title=Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients. | journal=J Neurol Sci | year= 2012 | volume= 317 | issue= 1-2 | pages= 35-9 | pmid=22482824 | doi=10.1016/j.jns.2012.03.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22482824  }} </ref><ref name="pmid24365430">{{cite journal |vauthors=Berger JR, Dean D |title=Neurosyphilis |journal=Handb Clin Neurol |volume=121 |issue= |pages=1461–72 |year=2014 |pmid=24365430 |doi=10.1016/B978-0-7020-4088-7.00098-5 |url=}}</ref>
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Sexually transmitted disease|STI]]<nowiki/>s
|style="background: #F5F5F5; padding: 5px; text-align:center" | +
|style="background: #F5F5F5; padding: 5px;" |'''↑''' [[Leukocytes]] and [[protein]]
|style="background: #F5F5F5; padding: 5px;" |CSF [[VDRL]]-specifc
CSF FTA-Ab -sensitive<ref name="pmid22421697">{{cite journal| author=Ho EL, Marra CM| title=Treponemal tests for neurosyphilis--less accurate than what we thought? | journal=Sex Transm Dis | year= 2012 | volume= 39 | issue= 4 | pages= 298-9 | pmid=22421697 | doi=10.1097/OLQ.0b013e31824ee574 | pmc=3746559 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22421697  }}</ref>
|style="background: #F5F5F5; padding: 5px;" |[[Blindness]], [[confusion]], [[depression]],
 
Abnormal [[gait]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Complex or atypical [[migraine]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" |Family history of [[migraine]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" |Clinical assesment
|style="background: #F5F5F5; padding: 5px;" |Presence of aura, [[nausea]], [[vomiting]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Hypertensive encephalopathy]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" |[[Hypertension]]
|style="background: #F5F5F5; padding: 5px;" | +
|style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" |Clinical assesment
|style="background: #F5F5F5; padding: 5px;" |[[Delirium]], [[cortical blindness]], [[cerebral edema]], [[seizure]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Wernicke's encephalopathy|Wernicke’s encephalopathy]]
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" |History of alcohal abuse
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |Clinical assesment and lab findings
|style="background: #F5F5F5; padding: 5px;" |[[Ophthalmoplegia]], [[confusion]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Brain abscess|CNS abscess]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" |History of [[drug abuse]], [[endocarditis]], [[immunosupression]]
|style="background: #F5F5F5; padding: 5px;" | +
|style="background: #F5F5F5; padding: 5px;" |'''↑''' leukocytes, '''↓''' glucose and '''↑''' protien
|style="background: #F5F5F5; padding: 5px;" |MRI is more sensitive and specific
|style="background: #F5F5F5; padding: 5px;" |High grade [[fever]], [[fatigue]],[[nausea]], [[vomiting]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]]
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |Drug screen test
|style="background: #F5F5F5; padding: 5px;" |[[Lithium]], [[Sedatives]], [[phenytoin]], [[carbamazepine]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" |
|style="background: #F5F5F5; padding: 5px text-align:center" |History of [[emotional stress]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" | -
|style="background: #F5F5F5; padding: 5px;" |Diagnosis of exclusion
|style="background: #F5F5F5; padding: 5px;" |[[Tremor|Tremors]], [[blindness]], difficulty [[swallowing]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |Metabolic disturbances ([[electrolyte imbalance]], [[hypoglycemia]])
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |[[Hypoglycemia]], [[Hyponatremia|hypo]] and [[hypernatremia]], [[Hypokalemia|hypo]] and [[hyperkalemia]]
|style="background: #F5F5F5; padding: 5px;" |Depends on the cause
| style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[seizure]], [[Palpitation|palpitations]], [[sweating]], [[dizziness]], [[hypoglycemia]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]] exacerbation
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" |History of relapses and remissions
| style="background: #F5F5F5; padding: 5px; text-align:center" | +
| style="background: #F5F5F5; padding: 5px; text-align:center" |'''↑'''  CSF IgG levels
(monoclonal bands)
| style="background: #F5F5F5; padding: 5px;" |Clinical assesment and [[MRI]] <ref name="pmid8274111">{{cite journal| author=Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH et al.| title=Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group. | journal=Arch Neurol | year= 1994 | volume= 51 | issue= 1 | pages= 61-6 | pmid=8274111 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8274111  }}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Blurred vision|Blurry vision]], [[urinary incontinence]], [[fatigue]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Seizure]]
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | -
|style="background: #F5F5F5; padding: 5px text-align:center" | +
|style="background: #F5F5F5; padding: 5px text-align:center" |Previous history of [[seizures]]
| style="background: #F5F5F5; padding: 5px;" | -
| style="background: #F5F5F5; padding: 5px;" |Mass lesion
| style="background: #F5F5F5; padding: 5px;" |Clinical assesment and [[EEG]] <ref name="pmid11385043">{{cite journal| author=Manford M| title=Assessment and investigation of possible epileptic seizures. | journal=J Neurol Neurosurg Psychiatry | year= 2001 | volume= 70 Suppl 2 | issue= | pages= II3-8 | pmid=11385043 | doi= | pmc=1765557 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11385043  }}</ref>
| style="background: #F5F5F5; padding: 5px;" |[[Confusion]], [[apathy]], [[irritability]],
|}


