Meningitis

Original Editors - Iris Partin from Bellarmine University's Pathophysiology of Complex Patient Problems project.

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Definition/Description

Meningitis is an infectious disease of the central nervous system that causes inflammation of the meningeal membranes, involving all three layers surorunding the brain and spinal cord: dura mater, arachnoid, and pia mater.  The arachnoid and pia mater become inflamed and opaque along with the first two layers of the cortex and the spinal cord . Many complications can result from this inflammation such as the increased risk of infarctions leading to blockage of cerebral spinal fluid flow, thromboses in the cortical veins and additional clinical symptoms . Meningitis can present as acute, subacute, or chronic.

Viral (aseptic) and Bacterial meningitis are the most common forms of acute meningitis. Meningitis is usually a result of fungi, viruses, parasites, bacteria, or a noninfectious inflammation. Viral meningitis is less severe and symptoms can resolve without treatment. However, bacterial meningitis is a more severe form leading to numerous complications and early treatment is key. If diagnosis is delayed, this infectious inflammation can be fatal . 

Meningitis can be difficult to diagnose due to its similar presentations to other infectious disease such as influenza or encephalitis. The risk of developing the disease is highest in the first seven days following onset, and can persist for at least four weeks¹. Progression is very rapid and is distinguished by purulent CSF. Below is a picture of the meninges which are affected by meningitis.

 

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Prevalence

The prevalence of meningitis has greatly decreased over the last fifteen years due to the development of vaccines. The second most common bacteria that causes acute bacterial meningitis, meningocicci, is present in the nasopharynx of approximately 5% of the population. Close contact or respiratory droplets may spread the bacteria. Of the population that has the bacteria, only a small fraction develops meningitis and the most prevalent age range is from birth to one year. Individuals are more vulnerable to developing meningitis under the age of five, teenagers in their late teens or older than 65 years of age.

Bacterial meningitis appears more frequently in populations that are in close living quarters such as college dormitories, military barracks, and boarding schools.   Although the prevalence of meningitis has decreased, it is believed that many cases go unreported³. The incidence of meningitis is 2 of 6 per 10,000 adults per year in developed countries and is up to ten times higher in less-developed coutnries6. In Africa, a large recurring epidemic is reported in a region including 26 countries known as the “meningitis belt.” This region stretches east from Ethiopia to the west, Senegal compromising approximately 300 million occupants.  In the United States, meningitis incidence have decreased from .3 to .18 cases per 100,00 population in 2013⁴.

Characteristics/Clinical Presentation

Headache, fever, vomiting, and rigidity of the neck are the most common symptoms that present with the onset of meningitis. Early symptoms include nausea, drowsiness and confusion. Pain in the posterior thigh or lumbar region may also be noted.  Later symptoms can include seizures, photophobia and rapid breathing rate. In addition, a rash on the skin, scanty petechial (red or purple non-blanching macules smaller than 2mm in diameter) or a purpuric (larger than 2mm) appears on approximately 80-90% of individuals with bacterial meningitis^1,5.  

Meningitis causes inflammation of the meningeal membranes; as a result nerve roots may endure tension as they pass through these inflamed membranes. Passive ROM of the neck into flexion will gradually become painful and limited. Also, neck extension and rotation may be painful as well, however not to the extent of flexion. In severe cases Brudzinki’s sign or Kernig’s may be presented. Brudzinki’s sign is caused by passive neck flexion producing flexion of the hips or knees. Kernig’s sign presents, as restrictive passive extension of the knee while the hip is flexed². In cases when meningitis is not treated immediately (especially bacterial meningitis), the parenchyma within the brain may be involved. As a result individuals may present with lethargy, vomiting, seizures, papilledema, confusion, coma, focal deficits, and cranial nerve palsies.

Brudzinski's SignImage:Kernig's_sign.jpg 

Many colleges raise awareness about meningitis to their students secondary to the increased incidence meningitis. Many large colleges require students to receive the vaccine prior to beginning school due to the high risk of spreading the disease to other students.

