Meningitis: Difference between revisions

	Meningitis Main Page
Patient Information
Overview
Causes
Classification Viral Meningitis Bacterial Meningitis Fungal Meningitis
Differential Diagnosis
Diagnosis
Treatment

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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	Streptococcus pneumoniae Neisseria meningitis Hemophilus influenza Group B streptococcus Listeria monocytogenes	Staphylococcus aureus Klebsiella Pseudomonas E. coli Kingella Kingae Mycobacterium tuberculosis Diphtheroids Propionibacterium acnes Serratia marcescens Salmonella species Brucella sp Nocardia Francisella tularensis Streptococcus suis Ehrlichia chaffeensis
Viral	Enteroviruses Herpes simplex viruses 1 and 2 Arboviruses	Influenza virus Herpes zoster Human Herpes Virus 6 Epstein barr virus (EBV) Lymphocytic choriomeningitis virus Mumps Cytomegalo virus (CMV) Human immunodeficiency virus (HIV) West nile virus Human T cell lymphotrophic virus I and II Varicella zoster virus SARS-CoV-2 virus (corona virus)
Fungal	Cryptococcus neoformans Aspergillus sp. Blastomyces dermatitidis Coccidioides immitis Candida spp. Histoplasma capsulatum Sporothrix schencki	Xylohypha (formerly Cladosporium) trichoides and other dark-walled (demateaceous) fungi such as Curvularia and Drechslera Mucor Arthrographis kalrae Pneumocystis jirovecii^[9]^[10] Cryptococcus albidus^[11] Alternaria spp^[12] Rhodotorula spp ^[13] Acremonium spp.^[14] Dreschlera spp^[15] Malassezia spp^[16] Scedosporium spp^[17] Arthrographis spp^[18] Blastoschizomyces^[19]^[20] Paecilomyces^[21]^[22] Aureobasidium^[23] Clavispora^[24] Ustilago^[25] Exophiala (Wangiella)^[26] Exserohilum^[27]
Spirochetal	Treponema pallidum Borrelia burgdoferi	--
Protozoal and Helminthic	Amebas (Naegleria, Acanthamoeba, and Balamuthia)	Angiostrongylus cantonensis Gnathostoma species Baylisascaris procyonis Toxocara species Taenia solium
Noninfectious conditions	Neoplastic Sarcoidosis Systemic lupus erythematosus Granulomatosis with polyangiitis (Wegener's) Behçet's disease	Fabry disease Central nervous system vasculitis Vogt-Koyanagi-Harada disease Chemical or drug-induced meningitis Nonsteroidal antiinflammatory drugs Intravenous immunoglobulin Intrathecal agents Certain antibiotics (eg, trimethoprim-sulfamethoxazole)

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:

Nonsteroidal antiinflammatory drugs (NSAIDs)
Intravenous immunoglobulin
Intrathecal agents
Certain antibiotics (eg, trimethoprim-sulfamethoxazole)

Differential diagnosis

Diseases	Symptoms				Physical Examination					Past medical history	Diagnostic tests			Other Findings
Diseases	Headache	↓LOC	Motor weakness	Abnormal sensory	Motor Deficit	Sensory deficit	Speech difficulty	Gait abnormality	Cranial nerves	Past medical history	CT /MRI	CSF Findings	Gold standard test	Other Findings
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

References

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↑ Centers for Disease Control and Prevention (CDC) (2002). "Exophiala infection from contaminated injectable steroids prepared by a compounding pharmacy--United States, July-November 2002". MMWR Morb Mortal Wkly Rep. 51 (49): 1109–12. PMID 12530707.
↑ Pettit AC, Pugh ME (2013). "Index case for the fungal meningitis outbreak, United States". N Engl J Med. 368 (10): 970. doi:10.1056/NEJMc1300630. PMID 23465119.
↑ 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.
↑ 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.
↑ ^31.0 ^31.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
↑ ^32.0 ^32.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
↑ 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.
↑ 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.
↑ ^39.0 ^39.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.
↑ ^40.0 ^40.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
↑ ^41.0 ^41.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
↑ ^42.0 ^42.1 ^42.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.
↑ Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.

Template:WikiDoc Sources

[pmid10411200-1] Attia J, Hatala R, Cook DJ, Wong JG (1999). "The rational clinical examination. Does this adult patient have acute meningitis?". JAMA. 282 (2): 175–81. PMID 10411200.

[abc-2] ttps://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0047163/ Accessed on Jan 9th, 2017

[pmid20610819-3] 3.0 ^3.1 Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.

[pmid8416268-4] 4.0 ^4.1 Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS; et al. (1993). "Acute bacterial meningitis in adults. A review of 493 episodes". N Engl J Med. 328 (1): 21–8. doi:10.1056/NEJM199301073280104. PMID 8416268.

[pmid15509818-5] van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M (2004). "Clinical features and prognostic factors in adults with bacterial meningitis". N Engl J Med. 351 (18): 1849–59. doi:10.1056/NEJMoa040845. PMID 15509818.

[6] van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M (2004). "Clinical features and prognostic factors in adults with bacterial meningitis". N. Engl. J. Med. 351 (18): 1849–59. doi:10.1056/NEJMoa040845. PMID 15509818.

[pmid3403999-7] Domingo P, Mancebo J, Blanch L, Net A, Nolla J (1988). "Fever in adult patients with acute bacterial meningitis". J Infect Dis. 158 (2): 496. PMID 3403999.

[pmid12060874-8] Thomas KE, Hasbun R, Jekel J, Quagliarello VJ (2002). "The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis". Clin Infect Dis. 35 (1): 46–52. doi:10.1086/340979. PMID 12060874.

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[pmid12530707-26] Centers for Disease Control and Prevention (CDC) (2002). "Exophiala infection from contaminated injectable steroids prepared by a compounding pharmacy--United States, July-November 2002". MMWR Morb Mortal Wkly Rep. 51 (49): 1109–12. PMID 12530707.

[pmid23465119-27] Pettit AC, Pugh ME (2013). "Index case for the fungal meningitis outbreak, United States". N Engl J Med. 368 (10): 970. doi:10.1056/NEJMc1300630. PMID 23465119.

[pmid19398286-28] 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.

[pmid10582668-29] Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.

[pmid21371327-30] 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.

[pmid21694755-31] 31.0 ^31.1 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.

[pmid21807345-32] 32.0 ^32.1 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.

[pmid1198628-33] Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.

[pmid22482824-34] 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.

[pmid24365430-35] Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.

[pmid22421697-36] 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.

[pmid8274111-37] 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.

[pmid11385043-38] Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.

[pmid23717798-39] 39.0 ^39.1 Le Rhun E, Taillibert S, Chamberlain MC (2013). "Carcinomatous meningitis: Leptomeningeal metastases in solid tumors". Surg Neurol Int. 4 (Suppl 4): S265–88. doi:10.4103/2152-7806.111304. PMC 3656567. PMID 23717798.

