Bacterial meningitis differential diagnosis
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Bacterial meningitis Microchapters |
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Diagnosis |
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Treatment |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]
Overview
Differential diagnosis
Bacterial meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:
Differentiating bacterial meningite is from other diseases
| Diseases | Diagnostic tests | Physical Examination | Symptoms | Past medical history | Other Findings | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Na+, K+, Ca2+ | CT /MRI | CSF Findings | Gold standard test | Neck stiffness | Motor or Sensory deficit | Papilledema | Bulging fontanelle | Cranial nerves | Headache | Fever | Altered mental status | |||
| Brain tumour[1] | ✔ | Cancer cells[2] | MRI | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Cachexia, gradual progression of symptoms | ||||
| Delerium Tremens | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Hypertension | Neck stiffness | |||
| Subarachnoid hemorrhage | ✔ | Xanthochromia[3] | CT scan without contrast[4][5] | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Trauma/fall | Confusion, dizziness, nausea, vomiting | |
| Neurosyphilis[6][7] | ✔ | ↑ Leukocytes and protein | CSF VDRL-specifc
CSF FTA-Ab -sensitive[8] |
✔ | ✔ | ✔ | ✔ | ✔ | ✔ | STIs | Blindness, confusion, depression,
Abnormal gait | |||
| Encephalitis | Clinical assesment | ✔ | ✔ | Family history of migraine | Presence of aura, nausea, vomiting | |||||||||
| Herpes simplex encephalitis | ✔ | Clinical assesment | ✔ | ✔ | ✔ | ✔ | ✔ | History of hypertension | Delirium, cortical blindness, cerebral edema, seizure | |||||
| Wernicke’s encephalopathy | ✔ | ✔ | ✔ | History of alcohal abuse | Ophthalmoplegia, confusion | |||||||||
| CNS abscess | ✔ | ↑ leukocytes, ↓ glucose and ↑ protien | MRI is more sensitive and specific | ✔ | ✔ | ✔ | ✔ | ✔ | History of drug abuse, endocarditis, ↓ immune status | High grade fever, fatigue,nausea, vomiting | ||||
| Drug toxicity | ✔ | ✔ | ✔ | Lithium, Sedatives, phenytoin, carbamazepine | ||||||||||
| Conversion disorder | Diagnosis of exclusion | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | Tremors, blindness, difficulty swallowing | |||||
| Electrolyte disturbance | ↓ or ↑ | Depends on the cause | Confusion, seizures | |||||||||||
| Febrile seizures | ↑ Leukocytes,
↑ Protein ↓ Glucose |
CSF analysis[9] | ✔ | ✔ | Fever, neck
rigidity | |||||||||
| Subdural empyema | ✔ | ↑ CSF IgG levels
(monoclonal bands) |
Clinical assesment and MRI [10] | ✔ | ✔ | ✔ | ✔ | ✔ | ✔ | History of relapses and remissions | Blurry vision, urinary incontinence, fatigue | |||
| Seizure | ↓ or ↑ | Clinical assesment and EEG [11] | ✔ | ✔ | ✔ | Previous history of seizures | Confusion, apathy, irritability, | |||||||
| Hypoglycemia | ↓ or ↑ | Serum blood glucose | ✔ | ✔ | ✔ | ✔ | History of diabetes | Palpitations, sweating, dizziness, low serum, glucose | ||||||
Differentiating bacterial meningitis from other causes of meningitis
| Cerebrospinal Fluid | |||||
| Normal Levels | Acute Bacterial M. | Acute Viral M. | TB M. | Neuroborreliosis | |
| Cells/ul | < 5 | In the 1000s | In the 100s | In the 100s | Some 100 |
| Cells | Lymph:Monos 7:3 | Gran. > Lymph. | Lymph. > Gran. | Various leukos | Lymph. monocytic |
| Total Protein (mg/dl) | 45-60 | Typically 100-500 | Typically normal | Typically 100-200 | Typically up to 350 |
| Glucose Ratio (CSF/plasma) | Typically > 0.5 | < 0.3 | > 0.6 | < 0.5 | Normal |
| Lactate (mmol/l) | < 2.1 | > 2.1 | < 2.1 | > 2.1 | - |
| Others | ICP: 6-22 (cm H2O) | PCR of HSV-DNA | PCR of TBC-DNA | IgG/IgM CSF/Serum Ratio |
References
- ↑ Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
- ↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
- ↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
- ↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
- ↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
- ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
- ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
- ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
- ↑ Carbonnelle E (2009). "[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]". Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.
- ↑ Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). "Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group". Arch Neurol. 51 (1): 61–6. PMID 8274111.
- ↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.