==[[Meningitis natural history|Natural History, Complications & Prognosis]]==


==Diagnosis==
==Diagnosis==
[[Meningitis history and symptoms|History and Symptoms]] | [[Meningitis physical examination|Physical Examination]] | [[Meningitis laboratory findings|Laboratory Findings]] | [[Meningitis electrocardiogram|Electrocardiogram]] | [[Meningitis chest x ray|Chest X Ray]] | [[Meningitis CT|CT]] | [[Meningitis MRI|MRI]] | [[Meningitis echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Meningitis other imaging findings|Other Imaging Findings]] | [[Meningitis other diagnostic studies|Other Diagnostic Studies]]
Diagnosis of meningitis, is based on clinical presentation in combination with CSF analysis. CSF analysis has major role for diagnosis and rule out other possibilities. The following table summarizes the CSF findings in different types of meningitis.<ref name="pmid23717798">{{cite journal| author=Le Rhun E, Taillibert S, Chamberlain MC| title=Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. | journal=Surg Neurol Int | year= 2013 | volume= 4 | issue= Suppl 4 | pages= S265-88 | pmid=23717798 | doi=10.4103/2152-7806.111304 | pmc=3656567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23717798  }} </ref><ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618  }} </ref><ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096  }} </ref><ref name="pmid10654948">{{cite journal| author=Negrini B, Kelleher KJ, Wald ER| title=Cerebrospinal fluid findings in aseptic versus bacterial meningitis. | journal=Pediatrics | year= 2000 | volume= 105 | issue= 2 | pages= 316-9 | pmid=10654948 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10654948  }} </ref><ref name="pmid20610819">{{cite journal| author=Brouwer MC, Tunkel AR, van de Beek D| title=Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis. | journal=Clin Microbiol Rev | year= 2010 | volume= 23 | issue= 3 | pages= 467-92 | pmid=20610819 | doi=10.1128/CMR.00070-09 | pmc=2901656 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610819  }} </ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Cerebrospinal fluid level}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Normal level}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Bacterial meningitis}}<ref name="pmid10654948">{{cite journal| author=Negrini B, Kelleher KJ, Wald ER| title=Cerebrospinal fluid findings in aseptic versus bacterial meningitis. | journal=Pediatrics | year= 2000 | volume= 105 | issue= 2 | pages= 316-9 | pmid=10654948 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10654948  }} </ref>
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Viral meningitis (except SARS-CoV-2 meningitis)}} <ref name="pmid10654948">{{cite journal| author=Negrini B, Kelleher KJ, Wald ER| title=Cerebrospinal fluid findings in aseptic versus bacterial meningitis. | journal=Pediatrics | year= 2000 | volume= 105 | issue= 2 | pages= 316-9 | pmid=10654948 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10654948  }} </ref>
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|SARS-CoV-2 associated meningitis}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Fungal meningitis}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Tuberculous meningitis}}<ref name="pmid20146981">{{cite journal| author=Caudie C, Tholance Y, Quadrio I, Peysson S| title=[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]. | journal=Ann Biol Clin (Paris) | year= 2010 | volume= 68 | issue= 1 | pages= 107-11 | pmid=20146981 | doi=10.1684/abc.2010.0407 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20146981  }} </ref>
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Neoplastic meningitis}}<ref name="pmid23717798">{{cite journal| author=Le Rhun E, Taillibert S, Chamberlain MC| title=Carcinomatous meningitis: Leptomeningeal metastases in solid tumors. | journal=Surg Neurol Int | year= 2013 | volume= 4 | issue= Suppl 4 | pages= S265-88 | pmid=23717798 | doi=10.4103/2152-7806.111304 | pmc=3656567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23717798  }} </ref>
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Cells/ul'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''< 5'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''>300'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''10-1000'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''10-1000'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''10-500'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''50-500'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''>4'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Cells'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Lymphocyte]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Leukocyte]] > [[Lymphocyte]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Lymphocyte]] > [[Leukocyte]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Lymphocyte]] > [[Neutrophil]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Lymphocyte]] > [[Leukocyte]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Lymphocyte]] > [[Leukocyte]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Lymphocyte]] > [[Leukocyte]]'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Total protein (mg/dl''')
| style="padding: 5px 5px; background: #F5F5F5;" |'''45-60'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Typically 100-500'''
| style="padding: 5px 5px; background: #F5F5F5;" | '''Normal or slightly high'''
| style="padding: 5px 5px; background: #F5F5F5;" | '''Normal or slightly high'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''High'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Typically 100-200'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''>50'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Glucose ratio (CSF/plasma)<ref name="pmid24326618">{{cite journal| author=Chow E, Troy SB| title=The differential diagnosis of hypoglycorrhachia in adult patients. | journal=Am J Med Sci | year= 2014 | volume= 348 | issue= 3 | pages= 186-90 | pmid=24326618 | doi=10.1097/MAJ.0000000000000217 | pmc=4065645 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24326618  }} </ref>'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''> 0.5'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''< 0.3'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''> 0.6'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''> 0.6'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''<0.3'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''< 0.5'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''<0.5'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Lactate (mmols/l)<ref name="pmid22880096">{{cite journal| author=Leen WG, Willemsen MA, Wevers RA, Verbeek MM| title=Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice. | journal=PLoS One | year= 2012 | volume= 7 | issue= 8 | pages= e42745 | pmid=22880096 | doi=10.1371/journal.pone.0042745 | pmc=3412827 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22880096  }} </ref>'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''< 2.1'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''> 2.1'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''< 2.1'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''NA'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''>3.2'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''> 2.1'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''>2.1'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Others'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[Intracranial pressure|Intra-cranial pressure]] (ICP) = 6-12 (cm H2O)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''CSF [[gram stain]], CSF culture, CSF bacterial antigen'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[PCR]] of HSV-DNA, VZV'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''RT-PCR for detection of viral RNA i n CSF ( not approved by FDA)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''CSF [[gram stain]], CSF india ink'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''[[PCR]] of TB-DNA'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''CSF tumour markers such as [[Alpha-fetoprotein|alpha fetoprotein]], [[CEA]]'''
|-
|}