File:Meningitis Symptoms.png

Associated Co-morbidities

Predisposing conditions of meningitis include sinusitis, mastoiditis, and otitis. These conditions may require specialized treatment. Damage or removal of the spleen increases the risk of pneumococcal disease which may lead to acute bacterial meningitis. Conditions in which an individuals immune system may become compromised increase the risk and severity of meningitis, such as HIV.  Other conditions that may predispose one for meningitis include alcoholism, prior neurosurgery, cancer, head trauma, parameningeal infection, and anatomical defects of the meningies.

Medications

Quick introduction of antibiotics is crucial when acute meningitis is suspected to prevent progression of the disease and increase the chance of recovery.  Delay of antibiotic administration is associated with poor outcomes⁴. If a patient presents with the cardinal signs and symptoms of meningitis antibiotics are immediately started after blood cultures are drawn. If the patient is not severely ill and the diagnosis of meningitis is questionable, introduction of antibiotics is held until results from CSF stains are determined. Once CSF gram stains are determined targeted antimicrobial treatment may begin. Duration of antimicrobial treatment is determined by CSF sterilization. Organism specific antibiotics used to treat acute bacterial meningitis may be found in Table 1. The table lists the common organisms that result in acute meningitis along with the age appropriate antibiotics.

Table 1: Common antibiotics used to treat specific acute bacterial meningitis. Adapted from The Merck Manual of Diagnosis and Therapy.

Organism	Age Group	Antibiotic
Unknown	Infants less than 1 month	Ampicillin Cefotaxime Gentamicin
Unknown	Children over 1 month of age and Adults	Ampicillin Cefotaxime Vancomycin
Gram-positive organisms (unidentified)	Children and Adults	Vancomycin + Cefotaxime & Ampicillin
Gram-negative bacilli (unidentified)	Children and Adults	Cefotaxime + Gentamicin
Haemophilus influenzatype b	Children and Adults	Cefotaxime
Meningococci	Children and Adults	Penicillin G + Cefotaxime
Streptococcus Pneumoniae	Children and Adults	Vancomycin + Cefotaxime
Listeria sp	Children and Adults	Ampicillin or Trimethoprim
Enteric gram-negative bacteria(Escherichia coli, Proteus sp, Klebsiella sp)	Children and Adults	Cefotaxime + Gentamicin
Pseudomonas	Children and Adults	Meropenem *These may be used with the addition of aminoglycoside Aztreonam
Staphylococcus Aureus	Children and Adults	Vancomycin or Nafcillin *May be prescribed with or without rifampin

Outpatient Antibiotic Therapy (OPAT) is an additional option for the different managements of infection including meningitis. This allows cost saving benefits for the patient to be treated in their own home. The patient is appropriate for OPAT, with the following indications³:

• Afebrile and clinically improving
• Received ≥ 5 days of inpatient therapy and monitoring
• Reliable intravenous access
• Able to access medical advise/care from the OPAT team
• No other acute medical needs

In addition to antibiotics, medications to control and relieve the symptoms of meningitis are introduced as well. Alterations of CSF flow may be controlled using corticosteroids for patients with pneumococcal meningitis. Dexamethasone is suspected to be linked to reducing mortality and morbidity, hearing loss and short term neurological sequelae³. Additional symptoms, nausea and headache, are controlled using the proper medications.

Diagnostic Tests/Lab Tests/Lab Values

The gold standard for diagnosing viral and bacterial meningitis is a CSF culture³. CSF obtained from a lumbar puncture is used to culture cells, glucose level, protein, cell count and differential, and to begin a Gram stain. The viruses that cause meningitis are easily determined by analysis of cell protein and glucose in the CSF³. Gram stains are positive 80% of the time in bacterial meningitis and are 97-100% diagnostically accurate³. Lumbar punctures are performed immediately in patients with suspected meningitis to diagnose and identify the causative organism. Once the organism is identified antimicrobial pharmacotherapy may begin immediately. CSF sterilization can occur within the first 2-4 hours of administration of antibiotics³.  If patient presents with hemodynamic instability, increased cranial pressure, coagulopathy, or neurologic findings indicate a mass lesion lumbar puncture is contraindicated³.

