Updated: 6/12/2019

Meningitis

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Questions
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Snapshot
  • A 19-year-old man presents to the emergency department with a headache. His headache was initially mild but then subsequently worsened over the course 2 days. His headaches are associated with fevers, chills, photophobia, and neck stiffness. His temperature is 101°F (38.3°C), blood pressure is 124/95 mmHg, pulse is 118/min, and respirations are 22/min. Physical examination is notable for nuchal rigidity and petechieal hemorrhages in the skin. An emergent lumbar puncture is performed and blood cultures are obtained. Immediately after, he is started on intravenous vancomycin and ceftriaxone. (Meningococcal meningitis)
Introduction
  • Definition
    • inflammation of the meninges that can be caused by
      • infection (bacterial, viral, and fungal)
      • autoimmune disease
      • malignancy
      • medications
  • Etiology
    • infection
      • bacterial
      • viral
      • fungal
    • autoimmune disease
      • neurosarcoid
      • Behcet syndrome
    • malignancy
      • leptomeningeal carcinomatosis
      • hemotologic malignancy
    • medications
      • trimethoprim-sulfamethoxazole
      • non-steroidal anti-inflammatory drugs
      • intravenous immunoglobulins
      • inflixamab
  • Epidemiology
    • incidence
      • aseptic meningitis is more common than bacterial meningitis
      • enteroviruses are the most common cause of viral meningitis
  • Prognosis
    • bacterial meningitis is a medical emergency requiring prompt antibiotic treatment
Presentation
  • Symptoms
    • headache
    • confusion
    • photophobia
  • Physical exam
    • nuchal rigidity
    • positive Kernig sign
      • patient supine
      • knee extension while hips are 90° flexed → resistance/pain
    • positive Brudzinski sign
      • patient supine
      • passive neck flexion → involuntary knee flexion
    • petechial rash 
      • may suggest Neisseria meningitidis infection
Studies
  • Lumbar puncture
    • helps suggest which type of meningitis the patient has 
    • studies must include
      • opening pressure
      • cell count
      • protein
      • glucose
      • Gram stain
      • culture
    • other tests depend on the clinical scenario
      • e.g., acid fast bacillus (AFB) stain in patients who are likely to have tuberculosis
  • Serum studies
    • blood cultures
      • especially helpful in patients who urgently require antibiotics but are unable to get a lumbar puncture immediately
 
Cerebrospinal Fluid Analysis
Test Normal Bacterial 
Viral Fungal/TB
Opening pressure
  • ≤ 20 cm H
    2
    O
  • Normal or slightly ↑
Color
  • Clear
  • Cloudy
  • Clear
  • Cloudy
Cell count
  • 0-5 cells/µL
  • ↑ (PMN)
  • ↑ (Lymphocytes)
  • ↑ (Lymphocytes)
Protein
  • < 45 mg/dL
  • Slighty ↑
CSF:Serum glucose
  • > 0.6
  • Normal

Treatment
 
Bacterial
Population Causative Organism Treatment
Infants (<1 month)

 

  • Streptococcus agalactiae (group B streptococcus)
  • Listeria monocytogenes
  • Escherichia coli
  • other gram-negative bacilli

 

  • Ampicillin and cefotaxime
1-23 months of age
  • Streptococcus pneumoniae
  • Neisseria meningitidis
  • S. agalactiae
  • Haemophilus influenzae
  • E. coli
  • Vancomycin and ceftriaxone
  • In cases of streptococcal pneumoniae, patients can benefit from dexamethasone 
2-50 years of age
  • N. meningitidis
  • S. pneumoniae
  • Vancomycin and ceftriaxone  
> 50 years of age of immunocompromised 
  • S. pneumoniae
  • N. meningitidis
  • L. monocytogenes
  • aerobic gram-negative bacilli
  • Vancomycin, ceftriaxone, and ampicillin 
 