==Treatment==
==Treatment==
===[[Meningitis medical therapy|Medical therapy]]===
===Medical Therapy===
[[Meningitis medical therapy#Bacterial meningitis|Bacterial meningitis]] | [[Meningitis medical therapy#Viral meningitis|Viral meningitis]] | [[Meningitis medical therapy#Fungal meningitis|Fungal meningitis]]
 
===[[Meningitis surgery|Surgery]]===
*Empiric therapy for meningitis must be initiated after CSF obtained.
===[[Meningitis primary prevention|Primary Prevention]]===
*The choice of empiric antibiotic therapy is depend on patient age and underlying comorbid disease.
===[[Meningitis secondary prevention|Secondary Prevention]]===
*Adapted from IDSA guidlines.
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Predisposing factor}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Common bacterial pathogen}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Antimicrobial therapy}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''1 month'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Streptococcus agalactiae, Escherichia coli, Listeriamonocytogenes, Klebsiellaspecie'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ampicillin plus cefotaxime or ampicillin plus anaminoglycoside'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''1–23 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Streptococcus pneumoniae, Neisseria meningitidis,S. agalactiae, Haemophilus influenzae, E. coli'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ampicillin plus cefotaxime or ampicillin plus anaminoglycoside'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''2–50 years,150 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''N . meningitidis, S. pneumoniae,S. pneumoniae, N. meningitidis, L. monocytogenes,aerobic gram-negative bacill'''
| style="padding: 5px 5px; background: #F5F5F5;" | '''Vancomycin plus a third-generation cephalosporin,Vancomycin plus ampicillin plus a third-generationcephalosporina,'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Head traumaBasilar skull fracture'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''S. pneumoniae, H. influenzae,group Ab-hemolyticstreptococci'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Vancomycin plus a third-generation cephalospori'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Penetrating trauma'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Staphylococcus aureus,coagulase-negative staphylo-cocci (especiallyStaphylococcus epidermidis),aer-obic gram-negative bacilli (includingPseudomonasaeruginosa)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Vancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Postneurosurgery'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Aerobic gram-negative bacilli (includingP. aeruginosa),S . aureus, coagulase-negative staphylococci (es-peciallyS. epidermidis)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''ancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''CSF shunt'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Coagulase-negative staphylococci (especiallyS. epi-dermidis), S. aureus,aerobic gram-negative bacilli(includingP. aeruginosa), Propionibacterium acnes'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''ancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem'''
|-
|}
 
*Recommendations for antimicrobial therapy in adult patients with presumptive pathogen identification by positive Gram stain.
*Adapted from IDSA guidlines.
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Microorganism}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Recommended therapy}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Alternative therapies}}
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Duration oftherapy, days}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Streptococcus pneumoniae'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Vancomycin plus a third-generationcephalosporina,'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Meropenem , fluoroquinolonec'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''7'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Neisseria meningitidis'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Third-generation cephalospori'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Penicillin G, ampicillin, chloramphenicol, fluoro-quinolone, aztreonam'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''7'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Listeria monocytogenes'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ampicillindor penicillin G'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Trimethoprim-sulfamethoxazole, meropenem'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''10-14'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Streptococcus agalactiae'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ampicillindor penicillin G'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Third-generation cephalosporin'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''14-21'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Haemophilus influenzae'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Third-generation cephalospori'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Chloramphenicol, cefepime , meropenem ,fluoroquinolon'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''21'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Escherichia coli'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Third-generation cephalospori'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Cefepime, meropenem, aztreonam, fluoroquino-lone, trimethoprim-sulfamethoxazole'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''>21'''
|-
|}
 
===Surgery===
*Surgical intervention is not recommended for the management of meningitis.
 
===Primary Prevention===
*Adapted from the recommendations of the United States Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP) for the use of meningococcal vaccines.
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Targeted group by age and/or risk factor}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Primary dose(s)}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Booster dose(s)}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For ages 11 through 18 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo, preferably at age 11 or 12 years.
 