While CSF culture is the gold standard, other diagnostic tests and lab tests are performed when meningitis is suspected. In situations when the patient presents with papilledema, seizures, focal deficits, or deterioration in consciousness an MRI or CT scan are performed to rule out a brain abscess or infarction. A brain abscess or infarction must be ruled out prior to the lumbar puncture to the risk of cerebral herniation. A combination of laboratory tests may be needed in addition to the lumbar puncture when the gram culture and stains are negative. In a case of positive blood culture, increase procalcitonin levels are present in bacterial meningitis differentiating it from a viral meningitis^3,4. Further lab tests are needed to examine blood cultures, a complete blood count, electrolytes, glucose, protein as well as close monitoring of pressure³.  

Causes

Neonates receive antibodies via placenta for bacteria such as Listeria monocytogenes, Escherichia coli, and group B streptococcus. With age, these antibodies decline resulting in increased susceptibility especially in ages 1 to 2 for meningococcus, pneumococcus, and Haemophilus influenzae type b (Hib). Geriatric and the adult population are more affected by Neisseria meningitis and Streptococcus pneumoniae. Pneumococci infections are especially common in adults who suffer from alcoholism, CSF leaks, chronic otitis, mastoiditis, sinusitis, sickle cell disease, pneumococcal pneumonia, and asplenia. These organisms are most commonly found in the upper respiratory tract in the mucosal layers.

Aseptic meningitis is most commonly a result of a viral infection. Enteroviruses (echovirus and coxsackievirus) and herpes simplex virus are the most common viruses representing 40% of the cases of meningitis in individuals 30-60 years old and 20% of all individuals with meningitis, respectively. Individuals in late adolescence and early adulthood who develop meningitis usually came in contact with the Epstein-Barr virus (EBV). Other causes of viral meningitis include intracranial tumor rupture, mumps, systemic lupus erythematosus (SLE), radiopaque agents, lead poisoning, itrathecal drug use, and NSAIDs especially as a result of exposure during surgery.

Bacterial meningitis is transmitted person to person through droplets of respiratory such as coughing or sneezing or throat secretions from carriers. Usually transmitted through close or prolonged contact. Average incubation is 4 days but can range between 2-10 days⁴. 

Systemic Involvement

Nervous
• Inflammation of subarachnoid space
• Spread of inflammation to parenchyma
• Focal ischemic lesions
• Hydrocephaly
• Impaired consciousness
           o Stages include irritability, confusion, drowsiness, stupor, and coma
• Hemiparesis
• Seizures
• Cranial nerve palsy
• Hypothalamic dysfunction in children

Vascular
• Inflammation of small subarachnoid vessels (especially veins)
• Thrombotic obstruction of vessels

Musculoskeletal
• Opisthotonic posture
           o See image below
• Infectious spread to joints

Sensory
• Impaired hearing
• Loss of vision

Metabolic
• Dehydration
• Hyponatremia

Gastrointestinal
• Vomiting

Integumentary
• Petechial rash of skin (usually associated with bacterial meningitis)

Opisthotonic PosturingOpisthotonic Posturing 

Medical Management (current best evidence)

In children and infants treatment usually consist of six or more days of inpatient antimicrobial therapy followed by close follow-up outpatient management. Duration of inpatient treatment is dependant upon absence of fever for at least 24 to 48 hours, no focal findings, ability to take fluids by mouth, no seizure activity, no significant neurologic dysfunction, and improvement or stabilization of condition.