[pmid24326618-40] 40.0 ^40.1 Chow E, Troy SB (2014). "The differential diagnosis of hypoglycorrhachia in adult patients". Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.

[pmid22880096-41] 41.0 ^41.1 Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). "Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice". PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.

[pmid10654948-42] 42.0 ^42.1 ^42.2 Negrini B, Kelleher KJ, Wald ER (2000). "Cerebrospinal fluid findings in aseptic versus bacterial meningitis". Pediatrics. 105 (2): 316–9. PMID 10654948.

[pmid20146981-43] Caudie C, Tholance Y, Quadrio I, Peysson S (2010). "[Contribution of CSF analysis to diagnosis and follow-up of tuberculous meningitis]". Ann Biol Clin (Paris). 68 (1): 107–11. doi:10.1684/abc.2010.0407. PMID 20146981.

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@@ Line 1: / Line 1: @@
+__NOTOC__
+{| 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
   | Name           = Meningitis
   | Image          = Illu_meninges.jpg
   | 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
- | eMedicineSubj  = med
- | eMedicineTopic = 2613
- | eMedicine_mult = {{eMedicine2|emerg|309}} {{eMedicine2|emerg|390}}
- | MeshID = D008581
   }}
-{{SI}}
+{{Meningitis}}
-{{CMG}}
+'''For patient information click [[Meningitis (patient information)|here]].'''
-'''Associate Editor-In-Chief:'''  {{CZ}}
+{{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>
-{{editor help}}
-==Overview==
-'''Meningitis''' is the [[inflammation]] of the protective membranes covering the [[central nervous system]], known collectively as the [[meninges]] (the leptomeninges and underlying subarachnoid cerebrospinal fluid). Meningitis may develop in response to a number of causes, including infectious agents (bacteria, viruses, fungi, or other organisms), physical injury, [[cancer]], or certain drugs. While some forms of meningitis are mild and resolve on their own, 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. Infectious meningitis, the most common form, is typically treated with [[antibiotic]]s and close observation. <ref>Durand, M.L., et.al., Acute bacterial meningitis: a review of 493 episodes, NEJM 1993; 328: 21-28. PMID 8416268</ref> <ref>Fekete, T., Clinical features of acute bacterial meningitis, in UpToDate, October 5, 1997.</ref> <ref>Quagliarello, V., Scheld, W.M., Bacterial meningitis: pathogenesis, pathophysiology, and progress, NEJM 1992; 327: 864-872. PMID 1508247</ref> <ref>Quagliarello, V., Scheld, W.M., Treatment of bacterial meningitis, NEJM 1997; 336: 708-716. PMID 9041103</ref> <ref>Schuchat, A., et.al., Bacterial meningitis in the United States in 1995, NEJM 1997; 337: 970-976. PMID 9395430</ref> <ref>Townsend, G.C., Scheld, W.M., The use of corticosteroids in the management of bacterial meningitis in adults, J Antimicrobial Chemotherapy 1996; 37: 1061-1061. PMID 8836809 </ref>
-==History==
+==Causes==
-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.
+<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]]
-In the 19th century, meningitis was a scourge of the Japanese imperial family, playing the largest role in the horrendous pre-maturity death rate the family endured. In the mid-1800s, only the Emperor Kōmei and two of his siblings reached maturity out of fifteen total children surviving birth. Kōmei's son, the Emperor Meiji, was one of two survivors out of Kōmei's six children, including an elder brother of Meiji who would have taken the throne had he lived to maturity.  Five of Meiji's 15 children survived, including only his third son, Emperor Taishō, who was [[feeble-minded]], perhaps as a result of having contracted meningitis himself. By Emperor Hirohito's generation the family was receiving modern medical attention. As the focal point of tradition in Japan, during the Tokugawa Shogunate the family was denied modern "Dutch" medical treatment then in use among the upper caste; despite extensive modernization during the Meiji Restoration the Emperor insisted on traditional medical care for his children.
+|-
+|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>
-==Epidemiology==
+*[[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>
-[[Image:Meningite.jpg|thumb|right|350px|Demography of [[meningococcus|meningococcal]] meningitis. Red: meningitis belt, orange: epidemic meningitis, grey: sporadic cases]]
-Meningitis refers to the inflammation arachnoid matter, the sub-arachnoid space and the cerebrospinal fluid (CSF, including the ventricles). Meningitis can affect anyone in any age group, from the newborn to the elderly.
+*[[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>
-From its recognition in 1805 until the early 20th century, bacterial meningitis was virtually uniformly fatal.  Until recent years, up to 50% of patients who survived the acute infection would be left with permanent sequelae such as mental retardation and hearing loss. Over the past several years, there has been a striking shift in the demography of meningitis.
+*[[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>
-* In 1986, the median age of a patient with meningitis was 15 months, as compared with 25 years in 1995.
-* Before the widespread use of the conjugated Haemophilus influenzae type B  (HIB) vaccine in 1990, H. influenzae type b meningitis developed in nearly 1 in 200 children < 5 years old, and almost 70% of the cases of meningitis in children < 5 were due to H influenzae.
-*:* It was necessary to conjugate the H. influenzae type b polysaccharide to a carrier protein in order to make a T-cell dependant antigen that could induce an immune response in infants.
-* In the study by Schuchat et.al. in 1995, H. influenzae only accounted for 7% of cases.
-*:* The case-fatality rate varied significantly amongst the different organisms, and the pathogenic organisms responsible for disease varied greatly with age.
-*:* Group B Streptococcus agalactiae (S. agalactiae) was the main cause of meningitis in infants < 1 month with Listeria accounting for ~ 20% of cases.
-*:*:* In infants 1 month – 23 month of age, Streptococcus pneumoniae (S. pneumoniae) and Neisseria meningitidis (N. meningitidis) caused 45% and 31% of the cases, respectively.
-*:*:* In the 2 – 18 year old age group, N. meningitidis caused 59% of the cases, and in people 19 – 59 years old S. pneumoniae caused 62% of the cases.
-*:* Nosocomial infections with Gram-negative bacilli are becoming increasingly important as well.
-The "Meningitis Belt" is an area in sub-Saharan Africa which stretches from Senegal in the west to Ethiopia in the east in which large epidemics of meningococcal meningitis occur (this largely coincides with the Sahel region). It contains an estimated total population of 300 million people. The largest epidemic outbreak was in 1996, when over 250,000 cases occurred and 25,000 people died as a consequence of the disease.
+*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>
-== Pathophysiology & Etiology==
