From the Guidelines
Meningitis should be suspected in patients presenting with fever, headache, neck stiffness, and altered mental status, and immediate medical attention is warranted due to the potential for rapid progression and fatal outcomes. The classic triad of symptoms includes fever, neck stiffness (nuchal rigidity), and altered mental status, though not all patients exhibit all three signs 1. Severe headache is extremely common and often described as the worst headache of one's life. Other symptoms include photophobia (sensitivity to light), phonophobia (sensitivity to sound), nausea, vomiting, and confusion. In infants, symptoms may be less specific and include irritability, poor feeding, and a bulging fontanelle.
Some key points to consider when suspecting meningitis include:
- The presence of a petechial or purpuric rash, which may indicate meningococcal meningitis, a medical emergency 1
- Kernig's sign and Brudzinski's sign, although not reliable for diagnosis, can be indicative of meningitis 1
- The importance of prompt lumbar puncture for definitive diagnosis, although treatment with antibiotics should not be delayed if meningitis is suspected 1
- The need for urgent hospital referral in adults with suspected meningitis or meningococcal sepsis due to the possibility of rapid deterioration 1
It is essential to note that bacterial meningitis can progress rapidly and be fatal within hours, so anyone with these symptoms should seek emergency care immediately 1. The inflammation of the meninges (protective membranes covering the brain and spinal cord) causes these symptoms by irritating nerve roots, increasing intracranial pressure, and triggering systemic inflammatory responses.
In terms of diagnostic work-up, a recent prospective study on the diagnostic accuracy of clinical and laboratory features in the diagnosis of central nervous system infection and bacterial meningitis showed limited diagnostic accuracy for clinical characteristics and laboratory parameters in the diagnosis of bacterial meningitis 1. However, the cerebrospinal fluid (CSF) leucocyte count was found to be the best diagnostic parameter for differentiating bacterial meningitis from other diagnoses, with an area under the curve of 0.95 in a receiver operating characteristics analysis 1.
The ESCMID guideline recommends that CSF examination is strongly recommended in patients with suspected bacterial meningitis, even in the absence of classic symptoms 1. Additionally, the guideline advises to strive for treatment of all patients with suspected bacterial meningitis within one hour, irrespective of cranial imaging before the lumbar puncture 1.
From the Research
Symptoms and Signs of Meningitis
The symptoms and signs that suggest meningitis include:
- Sudden onset severe headache
- Fever
- Altered mental status
- Stiff neck (positive Kernig's sign)
- Seizures
- Vomiting
Risk Factors for Meningitis
Certain risk factors can increase the suspicion of meningitis, such as:
Importance of Early Recognition and Treatment
Early recognition of symptoms and signs of meningitis is crucial to direct physicians quickly towards appropriate diagnostic measures and empiric antibiotic therapy 3. Delay in treatment can lead to high mortality and morbidity.
Diagnostic Measures
Diagnostic measures for meningitis include:
- Lumbar puncture (LP) for cerebrospinal fluid (CSF) examination 4, 2
- Blood culture
- Imaging studies (e.g. CT scan)
Treatment of Meningitis
Treatment of meningitis typically involves antibiotics, such as ceftriaxone 4, 5 and vancomycin 6, and adjunctive corticosteroids, such as dexamethasone 4, 6. The choice of antibiotic and dosage may depend on the suspected or confirmed cause of meningitis.