  • Viral meningitis
    • supportive treatment 
  • Meningococcal prophylaxis 
    • indication
      • roomates or intimate contacts
      • child care center workers
      • direct exposure (e.g., kissing and endotracheal intubation)
      • sitting next to the affected person for  8 hours
    • medication
      • rifampin 
        • interacts with oral contraceptives and other medications that use the cytochrome P450 system
      • ceftriaxone
      • ciprofloxacin
  • Cryptococcal meningitis
    • treatment
      • amphotericin with flucytosine followed by fluconazole 
Complications
  • Neurological sequela (e.g., cognitive deficit)
  • Septic sinus thrombosis
  • Subudural effusion or empyema
 

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Questions (11)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.NE.14) A 55-year-old woman presents to the emergency department with recent onset confusion and photophobia. Upon questioning her husband, you discover the patient has been sick over the past week with fevers and productive sputum. Her vital signs are Temperature 102.6 Pulse 80 Respirations 18 Blood Pressure 110/70. The physical exam is significant for lethargy and nuchal rigidity. A lumbar puncture is performed and demonstrates cloudy fluid with an opening pressure of 35 cm H20, cell count of 1500 cells/uL (neutrophil predominant), protein level of 50 mg/dL and glucose of 30 mg/dL. Computed tomography scan demonstrates no space-occupying lesions. What is the most appropriate initial treatment for this patient? Review Topic

QID: 105831
1

Acyclovir

0%

(0/0)

2

Supportive treatment, no antibiotics

0%

(0/0)

3

Ceftriaxone and dexamethasone

0%

(0/0)

4

Vancomycin, ceftriaxone, ampicillin and dexamethasone

0%

(0/0)

5

Vancomycin, ceftriaxone and ampicillin

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.NE.58) An 18-year-old female college student is brought to the emergency department by ambulance for a headache and altered mental status. The patient lives with her boyfriend who is with her currently. He states she had not been feeling well for the past day and has vomited several times in the past 12 hours. Lumbar puncture is performed in the emergency room and demonstrates an increased cell count with a neutrophil predominance and gram-negative diplococci on Gram stain. The patient is started on vancomycin and ceftriaxone. Which of the following is the best next step in management? Review Topic

QID: 102687
1

Add ampicillin, dexamethasone, and rifampin to treatment regimen

58%

(11/19)

2

Add ampicillin to treatment regimen

0%

(0/19)

3

Add dexamethasone to treatment regimen

0%

(0/19)

4

Treat boyfriend with ceftriaxone and vancomycin

0%

(0/19)

5

Treat boyfriend with rifampin

42%

(8/19)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M2.NE.60) A 22-year-old male college student is brought to the emergency department with fever and headache and is accompanied by his girlfriend. Lumbar puncture is performed and the Gram stain is shown in Figure A. Appropriate treatment is initiated and the patient is hospitalized. His girlfriend reports that they spend all their time together and also have been intimate the past several days. She is currently asymptomatic. What is the most appropriate treatment for the girlfriend?
Review Topic

QID: 103550
FIGURES:
1

No treatment necessary

10%

(8/78)

2

Oral rifampin

77%

(60/78)

3

Amoxicillin/clavulanate

6%

(5/78)

4

Hospitalize and observe

3%

(2/78)

5

Vancomycin

3%

(2/78)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.NE.203) A 45-year-old male presents to the emergency room following a seizure. The patient suffered from an upper respiratory infection complicated by sinusitis two weeks ago. The patient's past medical history is remarkable for hypertension for which he takes hydrochlorathiazide. Temperature is 39.5C, blood pressure is 120/60 mmHg, pulse is 85/min, and respiratory rate is 20/min. Upon interview, the patient appears confused and exhibits photophobia. CSF cultures are obtained. Which of the following is the most appropriate next step in the management of this patient? Review Topic

QID: 106230
1

Ceftriaxone

4%

(3/77)

2

Ceftriaxone and vancomycin

39%

(30/77)

3

Ceftriaxone, vancomycin and ampicillin

23%

(18/77)

4

MRI of the head

8%

(6/77)

5

Head CT

23%

(18/77)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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