Rhonda Cadena explains the process of diagnosing and managing meningitis. It is a skill that involves rapid identification, workup, and treatment. In most cases, the diagnosis of meningitis is not a diagnostic dilemma, but the workup and treatment are not as straightforward. Meningitis is inflammation of the lining of the brain and spinal cord. This can be caused by bacteria, autoimmune process, drug reactions, viruses, and fungi. Rhonda delves deeper into bacterial meningitis. Worldwide there are over 1 million cases per year of bacterial meningitis. This equates to 135 000 deaths. Of the survivors, half will be left with neurological deficits. So, the swift identification and treatment of this disease process is crucial. Symptoms include fever, headache, nuchal rigidity and altered mental status with almost all patients having at least two. A lumbar puncture is absolutely necessary. Only insist on a CT first if you suspect a mass lesion or increased intracranial pressure. Otherwise, the delay in antibiotics can lead to an increased morbidity and mortality. Labs are next in the workup. All the common labs should be ordered along with a procalcitonin which can be diagnostic for a bacterial infection (although it will be positive with any bacterial infection so make sure it fits the clinical picture!) Likewise, fungitell can be useful in looking for some of the more common fungal infections. Blood cultures will guide antibiotic coverage. Steroids can be beneficial for prevention of neurological sequalae in patients who are infected with pneumococcal meningitis. They should be started in anyone with suspected meningitis. You can then cease if cultures come back negative for pneumococcus. Importantly steroids must be started before or during antibiotics. Finally Rhonda discusses prophylactic treatment. This is necessary for contacts of patients with Neisseria infections. Think household member, day care contacts, and anyone exposed to secretions. This scintillating talk addresses the challenges during the workup, which labs to send during the initial workup, and how specialized labs such as CSF lactate, procalcitonin, and fungitell may help in the workup along with helpful advice for management.

1. Rhonda Cadena, MD
University of North Carolina, Departments of Neurology, Neurosurgery, and Emergency Medicine
MENINGITIS: CHALLENGES

2. MENINGITIS: DEFINITION
▶ Aseptic
▶ Viral
▶ Fungal
▶ Bacterial

3. BACTERIAL MENINGITIS
1.2 million cases/yr 135,000 deaths/yr 50% with neuro sequelae

7. OTHER CAUSES

8. SYMPTOMS
> >>

9. DIAGNOSING: EXAM
Kernig
Brudzinkski jolt accentuation of headache

10. LUMBAR PUNCTURE
CT necessary?
▶ New onset seizure
▶ Immunocompromised
▶ si/sx intracranial lesion
▶ si/sx impending herniation
▶ Impaired/declining LOC

11. LABS
▶ Blood cultures
Meningitis cause: Normal Viral Bacterial Fungal Tuberculous
Cell count (WBC/microL) < 5 (1:500 RBC) < 1000 (lymph) >1000-2000 (neut) 100-500 (lymph) 5-500 (mono)
Glucose CSF:serum > 0.6 Normal < 45 mg/dL
CSF:serum ≤0.4
Low to normal < 45 mg/dL
Protein < 50 mg/dL 50-300mg/dL 100-500mg/dL Normal to high 50-500 mg/dL
Gram stain 60-90% sensitive
Lactate < 3.5 mEq/L > 3.8 mmol/l
Additional studies
PCT = Procalcitonin
PCR = polymerase chain reaction
(may detect pneumococcal, h.flu
meningococcal
PCT <0.5 ng/ml
PCR: run on saved
sample if negative
cultures
PCT levels >0.5
ng/ml
Fungitell to exclude:
Candida, Acremonium,
Aspergillus, Coccidioides,
Fusarium, Histoplasma,
Trichosporon, Sporothrix,
Saccharomyces cerevisiae,
and Pneumocystis jiroveci

12. TREATMENT
▶ Antibiotics:
▶ Don’t delay if delay in LP,
you have hours before sterile cultures
(except meningococcus, but that’s OK)
▶ Steroids:
▶ Before or during antibiotics
▶ Improved morbidity and mortality with
pneumococcus (mostly in sicker ones)
▶ Other stuff
▶ Source control
▶ Respiratory isolation x 24 hours for
meningococcal infection only

13. PROPHYLAXIS: MENINGOCOCCAL
▶ Who needs it?
▶ Household members
▶ Day care center contacts
▶ Anyone directly exposed to oral secretions (mouth-to-mouth,
intubation, or ETT management)
▶ Timing
▶ Within 24 hours of case identification
▶ Drugs
▶ Rifampin BID x 2 days or ciprofloxacin x 1 dose

14. QUESTIONS?