Meningitis
Robert is a 23 year old student who presents with a gradual onset of a generalized
headache. The headache started yesterday at the back of his head and now has spread all
over. The pain is a constant ache of 7/10 and has only lessened a bit in intensity with
motrim. He has no associated nausea, vomiting, photophobia or visual disturbance. He
has not taken his temperature but says he has had some chills and feels unwell. He has
had occasional headaches in the past which he has put down to tension headaches but
they have not been as bad as this headache. He has a recent history of an upper
respiratory tract infection with rhinorrhea and mild sore throat but no ear pain. In the past
he had an inguinal hernia repair as a baby but has no other relevant past medical history.
He is on no prescribed medication and does not usually take over the counter medication.
He is a postgraduate student and drinks 6-10 beers a week and is a non smoker. He has
had 2 lifetime female sexual partners and is currently not sexually active.
Physical examination:
Patient looks his stated age and is in moderate distress.
Vital signs.
Temp: 38.8C,
Pulse: 96
BP: 130/86
Resp rate: 18
Weight 165lbs.
Head, EENT. Mild rhinorrhea, otherwise normal.
Neck.
Pain in neck with flexing chin to chest
Kernigs sign: negative
Brudzinskis sign: negative
Chest.
Clear to auscultation and percussion.
Heart.
Normal heart sounds with no added sounds.
Abdomen.
Soft and non tender. Normal liver. Spleen not palpable. Normal bowel
sounds.
Neurological Orientated x3. Cranial nerves II-XII intact. Normal tone, power, sensation
reflexes and cerebellar function.
Commentary:
This patient presents with what he describes as a worse than usual headache and systemic
symptoms of possible fever and malaise. Any patient presenting with a worse than usual
headache needs to be evaluated carefully to rule out life threatening causes of
headache.(Table 1). Guidelines from the American college of emergency physicians state
that neuro imaging needs to be considered for any patient presenting with an acute onset
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headache to evaluate for an intracranial hemorrhage 1. (Table 2). Generally the clinical
history is not useful in diagnosing meningitis even the symptoms of generalized
headache, neck pain, nausea and vomiting are not specific enough in establishing the
diagnosis of meningitis. However the history of an ante-cedent febrile illness such as
otitis media, pneumonia or an upper respiratory tract infection is not uncommon in
meningitis.2 (Table 3).The clinical examination can be helpful. In a systematic review
analyzing the sensitivity of the physical examination in the diagnosis of meningitis the
two largest studies containing 398 patients reported that 99-100% of patients had at least
one of neck stiffness, fever or change in mental status, which means meningitis can
virtually be ruled out in a patient without any of these signs. 3
Signs of Meningeal Irritation
1. Neck stiffness: in multiple studies including 733 patients, neck stiffness had a pooled
sensitivity of 70%.3
2. Kernigs and Brudzinskis signs: these have not been well studied. In Brudzinskis
original paper of 42 cases of meningitis Kernigs sign had a sensitivity of 42% and
Brudzinskis had a sensitivity of 97%. 4
3. Jolt accentuation of headache.
In the one small study describing this sign the sensitivity was 100% with a positive
likelihood ratio of 2.2 and a negative likelihood ratio of 0. 5
Other signs and symptoms associated with meningitis.
 Paralysis of the 4th, 5th , 6th and 7th cranial nerves can occur in 5-10% of adults
with community acquired meningitis and papilledema occurs in 1%. (6)
 A petechial or purpuric rash can occur in meningococcal meningitis.
 Seizures may occur particularly in meningitis due to streptococci pnemoniae.
Causes of meningitis
The most common cause of meningitis is viral most often an enterovirus. Arboviruses,
herpes viruses and HIV are other viral causes of meningitis. The term aseptic meningitis
is used for meningitis not caused by a bacterial infection but would also include
meningitis caused by chemicals and carcinomatosis. Viral meningitis usually causes
symptoms less severe than those of bacterial meningitis but a definitive diagnosis can
only be made after examination of the CSF
The most common causes of bacterial meningitis are Streptococcus pneumoniae and
Neisseria meningitides which cause over 90% of bacterial meningitis in adults. Other
bacterial causes are Listeria monocytogenes, E.Coli and Hemophilus influenzae.
Bacterial meningitis is more severe than viral meningitis and can rapidly lead to death if
not treated promptly. 6
Management
In this situation where the patient is febrile it would be reasonable to proceed with a
lumbar puncture to evaluate the CSF for a cell count, protein and glucose measurement
and gram stain and culture. If there was doubt about the diagnosis of meningitis vs.
subarachnoid hemorrhage a CT scan would be indicated to look for evidence of raised
intra cranial pressure prior to doing the lumbar puncture.
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Summary
1.
In a patient without any of fever, neck stiffness and change in mental status
the diagnosis of meningitis is highly unlikely.
2.
Fever is the most sensitive sign out of the above triad.
3.
The classic signs of Kernigs and Brudzinski have a low sensitivity but high
specificity.
4.
Jolt accentuation of headache may be a useful additional sign of meningitis.
Indications for Neuroimaging in patients with
Headache.
Life threatening causes of headache.
1.
2.
3.
4.
Abnormal neurological examination. (Level B)
Acute sudden onset headache. (Level B)
HIV positive patients. (Level B)
Patients over 50 yrs with a new type of
headache.
(Level A)
1. Meningitis
2. Intracranial hemorrhage
3. Hypertensive encephalopathy
Table 1
Table 2.(1)
Jolt accentuation of
headache.
A positive sign is when
the patient’s headache
worsens when he turns
his head horizontally at
a rate of 2 to 3 rotations
per second.
(5)
Brudzinski Sign
The patient is supine
a positive sign is
when passive neck
flexion causes
flexion of the hips
and knees.
Kernigs sign
The patient is supine
with the hip flexed at 90
degrees. A positive sign
is when extension of the
knee causes resistance
or pain in the back or
posterior thigh.
Predisposing Factors for
Bacterial Meningitis.
1.
Diabetes
2.
Otitis media
3.
Pneumonia
4.
Sinusitis
5.
Alcohol abuse.
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Table 3. (2)
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References.
1. Clinical policy: Critical issues in the evaluation and management of patients
presenting to the emergency department with acute headache. Annals of Emerg
Med. 2002 ;39 (1): 108-22.
2. Goldman: Cecil textbook of Medicine 21st edition. Copyright 2000. W. B
Saunders.
3. Attia J, Hatala R, Cook DJ, Wong JG. Does the adult patient have meningitis?
JAMA 1999;281:175-181.
4. Brody IA, Wilkins RH. The signs of Kernig and Brudzinski. Aqrch
Neurol.1969;21:215-218.
5. Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign
of pleocytosis. Headache.1991;31:167-171.
6. Durand ML et al. Acute bacterial meningitis in adults-a review of 493 episodes.
NEJM 1993;328(1):21-28.
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