+*[[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>
-The clinical picture of meningitis largely arises from the host response to the inciting organism in the CSF.
+*[[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>
-* It seems that the subcapsular components (the cell wall and lipopolysaccharide) of bacteria are more important in determining inflammation than the surface components (pili and polysaccharide capsule).
-* The primary site of breakdown of the blood-brain barrier is the cerebral microvascular endothelium.
-*:* Electron microscope (EM) studies have shown complete separation of the intercellular tight junctions
-* It appears that there is a final common pathway, mediated by TNF-alpha, IL-1 and IL-6, that results in meningeal inflammation and loss of the blood-brain barrier.
-*:* One of the major roles of these cytokines is to facilitate the migration of neutrophils across the vascular endothelium into the CSF.
-*:* A key initial step in this process is obviously adhesion of the PMN to the endothelial surface.
-*:*:* This is mediated by the expression of specific transmembrane glycoproteins expressed on the endothelial surface that interact with specific counterparts on the neutrophils.
-*:*:* These adhesion molecules fall into three large categories: the immunoglobin superfamily (including the antigen-specific T and B cell receptors, ICAM-1 and ICAM-2), the integrin family (beta-1, beta-2, and beta-3) and the selectin family (including ELAM-1).
-*:* The interaction of beta-2 integrin (CD18) and ICAM-1 is largely responsible for PMN diapedesis.
-* Additionally, patients get cerebral edema that is mediated by an increase in capillary permeability, the inflammatory response from the neutrophils, and CSF outflow resistance.
-* The above pathophysiologic processes are not only important in producing the symptoms associated with meningitis, but the understanding of the underlying disease process is necessary to guide therapy (see below).
-== Mechanism ==
+*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>
-* In order to gain access to the CNS, the pathogen needs to colonize mucosal epithelium, invade and survive in the intravascular space, cross the blood-brain barrier and survive in the CSF.
+*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>
-* Colonization of the nasopharynx is usually asymptomatic, and during peak seasons, approximately 20% of the population are colonized with N. meningitidis.
-==Causes==
+*[[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>
-Most cases of meningitis are caused by [[microorganisms]], such as [[viruses]], [[bacteria]], [[fungi]], or [[parasite]]s, that spread into the blood and into the [[cerebrospinal fluid]] (CSF).<ref name=Sherris>{{cite book | author = Ryan KJ, Ray CG (editors) | title = Sherris Medical Microbiology | pages = 876&ndash;9 |edition = 4th ed. | publisher = McGraw Hill | year = 2004 | isbn = 0838585299 }}</ref>  Non-infectious causes include [[cancer]]s, [[systemic lupus erythematosus]] and certain [[drugs]].  The most common cause of meningitis is viral, and often runs its course within a few days. Bacterial meningitis is the second most frequent type and can be serious and life-threatening. Numerous microorganisms may cause bacterial meningitis, but ''[[Neisseria meningitidis]]'' ("meningococcus") and ''[[Streptococcus pneumoniae]]'' ("pneumococcus") are the most common pathogens in patients without immune deficiency, with meningococcal disease being more common in children. ''[[Staphylococcus aureus]]'' may complicate neurosurgical operations, and ''[[Listeria monocytogenes]]'' is associated with poor nutritional state and alcoholicism. ''[[Haemophilus influenzae]]'' (type B) incidence has been much reduced by immunization in many countries. ''[[Mycobacterium tuberculosis]]'' (the causative agent of [[tuberculosis]]) rarely causes meningitis in Western countries but is common and feared in countries where tuberculosis is endemic.
-==Diagnosis==
+*[[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>
-===History and Symptoms===
-In the study by Durand et.al., only 2/3 of patients had the classic triad of [[fever]], [[nuchal rigidity]] and [[mental status|change in mental status]].
+*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>
-* All patients, however, had at least one of these findings.
-* 95% had fever >100 degrees Fahrenheit, with a mean duration of 4 days.
-* [[Neck stiffness]] was present in 88%, and contrary to other reports, was not significantly lower amongst the elderly.
-*:* [[Kernig's sign]]: inability to allow full extension of the knee when the hip is flexed 90 degrees.
-*:* [[Brudzinski’s sign]]: spontaneous flexion of the hips during attempted passive neck flexion.
-* 11% of patients had a rash, and of these cases 73% of them were due to [[Neisseria meningitidis]] (most commonly [[petechiae]] and [[purpura]])
-* 78% of patients had an abnormal mental status, primarily [[lethargy]] and [[confusion]].
-*:* 23% of the patients had focal [[seizure]]s.
-In general:
+*[[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>
-[[Headache]] is the most common symptom of meningitis (87%) followed by [[nuchal rigidity]] ("neck stiffness", 83%). The classic triad of diagnostic signs consists of nuchal rigidity (being unable to flex the neck forward), [[fever]] and altered mental status. All three features are present in only 44% of all cases of infectious meningitis.<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> Other symptoms commonly associated with meningitis are [[photophobia]] (inability to tolerate bright light), [[phonophobia]] (inability to tolerate loud noises), [[irritability]] and [[delirium]] (in small children) and [[seizure]]s (in 20-40% of cases). In infants (0-6 months), swelling of the [[fontanelle]] (soft spot) may be present. [[Vomiting]] may be present.
+*[[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>
-===Physical Examination===
+*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>
-The suspicion of meningitis is generally based on the nature of the symptoms and findings on [[physical examination]]. Meningitis is a [[medical emergency]], and referral to hospital is indicated. If meningitis is suspected based on clinical examination, early administration of [[antibiotic]]s is recommended, as the condition may deteriorate rapidly. In the hospital setting, initial management consists of stabilization (e.g. securing the [[airway]] in a depressed level of consciousness, administration of [[intravenous fluid]]s in [[hypotension]] or [[Shock (medical)|shock]]), followed by antibiotics if not already administered.
+|-
+|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>
+|}
