Eperisone is Contraindicated in Suspected Acute Bacterial Meningitis
Do not use eperisone or any muscle relaxant for neck stiffness when acute bacterial meningitis is suspected—this is a life-threatening emergency requiring immediate empiric antibiotics, not symptomatic treatment of muscle spasm.
Critical Management Priority
- Initiate empiric antibiotics immediately when bacterial meningitis is suspected, regardless of whether imaging or lumbar puncture has been performed 1.
- Antibiotic therapy should be started as soon as possible because early treatment is directly associated with better outcomes and lower mortality 2.
- Never delay antibiotics while awaiting diagnostic confirmation, as mortality remains high in untreated bacterial meningitis 3.
Why Eperisone is Inappropriate
- Neck stiffness in suspected bacterial meningitis is a critical diagnostic sign of meningeal inflammation, not a primary muscle spasm disorder requiring muscle relaxant therapy 1.
- Treating the symptom (neck stiffness) with a muscle relaxant while missing the underlying life-threatening infection would be a catastrophic error in clinical judgment.
- The focus must be on treating the infection itself, not providing symptomatic relief that could mask the severity of the condition or delay appropriate care.
Diagnostic Considerations
- The classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of bacterial meningitis cases, but 95% have at least two of four symptoms (headache, fever, neck stiffness, altered mental status) 1.
- Neck stiffness has only 31% sensitivity in adults, meaning it misses 69% of actual cases 1.
- Kernig and Brudzinski signs have extremely poor sensitivity (5-11%) and cannot rule out meningitis 1, 4.
Immediate Treatment Algorithm
Step 1: Empiric Antibiotic Regimen
- Ceftriaxone 2g IV q12h for coverage of S. pneumoniae and N. meningitidis 1.
- Add ampicillin 2g IV q4h if patient is >50 years old, immunocompromised, alcoholic, or diabetic to cover Listeria monocytogenes 1.
- Add vancomycin if septic cavernous sinus thrombosis is suspected (for S. aureus including MRSA) 1.
Step 2: Adjunctive Therapy
- Administer dexamethasone before or at the time of antibiotic initiation 5.
Step 3: Diagnostic Workup
- Perform lumbar puncture for CSF analysis unless contraindications exist (papilledema or focal neurological symptoms require CT first) 1, 6.
- CSF examination remains the principal diagnostic test with the highest accuracy (AUC 0.95) for bacterial meningitis 1.
Common Pitfall to Avoid
- Never treat neck stiffness symptomatically in the context of possible meningitis—this represents a fundamental misunderstanding of the pathophysiology and urgency of the condition.
- The absence of neck stiffness does not rule out bacterial meningitis given its poor sensitivity 4, 3.
- Elderly patients (>65 years) are less likely to present with fever or neck stiffness but more likely to have altered consciousness 1.