Discuss serogroup B meningococcus vaccination (Trumenba or Bexsero)*, which may be administered to adolescents and young adults 16 through 23 years of age; the preferred age for vaccination is 16 through 18 years of age (perhaps at the time of Menactra or Menveo booster).'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''If primary dose was given at age ≤12 years, give Menactra or Menveo booster at age 16 years. If primary dose was given at age 13 to 15 years, give Menactra or Menveo booster at age 16 to 18 years'''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For individuals ages 19 through 21 years who are first year college students living in residence halls'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''If not yet received a dose of vaccine, give one dose of Menactra or Menveo.
 
Discuss serogroup B meningococcus vaccination (Trumenba or Bexsero)*, which may be administered to adolescents and young adults 16 through 23 years of age; the preferred age for vaccination is 16 through 18 years of age.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menactra or Menveo booster if previous dose given at age younger than 16 years.'''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''|Patients with HIV infection'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age <2 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give four doses of Menveo (at ages 2, 4, 6, and 12 to 15 months) or give two doses of MenactraΔ (at age 9 to 23 months, 12 weeks apart).'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give additional dose of Menveo or Menactra three years after primary series. Booster doses should be repeated every five years thereafter.'''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age ≥2 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menveo or Menactra 8 to 12 weeks apart.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''For individuals age <7 years at previous dose, give additional dose of Menveo or Menactra three years after primary series. If the most recent dose was received before age 7 years, a booster dose should be readministered three years later. Booster doses should be repeated every five years thereafter.
 
For individuals age ≥7 years at previous dose, give additional dose of Menveo or Menactra five years after primary series; booster doses should be repeated every five years thereafter'''
 
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Travelers to or residents of countries where meningococcal disease is hyperendemic or epidemic'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 months through 18 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo at ages 2, 4, 6, and 12 to 15 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''If risk continues, give initial booster after three years followed by boosters every five years.'''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For children age 7 months through 23 months who have not initiated a series of Menveo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo (if age 7 to 23 months)§ or Menactra (if age 9 to 23 months); administer two doses separated by three months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''If risk continues, give initial booster after three years followed by boosters every five years.'''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 years through 55 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo'''


==Related chapters==
|-
* [[Aseptic meningitis]]
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 56 years and older'''
* [[Encephalitis]]
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo'''


{{Diseases of the nervous system}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''People with prolonged increased risk for exposure (eg, military recruits, microbiologists routinely working with Neisseria meningitidis)'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 10 years and older'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo.


[[af:Meningitis]]
Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
[[cs:Meningitida]]
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo.
[[da:Meningitis]]
[[de:Meningitis]]
[[es:Meningitis]]
[[eo:Meningito]]
[[eu:Meningitis]]
[[fa:مننژیت]]
[[fr:Méningite]]
[[gl:Meninxite]]
[[ko:수막염]]
[[hr:Meningitis]]
[[id:Meningitis]]
[[is:Heilahimnubólga]]
[[it:Meningite]]
[[he:דלקת קרום המוח]]
[[kk:Миқұрт]]
[[la:Meningitis]]
[[lt:Meningitas]]
[[hu:Agyhártyagyulladás]]
[[ms:Meningitis]]
[[nl:Hersenvliesontsteking]]
[[ja:髄膜炎]]
[[no:Meningitt]]
[[pt:Meningite]]
[[qu:Ñutqu p'istuq llika unquy]]
[[ru:Менингит]]
[[sq:Meningjiti]]
[[simple:Meningitis]]
[[sl:Meningitis]]
[[fi:Aivokalvontulehdus]]
[[sv:Hjärnhinneinflammation]]
[[vi:Viêm màng não]]
[[zh:脑膜炎]]
[[pl:Zapalenie opon mózgowo-rdzeniowych]]
[[tr:Menenjit]]


{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
 
Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
 
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" | '''People present during outbreaks caused by a meningococcal vaccine serogroup'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 months through 18 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo at ages 2, 4, 6, and 12 to 15 months.'''
| style="padding: 5px 5px; background: #F5F5F5;" |''''''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For children age 7 months through 23 months who have not initiated a series of Menveo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo (if age 7 to 23 months)§ or Menactra (if age 9 to 23 months); administer two doses separated by 3 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |''''''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 years through 9 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo'''
| style="padding: 5px 5px; background: #F5F5F5;" |''''''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 10 years through 55 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo.
 
Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
| style="padding: 5px 5px; background: #F5F5F5;" |''''''
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 56 years and older'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo.
 
Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
| style="padding: 5px 5px; background: #F5F5F5;" |''''''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''People with persistent complement component deficiencies'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 months through 18 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo at ages 2, 4, 6, and 12 to 15 months.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menactra or Menveo booster after three years followed by boosters every five years thereafter.'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For children age 7 months through 23 months who have not initiated a series of Menveo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo (if age 7 to 23 months)§ or Menactra (if age 9 to 23 months); administer two doses separated by three months.'''
| style="padding: 5px 5px; background: #F5F5F5;" |''''''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 years through 9 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menactra or Menveo two months apart.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 10 years through 55 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''ive two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo.
 
 
Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 56 years and older'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo.
 
