Diagnosis:
Clinical features plus confirmation by CSF analysis
Findings in Bacterial meningitis:
- High opening pressure >180 mmH2O, turbid/purulent appearance
- White cell count: high, 10-10,000/microL
- Mainly neutrophils (usually >100), but monocytes are suggestive of Listeria monocytogenes
- Protein: High, >0.45 g/L (>45 mg/dL)
- Glucose: low, <0.4 of serum (roughly <1/2 serum), or <2.2 mmol/L (<40 mg/dL)
- Borrelia burgdorferi, Lyme disease:
- White cell count <100/mm3, <30% neurtrophils
- Protein: normal or high
- Glucose: normal
- CSF PCR for Neisseria meningitides, Haemophilis influenzae, Listeria monocytogenes, Borrelia burgdorferi
- Meningococcal septicemia: blood cultures, skin scrapings of the rash, +/-PCR
Pathology:
Gross:
- Creamy yellow pus surrounding the brain
Microscopic:
- Neutrophils in the subarachnoid space & in Virchow-Robin spaces surrounding vessels. Leptomeningeal vessels may be involved.
- Gram stain: organisms
Monitor:
- In children with meningitis consider get follow up hearing tests
Treament:
This is an emergency, start abx. before confirming the diagnosis by lumbar puncture
Antibiotics considerations:
- See updated list according to current bacterial sensitivities in your community
- Penicillin intravenous +3rd generation cephalosporin (Cefotaxime or ceftriaxone) I.V. X10 days
- Or Vancomycin +3rd generation cephalosporin I.V.
- Or if Listeria is suspected Ampicillin I.V. +Vancomycin +3rd generation cephalosporin I.V.
- If neonatal:
- Ampicillin I.V. +(Cefotaxime or ceftriaxone) X14-21 days
- Or Ampicillin I.V. +gentamicin I.V.
- If pregnant: consider Cefotaxime +ampicillin
- If pneumococcus is suspected or confirmed. +Dexamethazone 0.15 mg/kg q6h X4 days starting before or with first dose of abx.
- If Borrelia X14-28 days
- Consider protein C administration [Debatable]
- If mastoiditis, mastoidectomy
Prophylaxis of contacts:
- If N. meningitides:
- Give ciprofloxacin or rifampin to eradicate pharyngeal carriage.
- In outbreaks use ciprofloxacin.
Related articles:
References:
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. Epub 2004 Oct 6.