-Nuchal rigidity is typically assessed with the patient lying [[Supine position|supine]], and both hips and knees flexed. If pain is elicited when the knees are passively extended ([[Kernig's sign]]), this indicates nuchal rigidity and meningitis. In infants, forward flexion of the neck may cause involuntary knee and hip flexion ([[Brudzinski's sign]]). Although commonly tested, the sensitivity and specificity of Kernig's and Brudzinski's tests are uncertain.<ref name=Thomas_2002>{{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. |volume=35 |issue=1 |pages=46-52 |year=2002 |pmid=12060874 |doi=}}</ref>
+==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>
-In "meningococcal" meningitis (i.e. meningitis caused by the bacteria [[Neisseria meningitidis]]), a rapidly-spreading [[petechial rash]] is typical, and may precede other symptoms. The rash consists of numerous small, irregular purple or red spots on the trunk, lower extremities, mucous membranes, conjunctiva, and occasionally on the palms of hands and soles of feet.
+===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.
-===Laboratory Evaluations===
+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]],
-Investigations include [[blood test]]s (electrolytes, liver and kidney function, inflammatory markers and a [[complete blood count]]) and usually [[X-ray]] examination of the chest. The most important test in identifying or ruling out meningitis is analysis of the [[cerebrospinal fluid]] (fluid that envelops the brain and the spinal cord) through [[lumbar puncture]] (LP). However, if the patient is at risk for a cerebral mass lesion or elevated [[intracranial pressure]] (recent head injury, a known immune system problem, localizing neurological signs, or evidence on examination of a raised ICP), a lumbar puncture may be contraindicated because of the possibility of fatal [[brain herniation]]. In such cases a [[Computed tomography|CT]] or [[Magnetic resonance imaging|MRI]] scan is generally performed prior to the lumbar puncture to exclude this possibility. Otherwise, the CT or MRI should be performed after the LP, with MRI preferred over CT due to its superiority in demonstrating areas of cerebral edema, ischemia, and meningeal inflammation.
+'''↑''' Protein
-During the lumbar puncture procedure, the opening pressure is measured. A pressure of over 180 mmH<sub>2</sub>O is indicative of bacterial meningitis.
+↓ 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]],
-The CSF sample is examined for [[white blood cell]]s (and which subtypes), [[red blood cell]]s, [[protein]] content and [[glucose]] level. [[Gram staining]] of the sample may demonstrate bacteria in bacterial meningitis, but absence of bacteria does not exclude bacterial meningitis; [[microbiological culture]] of the sample may still yield a causative organism. The type of white blood cell predominantly present predicts whether meningitis is due to bacterial or [[virus|viral]] infection. Other tests performed on the CSF sample include  [[latex agglutination test]], limulus lysates, or [[polymerase chain reaction]] (PCR) for bacterial or viral DNA. If the patient is [[immunodeficiency|immunocompromised]], testing the CSF for [[toxoplasmosis]], [[Epstein-Barr virus]], [[cytomegalovirus]], [[JC virus]] and [[fungi|fungal infection]] may be performed.
+Abnormal [[gait]]
-[[Image:Streptococcus pneumoniae meningitis, gross pathology 33 lores.jpg|thumb|200px|right|An [[autopsy]] demonstrating signs of [[pneumococcus|pneumococcal]] '''meningitis'''. The [[forceps]] (center) are retracting the [[dura mater]] (white). Underneath the dura mater are the [[leptomeninges]], which are [[edema]]tous and have multiple small [[hemorrhage|hemorrhagic]] foci (red).]]
+|-
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |Complex or atypical [[migraine]]
-{| style="background:#FDF5E6;padding:0.3em; margin-left:5px; border:1px solid #996666"
+|style="background: #F5F5F5; padding: 5px text-align:center" | +
-|+ style="color:#996666"|'''CSF finding in different conditions'''<ref>{{cite book |last=Provan |first= Drew|authorlink= |coauthors=Andrew Krentz |title= Oxford Handbook of clinical and laboratory investigation|year=2005 |publisher=Oxford university press |location=Oxford |isbn=0198566638 }}</ref>
+|style="background: #F5F5F5; padding: 5px text-align:center" | -
-!bgcolor="#FFEFD5"|Condition !! bgcolor="#FFEFD5"|Glucose !! bgcolor="#FFEFD5"|Protein!!bgcolor="#FFEFD5"|Cells
+|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]]
 |-
-! bgcolor="#FFEFD5"|Acute bacterial meningitis
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Brain abscess|CNS abscess]]
-| Low|| high||high, often > 300/mm³
+|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]]
 |-
-! bgcolor="#FFEFD5"|Acute viral meningitis
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Drug toxicity]]
-|Normal ||normal or high|| [[Lymphocyte|mononuclear]], < 300/mm³
+|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]]
 |-
-! bgcolor="#FFEFD5"|Tuberculous meningitis
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Conversion disorder]]
-|Low ||high||[[pleocytosis]], mixed < 300/mm³
+|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]]
 |-
-! bgcolor="#FFEFD5"|Fungal meningitis
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |Metabolic disturbances ([[electrolyte imbalance]], [[hypoglycemia]])
-|Low||high||< 300/mm³
+|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]]
 |-
-! bgcolor="#FFEFD5"|Malignant meningitis
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Multiple sclerosis]] exacerbation
-|Low ||high||usually mononuclear
+|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]]
 |-
-! bgcolor="#FFEFD5"|Subarachnoid haemorrhage
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Seizure]]
-|Normal ||normal, or high ||[[Erythrocytes]]
+|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]],
 |}
-{|
+==Diagnosis==
-|-style="background:silver; color:black"
+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>
-| '''Cerebrospinal Fluid''' ||  ||  ||  ||  ||
+{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
-|-style="background:silver; color:black"
+|+
-|  || '''Normal Levels''' || '''Acute Bacterial M.''' || '''Acute Viral M.''' || '''TB M.''' || '''Neuroborreliosis'''
+! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Cerebrospinal fluid level}}
-|- style="background:silver; color:black"
+! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Normal level}}
-| '''Cells/ul''' || '''< 5''' || '''In the 1000s''' || '''In the 100s''' || '''In the 100s''' || '''Some 100'''
+! 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:silver; color:black"
+! 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>
-| '''Cells''' || '''Lymph:Monos 7:3''' || '''Gran. > Lymph.''' || '''Lymph. > Gran.''' || '''Various leukos''' || '''Lymph. monocytic'''
+! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|SARS-CoV-2 associated meningitis}}
-|-style="background:silver; color:black"
+! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Fungal meningitis}}
-| '''Total Protein (mg/dl)'''  || '''45-60''' || '''Typically 100-500''' || '''Typically normal''' || '''Typically 100-200''' || '''Typically up to 350'''