 
Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
|-
 
| style="padding: 5px 5px; background: #F5F5F5;" |'''People with functional or anatomic asplenia, including sickle cell disease'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 months through 18 months'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menveo at ages 2, 4, 6, and 12 months.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menactra or Menveo booster after three years followed by boosters every five years thereafter.'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For children age 19 months through 23 months who have not initiated a series of Menveo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menveo three months apart.'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give Menactra or Menveo booster after three years followed by boosters every five years thereafter.'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 2 years through 9 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menactra or Menveo two months apart'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 10 years through 55 years'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo.
 
 
Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains'''
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 56 years and older'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Give two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart).'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo.
 
 
Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
|-
|}
The quadrivalent meningococcal conjugate vaccines (MenACWY) are Menactra (MenACWY-DT) and Menveo (MenACWY-CRM); these have replaced the quadrivalent meningococcal polysaccharide vaccine Menomune (MPSV4). MenHibrix (HibMenCY), a combination conjugate vaccine against meningococcus serogroups C and Y and Haemophilus influenzae type b, was discontinued in 2017. Trumenba (MenB-FHbp) and Bexsero (MenB-4C) are meningococcus serogroup B vaccines.


[[Category:Disease]]
===Secondary Prevention===
[[Category:Infectious disease]]
*Secondary prevention with Antimicrobial chemoprophylaxis is necessary for individuals who have close contact with patients with invasive meningococcal disease. Close contacts include:
[[Category:Neurology]]
*1.household members , 2.child-care center contacts ,3.anyone directly exposed to the patient's oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management) in the 7 days before symptom onset. Health-care personnel should receive chemoprophylaxis if they were managing an airway or exposed to respiratory secretions of a patient with meningococcal disease. For travelers, antimicrobial chemoprophylaxis should be considered for any passenger who had direct contact with respiratory secretions from an index-patient or for anyone seated directly next to an index-patient on a prolonged flight (i.e., one lasting ≥8 hours)
[[Category:Emergency medicine]]
 
*Recommended chemoprophylaxis regimens for protection against meningococcal disease — Advisory Committee on Immunization Practices (ACIP), United States, 2012
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Drug}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Age group}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Dosage}}
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Duration and route of administration}}
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Rifampin'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Children aged <1 mo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''5 mg/kg every 12 hrs'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''2 days'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Rifampin'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Children aged ≥1 mo'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''10 mg/kg every 12 hrs'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''2 days'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Rifampin'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Adults'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''600 mg every 12 hrs'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''2 days'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ciprofloxacin'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Adults'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''500 mg'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Single dose'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ceftriaxone'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Children age <15 yrs'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''125 mg'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Single IM dose'''
|-
| style="padding: 5px 5px; background: #F5F5F5;" |'''Ceftriaxone'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Adults'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''250 mg'''
| style="padding: 5px 5px; background: #F5F5F5;" |'''Single IM dose'''
|-
|}


[[Category:Diseases involving the fasciae]]
==References==
[[Category:Inflammations]]
{{reflist|2}}
[[Category:Medical emergencies]]
[[Category:Neurological disorders]]


[[Category:Overview complete]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

Latest revision as of 14:31, 10 December 2020



Resident
Survival
Guide

Template:DiseaseDisorder infobox

Meningitis Main Page

Patient Information

Overview

Causes

Classification

Viral Meningitis
Bacterial Meningitis
Fungal Meningitis

Differential Diagnosis

Diagnosis

Treatment

For patient information click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Niloofarsadaat Eshaghhosseiny, MD[2]Seyedmahdi Pahlavani, M.D. [3]
Synonyms and keywords: Leptomeningitis, Inflammation of meninges

Overview

The meninges (singular meninx) is the system of membranes which envelop the central nervous system. The meninges consist of three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system. Meningitis is the inflammation of these protective membranes.
Meningitis may have been described in the Middle Ages, but it was first accurately identified by the Swiss Vieusseux (a scientific-literary association) during an outbreak in Geneva, Switzerland in 1805. In 1661, Thomas Willis first described the inflammation of meninges and an epidemic of meningitis. In the 17th century, Robert Whytt provided a detailed explanation of tuberculous meningitis and its stages. This was further elaborated by John Cheyne in the same century. Meningococcal meningitis was than described by Gaspard Vieusseux, Andre Matthey in Geneva and Elisa North in Massachussetes.
Meningitis may develop in response to a number of causes, including infectious agents (bacteria, viruses, fungi, or other organisms) or non-infectious causes, such as systemic illnesses that may involve CNS (e.g. neoplasms or connective tissue diseases, such as sarcoidosis, systemic lupus erythematosus (SLE), and wegener's) or certain drugs (e.g. nonsteroidal antiinflammatory drugs, intravenous immunoglobulin, intrathecal agents, and trimethoprim-sulfamethoxazole). While some forms of meningitis are mild and resolve spontaneously (e.g. viral meningitis), meningitis is a potentially serious condition owing to the proximity of the inflammation to the brain and spinal cord. The potential for serious neurologic damage or even death necessitates prompt medical attention and evaluation. The common presenting features of meningitis are, fever, neck stiffness and headache. Other symptoms include, photophobia (inability to tolerate bright light), phonophobia (inability to tolerate loud noises), irritability, altered mental status (in small children), and seizure. Physical examination of meningitis may vary in adults and infants. In adults, physical examination findings may include bradycardia, disorientation, papilledema, neck stiffness, positive brudzinski's and kernig's sign. However, petechial rash, bulging fontanelle, neck stiffness, jaundice, and convulsions are physical examination findings in infants. Diagnosis is based on clinical findings and CSF analysis. Treatment options are based on etiology and varies from supportive care and observing the patient (viral meningitis) to antibiotic therapy for bacterial meningitis or chemotherapy and/or irradiation for neoplastic meningitis.[1][2][3][4][5][6][4][7][8]


