What is the approach to examining a patient with viral (inflammation of the meninges caused by a virus) meningitis?

From the Guidelines

To examine a patient with viral meningitis, prioritize a thorough history and physical examination, documenting the presence or absence of headache, altered mental status, neck stiffness, fever, rash, seizures, and signs of shock, as these are crucial for diagnosis and management 1. When assessing a patient with suspected viral meningitis, it is essential to start with a comprehensive history, focusing on symptoms such as headache, fever, neck stiffness, photophobia, and altered mental status. Note the onset and progression of symptoms, recent illnesses, exposures to others with similar symptoms, and immune status.

• Perform a complete physical examination with special attention to:
  • Vital signs, particularly fever
  • Neurological assessment including mental status, cranial nerve function, motor and sensory function, reflexes, and coordination
  • Check for meningeal signs such as nuchal rigidity
• Although Kernig’s sign and Brudzinski’s sign are traditional meningeal signs, they should not be relied upon for diagnosis as per the guidelines 1.
• Examine for rashes, particularly those associated with certain viral infections.
• After the clinical examination, a lumbar puncture should be considered for further evaluation and diagnosis, as recommended for patients where meningitis is suspected 1.
• Additional tests including complete blood count, blood cultures, and viral studies (PCR for enteroviruses, herpes viruses, etc.) may be ordered based on the clinical presentation and laboratory findings.
• Neuroimaging with CT or MRI may be necessary before lumbar puncture if there are focal neurological findings, seizures, papilledema, or immunocompromise, but this should be decided on a case-by-case basis.

From the Research

Examination of a Patient with Viral Meningitis

To examine a patient with viral meningitis, the following steps can be taken:

• The clinical presentation of the patient should be assessed, including symptoms such as headache, nausea/vomiting, fever, neck stiffness, and altered mental status 2
• The absence of fever, neck stiffness, and altered mental status can effectively eliminate meningitis, with a sensitivity of 99%-100% for the presence of one of these findings 2
• Jolt accentuation of headache can be a useful adjunctive maneuver, with a sensitivity of 100%, specificity of 54%, positive likelihood ratio of 2.2, and negative likelihood ratio of 0 for the diagnosis of meningitis 2
• A lumbar puncture and cerebrospinal fluid (CSF) analysis can be performed, which is the gold standard for the diagnosis of meningitis 3
• The CSF analysis can include laboratory tests such as CSF cell count, glucose concentration, Gram's stain, and bacterial culture to identify the organism and differentiate between bacterial and viral meningitis 3

Laboratory Tests

The following laboratory tests can be used to aid in the diagnosis of viral meningitis:

• CSF cell count 3
• Glucose concentration 3
• Gram's stain 3
• Bacterial culture 3 These laboratory tests can be used in combination with the clinical presentation to determine which patient should be treated for bacterial meningitis while awaiting the result of CSF Gram's stain and bacterial culture 3