+! 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:silver; color:black"
+! 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>
-| '''Glucose Ratio (CSF/plasma)'''  || '''Typically > 0.5''' || '''< 0.3''' || '''> 0.6''' || '''< 0.5''' || '''Normal'''
+|-
-|-style="background:silver; color:black"
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Cells/ul'''
-| '''Lactate (mmol/l)'''  || '''< 2.1''' || '''> 2.1''' || '''< 2.1''' || '''> 2.1''' || '''-'''
+| style="padding: 5px 5px; background: #F5F5F5;" |'''< 5'''
-|-style="background:silver; color:black"
+| style="padding: 5px 5px; background: #F5F5F5;" |'''>300'''
-| '''Others''' || '''ICP: 6-22 (cm H2O)'''  ||  || '''PCR of HSV-DNA''' || '''PCR of TBC-DNA''' || '''IgG/IgM <br> CSF/Serum Ratio'''
+| 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]]'''
+|-
 |}
-{{clr}}
-In bacterial meningitis, the CSF glucose to serum glucose ratio is < 0.4. The Gram stain is positive in >60% of cases, and culture in >80%. Latex agglutination may be positive in meningitis due to ''[[Streptococcus pneumoniae]]'', ''[[Neisseria meningitidis]]'', ''[[Haemophilus influenzae]]'', ''[[Escherichia coli]]'', Group B Streptococci. Limulus lysates may be positive in Gram-negative meningitis.
-====CSF Cultures====
-Cultures are often negative if CSF is taken after the administration of antibiotics.  In these patients, [[polymerase chain reaction|PCR]] can be helpful in arriving at a diagnosis.  It has been suggested that CSF [[cortisol]] measurement may be helpful.<ref>{{cite journal | title=Cortisol levels in cerebrospinal fluid correlate with severity and bacterial origin of meningitis | author=Holub M, Beran O, Dzupova O, ''et al.'' | journal=Critical Care | year=2007 | volume=11 | pages=R41 | doi=10.1186/cc5729 }}</ref>
-===Prediction rules===
-The Bacterial Meningitis Score predicts reliably whether a child (older than two months) may have infectious meningitis.  In children with at least 1 risk factor (positive CSF Gram stain, CSF absolute neutrophil count ≥ 1000 cell/µL, CSF protein ≥ 80 mg/dL, peripheral blood absolute neutrophil count ≥ 10,000 cell/µL, history of seizure before or at presentation time) it had a [[sensitivity (tests)|sensitivity]] of 100%, [[specificity (tests)|specificity]] of 63.5%, and negative predictive value of 100%.<ref>{{cite journal |author=Nigrovic LE, Kuppermann N, Macias CG, ''et al'' |title=Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis |journal=JAMA |volume=297 |issue=1 |pages=52-60 |year=2007 |pmid=17200475 |doi=10.1001/jama.297.1.52}}</ref>
-===Computed Tomography===
-* The role of the head CT is controversial.  It should obviously be preformed in all patients with suspected elevations in intracranial pressure (ICP), however this is often a difficult clinical diagnosis.
-*:* Approximately 50% of the patients in Durand’s study with focal neuro findings had CT abnormalities, whereas CT findings were seen in only 17% of patients without focal findings on exam (p < 0.01).
-*:* Quagliarello and Scheld recommend getting CTs only in patients who are comatose, have papilledema or who have focal neuro deficits.
-=== Histopathology: Acute Bacterial Meningitis ===
-<youtube v=L9jpjxTSLws/>
-==Complete Differential Diagnosis of Underlying Causes of Meningitis==
-In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
-=== Common Causes ===
-* [[Escherichia coli]]
-* [[Gram-negative bacilli]]
-* [[Group B streptococci]]
-* [[Haemophilus influenzae]]
-* [[Klebsiella pneumoniae]]
-* [[Listeria monocytogenes]]
-* [[Neisseria Meningitis]]
-* [[Non-Group B streptococci]]
-* [[Staphylococci]]
-* [[Streptococcus agalactiae]]
-* [[Streptococcus pneumoniae]]
-=== Infectious Causes ===
-* [[Abscess]]
-* [[Adenovirus]]
-* [[Arboviruses]]
-* [[Aspergillosis]]
-* [[Borrelia]]
-* [[Candidiasis]]
-* [[Chlamydia psittaci]]
-* [[Coccidioidomycosis]]
-* [[Coxsackie viruses]]
-* [[Cryptococcosis]]
-* [[Cysticercosis]]
-* [[Cytomegalovirus]]
-* [[ECHO viruses]] ('''E'''ntero '''C'''ytopathogenic '''H'''uman '''O'''rphan)
-* [[Epstein-Barr Virus]]
-* [[Escherichia coli]]
-* [[Haemophilus influenzae]]
-* [[Herpes Simplex Virus]]
-* [[Histoplasmosis]]
-* [[HIV]]
-* [[Influenza]]
-* [[Klebsiella pneumoniae]]
-* [[Leptospira]]
-* [[Listeria monocytogenes]]
-* [[Malaria]]
-* [[Measles]]
-* [[Mumps]]
-* [[Mycobacteria]]
-* [[Mycoplasma pneumoniae]]
-* [[Neisseria Meningitidis]]
-* [[Otitis]]
-* [[Pertussis]]
-* [[Polio]]
-* [[Proteus]]
-* [[Pseudomonas]]
-* [[Rabies]]
-* [[Rickettsia]]
-* [[Rubella]]
-* [[Sarcoidosis]]
-* [[Schistosomiasis]]
-* [[Sinusitis]]
-* [[Smallpox]]
-* [[Staphylococcus aureus]]
-* [[Staphylococcus epidermidis]]
-* [[Streptococci]]
-* [[Streptococcus agalactiae]]
-* [[Streptococcus pneumoniae]]
-* [[Syphilis]]
-* [[Toxoplasmosis]]
-* [[Tuberculosis]]
-* [[Varicella-Zoster Virus]]
-* [[Whipple's Disease]]
-=== Noninfectious Causes ===
-* [[Behcet's Syndrome]]
-* [[Brain tumor]]
-* [[Cerebrovascular accident]]
-* [[Drugs]]
-* Meningeal carcinomatosis
-* Meningeal [[leukemia]]
-* [[Multiple Sclerosis]]
-* Vaccine reaction
-* Triquinine
 ==Treatment==
+===Medical Therapy===
-===Bacterial meningitis===
+*Empiric therapy for meningitis must be initiated after CSF obtained.
-Bacterial meningitis is a [[medical emergency]] and has a high mortality rate if untreated.<ref name=Beckham_2006>{{cite journal |author=Beckham J, Tyler K |title=Initial Management of Acute Bacterial Meningitis in Adults: Summary of IDSA Guidelines |journal=Rev Neurol Dis |volume=3 |issue=2 |pages=57-60 |year=2006 |pmid=16819421}}</ref> All suspected cases, however mild, need emergency medical attention. Empiric antibiotics must be started immediately, even before the results of the [[lumbar puncture]] and [[Cerebrospinal fluid|CSF]] analysis are known. Antibiotics started within 4 hours of lumbar puncture will not significantly affect lab results. Adjuvant treatment with [[corticosteroids]] reduces rates of mortality, severe hearing loss and neurological sequelae.<ref>{{cite journal |author=van de Beek D, de Gans J, McIntyre P, Prasad K |title=Corticosteroids for acute bacterial meningitis |journal=Cochrane database of systematic reviews (Online) |volume= |issue=1 |pages=CD004405 |year=2007 |pmid=17253505 |doi=10.1002/14651858.CD004405.pub2}}</ref>
+*The choice of empiric antibiotic therapy is depend on patient age and underlying comorbid disease.
+*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'''
+|-
+|}
-{| class = "prettytable" style = "float:right; font-size:85%; margin-left:15px"
+*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}}
 |-
-! Age group
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Streptococcus pneumoniae'''
-! Causes
+| 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'''
 |-
-| [[Neonate]]s
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Neisseria meningitidis'''
-| Group B Streptococci, ''[[Escherichia coli]]'', ''[[Listeria monocytogenes]]''