Causes


Etiology Common causes Less common causes
Bacterial
Viral
Fungal
  • Arthrographis spp[18]
Spirochetal --
Protozoal and Helminthic
Noninfectious conditions


Classification

Meningitis could be classified to two main groups based on etiology:

  • Infectious
  • Non-infectious

Infectious meningitis

Infectious meningitis may be classified as the following algorithm based on chronicity of symptoms.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious Meningitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Viral
 
 
 
 
 
 
 
Bacterial
 
 
 
 
 
 
 
 
 
 
 
 
Fungal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute
 
Chronic
 
Recurrent
 
 
Acute
 
Subacute
 
Chronic
 
 
Recurrent


Non-infectious meningitis

Systemic illnesses, such as malignancies and connective tissue diseases (e.g. sarcoidosis, SLE, and wegener's) may involve meninges in their course and present as chronic meningitis.

Certain drugs may cause meningeal irritation and resemble as meningitis including:

Differential diagnosis

Diseases Symptoms Physical Examination Past medical history Diagnostic tests Other Findings
Headache LOC Motor weakness Abnormal sensory Motor Deficit Sensory deficit Speech difficulty Gait abnormality Cranial nerves CT /MRI CSF Findings Gold standard test
Meningitis + - - - - + + - - History of fever and malaise - Leukocytes,

Protein

↓ Glucose

CSF analysis[28] Fever, neck

rigidity

Encephalitis + + +/- +/- - - + +/- + History of fever and malaise + Leukocytes, ↓ Glucose CSF PCR Fever, seizures, focal neurologic abnormalities
Brain tumor[29] + - - - + + + - + Weight loss, fatigue + Cancer cells[30] MRI Cachexia, gradual progression of symptoms
Hemorrhagic stroke + + + + + + + + - Hypertension + - CT scan without contrast[31][32] Neck stiffness
Subdural hemorrhage + + + + + - - - + Trauma, fall + Xanthochromia[33] CT scan without contrast[31][32] Confusion, dizziness, nausea, vomiting
Neurosyphilis[34][35] + - + + + + - + - STIs + Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[36]

Blindness, confusion, depression,

Abnormal gait

Complex or atypical migraine + - + + - - + - - Family history of migraine - - Clinical assesment Presence of aura, nausea, vomiting
Hypertensive encephalopathy + + - - - - + + - Hypertension + - Clinical assesment Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy - + - - - + + + + History of alcohal abuse - - Clinical assesment and lab findings Ophthalmoplegia, confusion
CNS abscess + + - - + + + - - History of drug abuse, endocarditis, immunosupression + leukocytes, glucose and protien MRI is more sensitive and specific High grade fever, fatigue,nausea, vomiting
Drug toxicity - + - + + + - + - - - - Drug screen test Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder + + + + + + + + History of emotional stress - - Diagnosis of exclusion Tremors, blindness, difficulty swallowing
Metabolic disturbances (electrolyte imbalance, hypoglycemia) - + + + + + - - + - - Hypoglycemia, hypo and hypernatremia, hypo and hyperkalemia Depends on the cause Confusion, seizure, palpitations, sweating, dizziness, hypoglycemia
Multiple sclerosis exacerbation - - + + - + + + + History of relapses and remissions + CSF IgG levels

(monoclonal bands)

Clinical assesment and MRI [37] Blurry vision, urinary incontinence, fatigue
Seizure + + - - + + - - + Previous history of seizures - Mass lesion Clinical assesment and EEG [38] Confusion, apathy, irritability,


Diagnosis

Diagnosis of meningitis, is based on clinical presentation in combination with CSF analysis. CSF analysis has major role for diagnosis and rule out other possibilities. The following table summarizes the CSF findings in different types of meningitis.[39][40][41][42][3]

Cerebrospinal fluid level Normal level Bacterial meningitis[42] Viral meningitis (except SARS-CoV-2 meningitis) [42] SARS-CoV-2 associated meningitis Fungal meningitis Tuberculous meningitis[43] Neoplastic meningitis[39]
Cells/ul < 5 >300 10-1000 10-1000 10-500 50-500 >4
Cells Lymphocyte Leukocyte > Lymphocyte Lymphocyte > Leukocyte Lymphocyte > Neutrophil Lymphocyte > Leukocyte Lymphocyte > Leukocyte Lymphocyte > Leukocyte
Total protein (mg/dl) 45-60 Typically 100-500 Normal or slightly high Normal or slightly high High Typically 100-200 >50
Glucose ratio (CSF/plasma)[40] > 0.5 < 0.3 > 0.6 > 0.6 <0.3 < 0.5 <0.5
Lactate (mmols/l)[41] < 2.1 > 2.1 < 2.1 NA >3.2 > 2.1 >2.1
Others Intra-cranial pressure (ICP) = 6-12 (cm H2O) CSF gram stain, CSF culture, CSF bacterial antigen PCR of HSV-DNA, VZV RT-PCR for detection of viral RNA i n CSF ( not approved by FDA) CSF gram stain, CSF india ink PCR of TB-DNA CSF tumour markers such as alpha fetoprotein, CEA