Currently there are vaccines available that are highly effective and safe for some serogroups of N. meningitides, Haemophilus influenzae type b (Hib), and many types of Streptococcus pneumoniae. It is recommended that the meningococcal conjugate vaccine be given between the ages of 11-18 due to the increased prevalence during adolescence. The Advisory Committee on Immunization Practices (ACIP) suggests the vaccines be given at the earliest. The ACIP highly recommends that prior to living in dormitories college freshmen should be vaccinated.

The vaccine for Streptococcus pneumoniae is known and the pneumococcal polysaccharide vaccine (PPSV) and is recommended for individuals between the ages 19-64 with asthma or who smoke and individuals older than 65 and at least 2 years of age with certain medical problems. Another form of the vaccine to prevent infection of pneumococcal is approved and routinely given to children younger than the age of 2.

• See Resources for more information on the prevention of meningococcal disease.

Physical Therapy Management (current best evidence)

According to the American Physical Therapy Association's Guide to Physical Therapist Practice infectious disorders of the central nervous system fall under the following preferred practice patterns; 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System- Acquired in Adulthood or Adolescence and 5I: Impaired Arousal, Range of Motion, and Motor Control Associated with Coma, Near Coma, or Vegetative State. Typically physical therapy treatment is initiated in the intensive care unit. The patient may present in a variety of manners similar to other brain injuries including symptoms similar to focal brain damage (comparable to symptoms of a neoplasm or stroke), brain damage not of infectious origin, and the patient may present with diffuse symptoms often seen with brain trauma.

It is important for the physical therapist to understand the various stages of consciousness a patient with a brain injury may go through. In order to provide effective treatment and minimize the patient’s agitation, the therapist should create an environment that would ease the patient’s hypersensitivity to light and sound and difficulty integrating sensory input. Close monitoring of the vital signs will allow the therapist to analyze the patient’s ability to sensory integrate and allow the therapist to gain insight into which activities may agitate the patient. The therapist should be familiar with the Glasgow Coma Scale and monitor the patient’s progression through the levels of consciousness.

Opisthotonic posture is often associated with meningitis. To maintain mobility of the trunk and neck it is important to initiate positioning and range of motion exercises in the acute phase. Maintain a calm environment during treatment to decrease patient agitation and a dark room may help decrease headache complaints. Another key component to treating a patient with a brain injury is education. Providing the patient and family education on the disease and disease stages can encourage the patient and family to become more involved in the treatment. It is very important to educate on the long process of neurological rehabilitation and how full recovery may take years.

Differential Diagnosis 

• Confusion/dementia
• Cervical arthritis (stiff neck)
• Subarachnoid hemorrhage

Case Reports

1. Case presentation of a 70-year-old male who presented with increasing memory disorders and 7 month history of left buttock pain, right transient temporal head pain, and right conjuctival injection who was later diagnosed with enteroviral meningoencephalitis: A Case of Enteroviral Meningoencephalitis Presenting as Rapidly Progressive Dementia.

2. A 46-year-old male presented to ER with 7 week history of headache, fatigue, and nausea as well as altered mental status over the last 2 days. Past medical history reveled an otherwise healthy individual. Cryptococcal meningitis was diagnosed. Not Your “Typical Patient”: Cryptococcal Meningitis in an Immunocompetent Patient.

3. Oitis noted as comorbitity for meningitis. Case report following a 77 year-old man who was admitted into the hospital for difficulty speaking, ear pain, fever, and altered mental status proceeding fall several days earlier. Diagnosis of bacterial meningitis given. Case 34-2007; A 77-Year_old Man with Ear Pain, Difficulty Speaking, and Altered Mental Status.

4. Meningitis is common in conditions of close living quarters. A case on a healthy 19-year-old female attending a college. Meningitis in a college student in Connecticut, 2007.

Resources

• Infections of the CNS: Meningitis
• Centers for Disease Control and Prevention Question and Answers
  

• Prevention and Control of Meningococcal disease          
  

• American College Health Association (ACHA)          
  

• Meningitis Foundation of America
  

Recent Related Research (from Pubmed)

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