+| 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'''
 |-
-| Infants
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Listeria monocytogenes'''
-| ''[[Neisseria meningitidis]]'', ''[[Haemophilus influenzae]]'', ''[[Streptococcus pneumoniae]]''
+| 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'''
 |-
-| Children
+| style="padding: 5px 5px; background: #DCDCDC;" | '''Streptococcus agalactiae'''
-|''N. meningitidis'', ''S. pneumoniae''
+| 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'''
 |-
-| Adults
-| ''S. pneumoniae'', ''N. meningitidis'', Mycobacteria, Cryptococci
 |}
-The choice of antibiotic depends on local advice.  In most of the developed world, the most common organisms involved are ''[[Streptococcus pneumoniae]]'' and ''[[Neisseria meningitidis]]'': first line treatment in the UK is a third-generation [[cephalosporin]] (such as [[ceftriaxone]] or [[cefotaxime]]). In those under 3 years of age, over 50 years of age, or immunocompromised, [[ampicillin]] should be added to cover ''[[Listeria monocytogenes]]''.  In the U.S. and other countries with high levels of penicillin resistance, the first line choice of antibiotics is [[vancomycin]] and a [[carbapenem]] (such as [[meropenem]]).  In sub-Saharan Africa, oily [[chloramphenicol]] or [[ceftriaxone]] are often used because only a single dose is needed in most cases.
-Staphylococci and gram-negative bacilli are common infective agents in patients who have just had a neurosurgical procedure. Again, the choice of antibiotic depends on local patterns of infection: [[cefotaxime]] and [[ceftriaxone]] remain good choices in many situations, but [[ceftazidime]] is used when ''[[Pseudomonas aeruginosa]]'' is a problem, and intraventricular [[vancomycin]] is used for those patients with intraventricular shunts because of high rates of [[Staphylococcus|staphylococcal]] infection.  In patients with intracerebral prosthetic material (metal plates, electrodes or implants, etc.) then sometimes [[chloramphenicol]] is the only antibiotic that will adequately cover infection by ''[[Staphylococcus aureus]]'' (cephalosporins and carbapenems are inadequate under these circumstances).
+===Surgery===
+*Surgical intervention is not recommended for the management of meningitis.
-Once the results of the CSF analysis are known along with the Gram-stain and culture, empiric therapy may be switched to therapy targeted to the specific causative organism and its sensitivities.
+===Primary Prevention===
-*''[[Neisseria meningitidis]]'' (Meningococcus) can usually be treated with a 7-day course of IV antibiotics:
+*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.
-**Penicillin-sensitive -- [[penicillin]] G or [[ampicillin]]
-**Penicillin-resistant -- [[ceftriaxone]] or [[cefotaxime]]
-**Prophylaxis for close contacts (contact with oral secretions) -- [[rifampin]] 600 mg bid for 2 days ''(adults)'' or 10 mg/kg bid ''(children)''. Rifampin is not recommended in pregnancy and as such, these patients should be treated with single doses of [[ciprofloxacin]], [[azithromycin]], or [[ceftriaxone]]
-*''[[Streptococcus pneumoniae]]'' (Pneumococcus) can usually be treated with a 2-week course of IV antibiotics:
-**Penicillin-sensitive -- [[penicillin]] G
-**Penicillin-intermediate -- [[ceftriaxone]] or [[cefotaxime]]
-**Penicillin-resistant -- [[ceftriaxone]] or [[cefotaxime]] + [[vancomycin]]
-*''[[Listeria monocytogenes]]'' is treated with a 3-week course of IV [[ampicillin]] + [[gentamicin]].
-*Gram negative bacilli -- [[ceftriaxone]] or [[cefotaxime]]
-*''[[Pseudomonas aeruginosa]]'' -- [[ceftazidime]]''
-*''[[Staphylococcus aureus]]''
-**Methicillin-sensitive -- [[nafcillin]]
-**Methicillin-resistant -- [[vancomycin]]
-*''[[Streptococcus agalactiae]]'' -- [[penicillin]] G or [[ampicillin]]
-*''[[Haemophilus influenzae]]'' -- [[ceftriaxone]] or [[cefotaxime]]
-===Viral meningitis===
+{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
-Unlike bacteria, viruses cannot be killed by antibiotics. Patients with very mild viral meningitis may only have to spend a few hours in a hospital, while those who have a more serious infection may be hospitalised for many more days for supportive care. Patients with mild cases, which often cause only flu-like symptoms, may be treated with fluids, bed rest (preferably in a quiet, dark room), and analgesics for pain and fever. Serious cases, especially in the case of young children or neonates, may require the use of antiviral drugs, such as [[acyclovir]]. The physician may also prescribe [[anticonvulsant]]s such as [[phenytoin]] to prevent [[seizure]]s and [[corticosteroid]]s to reduce brain inflammation. If inflammation is severe, pain medicine and sedatives may be prescribed to make the patient more comfortable.
+|+
+! 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.
-===Fungal meningitis===
+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).'''
-This form of meningitis is rare in otherwise healthy people, but is a higher risk in those who have [[AIDS]], other forms of [[immunodeficiency]] (an immune system that does not respond adequately to infections) and [[immunosuppression]] (immune system malfunction as a result of medical treatment). In AIDS, ''[[Cryptococcus neoformans]]'' is the most common cause of fungal meningitis; it requires Indian ink staining of the CSF sample for identification of this capsulated yeast. Fungal meningitis is treated with long courses of highly dosed [[Antifungal drug|antifungals]].<ref>{{cite journal |author=Gottfredsson M, Perfect JR |title=Fungal meningitis |journal=Seminars in neurology |volume=20 |issue=3 |pages=307-22 |year=2000 |pmid=11051295 |doi=}}</ref>
+| 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'''
-==Complications==
+|-
-In children there are several potential disabilities which result from damage to the nervous system.  These include [[sensorineural]] hearing loss, [[epilepsy]], [[cerebral oedema|diffuse brain swelling]], [[hydrocephalus]], cerebral vein thrombosis, [[Intracranial hemorrhage|intra cerebral bleeding]] and [[cerebral palsy]].<ref> {{cite journal|title=Neurological complications of pneumococcal meningitis|journal=Developmental Medicine and Child Neurology|date=Jan 2004|first=G|last=Vasallo|coauthors=T R Martland|volume=Vol. 46|issue=|pages= pg. 11|id= |url=|format=|accessdate=2007-09-03 }}</ref> Acute neurological complications may lead to  adverse consequences. In childhood acute bacterial meningitis deafness is the most common serious complication. [[Sensorineural hearing loss]] often develops during first few days of the illness as a result of [[inner ear]] dysfunction, but permanent deafness is rare and can be prevented by prompt treatment of meningitis.<ref name="pmid9068303">{{cite journal |author=Richardson MP, Reid A, Tarlow MJ, Rudd PT |title=Hearing loss during bacterial meningitis |journal=Arch. Dis. Child. |volume=76 |issue=2 |pages=134-8 |year=1997 |pmid=9068303 |doi=}}</ref>
+| 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.