Treatment

Medical Therapy

  • Empiric therapy for meningitis must be initiated after CSF obtained.
  • The choice of empiric antibiotic therapy is depend on patient age and underlying comorbid disease.
  • Adapted from IDSA guidlines.
Predisposing factor Common bacterial pathogen Antimicrobial therapy
1 month Streptococcus agalactiae, Escherichia coli, Listeriamonocytogenes, Klebsiellaspecie Ampicillin plus cefotaxime or ampicillin plus anaminoglycoside
1–23 months Streptococcus pneumoniae, Neisseria meningitidis,S. agalactiae, Haemophilus influenzae, E. coli Ampicillin plus cefotaxime or ampicillin plus anaminoglycoside
2–50 years,150 years N . meningitidis, S. pneumoniae,S. pneumoniae, N. meningitidis, L. monocytogenes,aerobic gram-negative bacill Vancomycin plus a third-generation cephalosporin,Vancomycin plus ampicillin plus a third-generationcephalosporina,
Head traumaBasilar skull fracture S. pneumoniae, H. influenzae,group Ab-hemolyticstreptococci Vancomycin plus a third-generation cephalospori
Penetrating trauma Staphylococcus aureus,coagulase-negative staphylo-cocci (especiallyStaphylococcus epidermidis),aer-obic gram-negative bacilli (includingPseudomonasaeruginosa) Vancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem
Postneurosurgery Aerobic gram-negative bacilli (includingP. aeruginosa),S . aureus, coagulase-negative staphylococci (es-peciallyS. epidermidis) ancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem
CSF shunt Coagulase-negative staphylococci (especiallyS. epi-dermidis), S. aureus,aerobic gram-negative bacilli(includingP. aeruginosa), Propionibacterium acnes ancomycin plus cefepime, vancomycin plus ceftazi-dime, or vancomycin plus meropenem
  • Recommendations for antimicrobial therapy in adult patients with presumptive pathogen identification by positive Gram stain.
  • Adapted from IDSA guidlines.
Microorganism Recommended therapy Alternative therapies Duration oftherapy, days
Streptococcus pneumoniae Vancomycin plus a third-generationcephalosporina, Meropenem , fluoroquinolonec 7
Neisseria meningitidis Third-generation cephalospori Penicillin G, ampicillin, chloramphenicol, fluoro-quinolone, aztreonam 7
Listeria monocytogenes Ampicillindor penicillin G Trimethoprim-sulfamethoxazole, meropenem 10-14
Streptococcus agalactiae Ampicillindor penicillin G Third-generation cephalosporin 14-21
Haemophilus influenzae Third-generation cephalospori Chloramphenicol, cefepime , meropenem ,fluoroquinolon 21
Escherichia coli Third-generation cephalospori Cefepime, meropenem, aztreonam, fluoroquino-lone, trimethoprim-sulfamethoxazole >21

Surgery

  • Surgical intervention is not recommended for the management of meningitis.

Primary Prevention

  • Adapted from the recommendations of the United States Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP) for the use of meningococcal vaccines.
Targeted group by age and/or risk factor Primary dose(s) Booster dose(s)
For ages 11 through 18 years Give one dose of Menactra or Menveo, preferably at age 11 or 12 years.

Discuss serogroup B meningococcus vaccination (Trumenba or Bexsero)*, which may be administered to adolescents and young adults 16 through 23 years of age; the preferred age for vaccination is 16 through 18 years of age (perhaps at the time of Menactra or Menveo booster).

If primary dose was given at age ≤12 years, give Menactra or Menveo booster at age 16 years. If primary dose was given at age 13 to 15 years, give Menactra or Menveo booster at age 16 to 18 years
For individuals ages 19 through 21 years who are first year college students living in residence halls If not yet received a dose of vaccine, give one dose of Menactra or Menveo.

Discuss serogroup B meningococcus vaccination (Trumenba or Bexsero)*, which may be administered to adolescents and young adults 16 through 23 years of age; the preferred age for vaccination is 16 through 18 years of age.

Give Menactra or Menveo booster if previous dose given at age younger than 16 years.
|Patients with HIV infection
For age <2 years Give four doses of Menveo (at ages 2, 4, 6, and 12 to 15 months) or give two doses of MenactraΔ (at age 9 to 23 months, 12 weeks apart). Give additional dose of Menveo or Menactra three years after primary series. Booster doses should be repeated every five years thereafter.
For age ≥2 years Give two doses of Menveo or Menactra 8 to 12 weeks apart. For individuals age <7 years at previous dose, give additional dose of Menveo or Menactra three years after primary series. If the most recent dose was received before age 7 years, a booster dose should be readministered three years later. Booster doses should be repeated every five years thereafter.

For individuals age ≥7 years at previous dose, give additional dose of Menveo or Menactra five years after primary series; booster doses should be repeated every five years thereafter

Travelers to or residents of countries where meningococcal disease is hyperendemic or epidemic
For age 2 months through 18 months Give Menveo at ages 2, 4, 6, and 12 to 15 months If risk continues, give initial booster after three years followed by boosters every five years.
For children age 7 months through 23 months who have not initiated a series of Menveo Give Menveo (if age 7 to 23 months)§ or Menactra (if age 9 to 23 months); administer two doses separated by three months If risk continues, give initial booster after three years followed by boosters every five years.
For age 2 years through 55 years Give one dose of Menactra or Menveo. Boost every five years with Menactra or Menveo
For age 56 years and older Give one dose of Menactra or Menveo Boost every five years with Menactra or Menveo
People with prolonged increased risk for exposure (eg, military recruits, microbiologists routinely working with Neisseria meningitidis)
For age 10 years and older Give one dose of Menactra or Menveo.

Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)

Boost every five years with Menactra or Menveo.


Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.

People present during outbreaks caused by a meningococcal vaccine serogroup
For age 2 months through 18 months Give Menveo at ages 2, 4, 6, and 12 to 15 months. '
For children age 7 months through 23 months who have not initiated a series of Menveo Give Menveo (if age 7 to 23 months)§ or Menactra (if age 9 to 23 months); administer two doses separated by 3 months '
For age 2 years through 9 years Give one dose of Menactra or Menveo '
For age 10 years through 55 years Give one dose of Menactra or Menveo.

Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)

'
For age 56 years and older Give one dose of Menactra or Menveo.

Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)

'
People with persistent complement component deficiencies
For age 2 months through 18 months Give Menveo at ages 2, 4, 6, and 12 to 15 months. Give Menactra or Menveo booster after three years followed by boosters every five years thereafter.
For children age 7 months through 23 months who have not initiated a series of Menveo Give Menveo (if age 7 to 23 months)§ or Menactra (if age 9 to 23 months); administer two doses separated by three months. '
For age 2 years through 9 years Give two doses of Menactra or Menveo two months apart. Boost every five years with Menactra or Menveo
For age 10 years through 55 years ive two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart) Boost every five years with Menactra or Menveo.


Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.

For age 56 years and older Give two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart) Boost every five years with Menactra or Menveo.


Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.

People with functional or anatomic asplenia, including sickle cell disease
For age 2 months through 18 months Give Menveo at ages 2, 4, 6, and 12 months. Give Menactra or Menveo booster after three years followed by boosters every five years thereafter.
For children age 19 months through 23 months who have not initiated a series of Menveo Give two doses of Menveo three months apart. Give Menactra or Menveo booster after three years followed by boosters every five years thereafter.
For age 2 years through 9 years Give two doses of Menactra or Menveo two months apart Boost every five years with Menactra or Menveo
For age 10 years through 55 years Give two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart) Boost every five years with Menactra or Menveo.


Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains

For age 56 years and older Give two doses of Menactra or Menveo two months apart and either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart). Boost every five years with Menactra or Menveo.


Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.

The quadrivalent meningococcal conjugate vaccines (MenACWY) are Menactra (MenACWY-DT) and Menveo (MenACWY-CRM); these have replaced the quadrivalent meningococcal polysaccharide vaccine Menomune (MPSV4). MenHibrix (HibMenCY), a combination conjugate vaccine against meningococcus serogroups C and Y and Haemophilus influenzae type b, was discontinued in 2017. Trumenba (MenB-FHbp) and Bexsero (MenB-4C) are meningococcus serogroup B vaccines.

Secondary Prevention

  • Secondary prevention with Antimicrobial chemoprophylaxis is necessary for individuals who have close contact with patients with invasive meningococcal disease. Close contacts include:
  • 1.household members , 2.child-care center contacts ,3.anyone directly exposed to the patient's oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management) in the 7 days before symptom onset. Health-care personnel should receive chemoprophylaxis if they were managing an airway or exposed to respiratory secretions of a patient with meningococcal disease. For travelers, antimicrobial chemoprophylaxis should be considered for any passenger who had direct contact with respiratory secretions from an index-patient or for anyone seated directly next to an index-patient on a prolonged flight (i.e., one lasting ≥8 hours)
  • Recommended chemoprophylaxis regimens for protection against meningococcal disease — Advisory Committee on Immunization Practices (ACIP), United States, 2012
Drug Age group Dosage Duration and route of administration
Rifampin Children aged <1 mo 5 mg/kg every 12 hrs 2 days
Rifampin Children aged ≥1 mo 10 mg/kg every 12 hrs 2 days
Rifampin Adults 600 mg every 12 hrs 2 days
Ciprofloxacin Adults 500 mg Single dose
Ceftriaxone Children age <15 yrs 125 mg Single IM dose
Ceftriaxone Adults 250 mg Single IM dose

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