-Those contract the disease during [[neonatal]] period and those infected by S pneumoniae and gram negative [[bacilli]] are in greater risk of developing neurological, auditory, or intellectual impairments or functionally important behaviour or learning disorders which can manifest as poor school performance.<ref name="pmid11546680">{{cite journal |author=Grimwood K |title=Legacy of bacterial meningitis in infancy. Many children continue to suffer functionally important deficits |journal=BMJ |volume=323 |issue=7312 |pages=523-4 |year=2001 |pmid=11546680 |doi=}}</ref>
+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.'''
-In adults [[central nervous system]] complications include [[cerebrovascular disease]], brain swelling, [[hydrocephalus]], intrcerebral bleeding; systemic complications are dominated by septic [[shock]], [[adult respiratory distress syndrome]] and [[disseminated intravascular coagulation]].<ref name="pmid8503793">{{cite journal |author=Pfister HW, Feiden W, Einhäupl KM |title=Spectrum of complications during bacterial meningitis in adults. Results of a prospective clinical study |journal=Arch. Neurol. |volume=50 |issue=6 |pages=575-81 |year=1993 |pmid=8503793 |doi=}}</ref> Those who have underlying predisposing conditions e.g. head injury may develop recurrent meningitis.<ref name="pmid17682979">{{cite journal |author=Adriani KS, van de Beek D, Brouwer MC, Spanjaard L, de Gans J |title=Community-acquired recurrent bacterial meningitis in adults |journal=Clin. Infect. Dis. |volume=45 |issue=5 |pages=e46-51 |year=2007 |pmid=17682979 |doi=10.1086/520682}}</ref> The case-fatality ratio is highest for [[gram-negative]] [[etiology]] and lowest for meningitis caused by [[Haemophilus influenzae|''H influenzae'']] (also a gram negative bacili). Fatal outcome in patients over 60 years of age are more likely to be from systemic complications e.g. [[pneumonia]], [[sepsis]], cardio-respiratory failure; however in younger individuals it is usually associated with neurological complications.<ref name="pmid17682979">{{cite journal |author=Adriani KS, van de Beek D, Brouwer MC, Spanjaard L, de Gans J |title=Community-acquired recurrent bacterial meningitis in adults |journal=Clin. Infect. Dis. |volume=45 |issue=5 |pages=e46-51 |year=2007 |pmid=17682979 |doi=10.1086/520682}}</ref> Age more than 60, low [[glasgow coma scale]] at presentation and [[seizure]] within 24 hours increase the risk of death among community acquired meningitis.<ref name="pmid8416268">{{cite journal |author=Durand ML, Calderwood SB, Weber DJ, ''et al'' |title=Acute bacterial meningitis in adults. A review of 493 episodes |journal=N. Engl. J. Med. |volume=328 |issue=1 |pages=21-8 |year=1993 |pmid=8416268 |doi=}}</ref>
+|-
+| 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.'''
-== Risk Stratification and Prognosis==
+|-
+| 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.
-The overall mortality rate in Durand’s study was 25%
+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'''
-* Three factors were associated with a significantly higher mortality:
-*:* Age > 60 (37% vs. 17%, p < 0.001, RR 2.1).
-*:* Obtunded mental status on admission (49% vs. 16%, p < 0.001, RR 3.0).
-*:* Onset of seizures within 48 hours of admission (72% vs. 18%, p < 0.001, RR 4.0).
-*:* 98% of the patients in this study who died had at least one of these three risk factors.
-==Prevention==
+|-
-===Immunization===
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Travelers to or residents of countries where meningococcal disease is hyperendemic or epidemic'''
-All current vaccines target only bacterial meningitis.
+|-
+| 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.'''
-Vaccinations against ''[[Haemophilus influenzae]]'' ([[Hib vaccine|Hib]]) have decreased early childhood meningitis significantly.<ref name="pmid10756001">{{cite journal |author=Peltola H |title=Worldwide Haemophilus influenzae type b disease at the beginning of the 21st century: global analysis of the disease burden 25 years after the use of the polysaccharide vaccine and a decade after the advent of conjugates |journal=Clin. Microbiol. Rev. |volume=13 |issue=2 |pages=302-17 |year=2000 | url=http://cmr.asm.org/cgi/content/full/13/2/302 |pmid=10756001 |accessdate=2007-09-03}}</ref>
+|-
+| 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.'''
-Vaccines against type A and C ''[[Neisseria meningitidis]]'', the kind that causes most disease in preschool children and teenagers in the United States, have also been around for a while. Type A is also prevalent in sub-Sahara Africa and W135 outbreaks have affected those on the Hajj pilgrimage to Mecca.
+|-
+| 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'''
-A vaccine called ''[[MeNZB]]'' for a specific strain of type B Neisseria meningitidis prevalent in New Zealand has completed trials and is being given to many people in the country under the age of 20. There is also a vaccine, MenBVac, for the specific strain of type B meningoccocal disease prevalent in Norway, and another specific vaccine for the strain prevalent in Cuba.
+|-
+| 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'''
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo'''
-[[Pneumococcal polysaccharide vaccine]] against ''[[Streptococcus pneumoniae]]'' is recommended for all people 65 years of age or older. [[Pneumococcal conjugate vaccine]] is recommended for all newborns starting at 6 weeks - 2 months, according to American Association of Pediatrics (AAP) recommendations.
+|-
+| 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.
-===Prophylaxis===
+Give either Trumenba (three doses administered at 0, 1 to 2, and 6 months) or Bexsero (two doses administered at least one month apart)'''
-In cases of meningococcal meningitis, prophylactic treatment of close relatives with antibiotics (e.g. [[rifampicin]], [[ciprofloxacin]] or [[ceftriaxone]]) may reduce the risk of further cases.<ref>{{cite journal |author=Fraser A, Gafter-Gvili A, Paul M, Leibovici L |title=Antibiotics for preventing meningococcal infections |journal=Cochrane database of systematic reviews (Online) |volume= |issue=4 |pages=CD004785 |year=2006 |pmid=17054214 |doi=10.1002/14651858.CD004785.pub3}}</ref>
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Boost every five years with Menactra or Menveo.
-===Pathological Findings===
-Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
+Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
-<div align="left">
+|-
-<gallery heights="175" widths="175">
-Image:Meningitis 1.jpg|Meningitis: Gross, purulent leptomeningitis due to pneumococcus infection, an excellent example.
-Image:Meningitis 2.jpg|Bacterial Meningitis: Gross, basilar view
-</gallery>
-</div>
+| 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;" |''''''
-<div align="left">
+|-
-<gallery heights="175" widths="175">
+| style="padding: 5px 5px; background: #DCDCDC;" | '''For children age 7 months through 23 months who have not initiated a series of Menveo'''
-Image:Meningitis 3.jpg|Bacterial Meningitis: Gross close-up
+| 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'''
-Image:Meningitis 4.jpg|Meningitis: Gross base of frontal lobes well shown meningitis burn case with Pseudomonas sepsis
+| style="padding: 5px 5px; background: #F5F5F5;" |''''''
-</gallery>
-</div>
+|-
+| 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;" |''''''
-<div align="left">
+|-
-<gallery heights="175" widths="175">
+| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 10 years through 55 years'''
-Image:Meningitis 5.jpg|Meningitis: Gross natural color excellent demonstration of greenish pus in subarachnoid space
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo.
-Image:Meningitis 6.jpg|Tuberculous Meningitis: Gross fixed tissue close-up of large areas of necrosis in frontal parasagittal cortex secondary to tuberculous vasculitis. An excellent example
-</gallery>
-</div>
+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;" |''''''
-<div align="left">
+|-
-<gallery heights="175" widths="175">
+| style="padding: 5px 5px; background: #DCDCDC;" | '''For age 56 years and older'''
-Image:Meningitis 7.jpg|Tuberculous Meningitis: Micro low mag H&E. An excellent example with giant cells.
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Give one dose of Menactra or Menveo.
-Image:Meningitis 8.jpg|Purulent Meningitis: Gross natural color excellent photo lateral aspect of brain with easily seen purulent exudate due to Pneumococcus infection.
-</gallery>
-</div>
+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.
-<div align="left">
-<gallery heights="175" widths="175">
-Image:Meningitis 9.jpg|Purulent Meningitis: Gross natural color close-up view outstanding example of purulent exudate adjacent to blood vessels
-Image:Meningitis 10.jpg|Purulent Meningitis: Gross natural color Staphylococcal meningitis.
-</gallery>
-</div>
+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.
-<div align="left">
-<gallery heights="175" widths="175">
-Image:Meningitis 11.jpg|Ependymitis Granular Neoplastic: Gross fixed tissue close-up view and a spectacular one of this lesion case also has carcinomatous meningitis primary is lung oat cell.
-Image:Meningitis 12.jpg|Purulent Meningitis: Gross natural color brain in situ with removed calvarium very good illustration of exudate in meninges over convexities pneumococcus.
-</gallery>
-</div>
-== Acute pyogenic (bacterial) meningitis ==
+Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
+|-
-<youtube v=L9jpjxTSLws/>
+| 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.
-==See also==
-* [[Aseptic meningitis]]
-* [[Encephalitis]]
-==References==
+Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains'''
-{{Reflist|2}}
+|-
+| 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.
-==External links==
-* {{dmoz|/Health/Conditions_and_Diseases/Neurological_Disorders/Meningitis/}}
-* [http://www.who.int/mediacentre/factsheets/fs141/en/ WHO: Meningococcal meningitis]
-* [http://www.merck.com/mrkshared/mmanual/section14/chapter176/176a.jsp Merck Manual: Central nervous system infections]
-* [http://www.immunisation.nhs.uk/ Vaccination information from the NHS, UK]
-* [http://www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=dis&obj=menin.htm CDC: Meningococcal disease]
-* [http://www.cnn.com/HEALTH/library/DS/00118.html CNN Health Library, Meningitis]
-* [http://www.meningitisuk.org Information on Meningitis UK and the charity's search for a vaccine]
-* [http://www.meningitis-trust.org Information from the Meningitis Trust]
-* [http://www.meningitis-trust.org.nz Information from the Meningitis Trust in New Zealand]
-{{Diseases of the nervous system}}
+Boost with one dose MenB (Trumenba or Bexsero) one year after primary series; revaccinate every 2 to 3 years if risk remains.'''
-{{SIB}}
+|-
+|}
+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.
-[[af:Meningitis]]
+===Secondary Prevention===
-[[cs:Meningitida]]
+*Secondary prevention with Antimicrobial chemoprophylaxis is necessary for individuals who have close contact with patients with invasive meningococcal disease. Close contacts include:
-[[da:Meningitis]]
+*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)
-[[de:Meningitis]]
-[[es:Meningitis]]
+*Recommended chemoprophylaxis regimens for protection against meningococcal disease — Advisory Committee on Immunization Practices (ACIP), United States, 2012
-[[eo:Meningito]]
+{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
-[[eu:Meningitis]]
+|+
-[[fa:مننژیت]]
+! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Drug}}
-[[fr:Méningite]]
+! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Age group}}
-[[gl:Meninxite]]
+! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Dosage}}
-[[ko:수막염]]
+! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Duration and route of administration}}
-[[hr:Meningitis]]
+|-
-[[id:Meningitis]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Rifampin'''
-[[is:Heilahimnubólga]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Children aged <1 mo'''
-[[it:Meningite]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''5 mg/kg every 12 hrs'''
-[[he:דלקת קרום המוח]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''2 days'''
-[[kk:Миқұрт]]
+|-
-[[la:Meningitis]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Rifampin'''
-[[lt:Meningitas]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Children aged ≥1 mo'''
-[[hu:Agyhártyagyulladás]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''10 mg/kg every 12 hrs'''
-[[ms:Meningitis]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''2 days'''
-[[nl:Hersenvliesontsteking]]
+|-
-[[ja:髄膜炎]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Rifampin'''
-[[no:Meningitt]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Adults'''
-[[pt:Meningite]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''600 mg every 12 hrs'''
-[[qu:Ñutqu p'istuq llika unquy]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''2 days'''
-[[ru:Менингит]]
+|-
-[[sq:Meningjiti]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Ciprofloxacin'''
-[[simple:Meningitis]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Adults'''
-[[sl:Meningitis]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''500 mg'''
-[[fi:Aivokalvontulehdus]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Single dose'''
-[[sv:Hjärnhinneinflammation]]
+|-
-[[vi:Viêm màng não]]
+| style="padding: 5px 5px; background: #F5F5F5;" |'''Ceftriaxone'''
-[[zh:脑膜炎]]
+| 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'''
+|-
+|}
+==References==
+{{reflist|2}}
-[[Category:Diseases involving the fasciae]]
-[[Category:Inflammations]]
-[[Category:Medical emergencies]]
-[[Category:Neurological disorders]]
-[[Category:Infectious Diseases]]
-[[Category:Neurology]]
-[[pl:Zapalenie opon mózgowo-rdzeniowych]]
-[[tr:Menenjit]]
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