Clinical features and diagnosis of acute bacterial meningitis in adults
- Allan R Tunkel, MD, PhD, MACP
Allan R Tunkel, MD, PhD, MACP
- Professor of Medicine
- Warren Alpert Medical School of Brown University
Meningitis is an inflammatory disease of the leptomeninges, the tissues surrounding the brain and spinal cord, and is defined by an abnormal number of white blood cells in the cerebrospinal fluid (CSF). The meninges consist of three parts: the pia, arachnoid, and dura maters. Bacterial meningitis reflects infection of the arachnoid mater and the CSF in both the subarachnoid space and the cerebral ventricles.
Approximately 1.2 million cases of bacterial meningitis occur annually worldwide . Meningitis is among the 10 most common infectious causes of death and is responsible for approximately 135,000 deaths throughout the world each year. Neurologic sequelae are common among survivors.
The clinical and laboratory features of acute bacterial meningitis in adults will be reviewed here. The pathogenesis, epidemiology, treatment, prognosis, and prevention of acute bacterial meningitis in adults and issues related to acute bacterial meningitis in children and to chronic and recurrent meningitis are discussed separately. (See "Pathogenesis and pathophysiology of bacterial meningitis" and "Epidemiology of bacterial meningitis in adults" and "Initial therapy and prognosis of bacterial meningitis in adults" and "Treatment of bacterial meningitis caused by specific pathogens in adults" and "Bacterial meningitis in children older than one month: Clinical features and diagnosis" and "Bacterial meningitis in children older than one month: Treatment and prognosis" and "Approach to the patient with chronic meningitis" and "Approach to the adult with recurrent infections", section on 'Meningitis'.)
The epidemiology of and risk factors for bacterial meningitis are discussed in detail elsewhere, but the major epidemiologic issues in adults can be summarized as follows (see "Epidemiology of bacterial meningitis in adults"):
●Bacterial meningitis can be community acquired or healthcare associated.
- Scheld WM, Koedel U, Nathan B, Pfister HW. Pathophysiology of bacterial meningitis: mechanism(s) of neuronal injury. J Infect Dis 2002; 186 Suppl 2:S225.
- de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347:1549.
- Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 1993; 328:21.
- van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351:1849.
- Aronin SI, Peduzzi P, Quagliarello VJ. Community-acquired bacterial meningitis: risk stratification for adverse clinical outcome and effect of antibiotic timing. Ann Intern Med 1998; 129:862.
- Domingo P, Mancebo J, Blanch L, et al. Fever in adult patients with acute bacterial meningitis. J Infect Dis 1988; 158:496.
- Thomas KE, Hasbun R, Jekel J, Quagliarello VJ. The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis 2002; 35:46.
- Choi C. Bacterial meningitis in aging adults. Clin Infect Dis 2001; 33:1380.
- Attia J, Hatala R, Cook DJ, Wong JG. The rational clinical examination. Does this adult patient have acute meningitis? JAMA 1999; 282:175.
- Schut ES, Lucas MJ, Brouwer MC, et al. Cerebral infarction in adults with bacterial meningitis. Neurocrit Care 2012; 16:421.
- Zoons E, Weisfelt M, de Gans J, et al. Seizures in adults with bacterial meningitis. Neurology 2008; 70:2109.
- Mylonakis E, Hohmann EL, Calderwood SB. Central nervous system infection with Listeria monocytogenes. 33 years' experience at a general hospital and review of 776 episodes from the literature. Medicine (Baltimore) 1998; 77:313.
- Brouwer MC, van de Beek D, Heckenberg SG, et al. Community-acquired Listeria monocytogenes meningitis in adults. Clin Infect Dis 2006; 43:1233.
- Heckenberg SG, de Gans J, Brouwer MC, et al. Clinical features, outcome, and meningococcal genotype in 258 adults with meningococcal meningitis: a prospective cohort study. Medicine (Baltimore) 2008; 87:185.
- Pace D, Pollard AJ. Meningococcal disease: clinical presentation and sequelae. Vaccine 2012; 30 Suppl 2:B3.
- Weisfelt M, van de Beek D, Spanjaard L, de Gans J. Arthritis in adults with community-acquired bacterial meningitis: a prospective cohort study. BMC Infect Dis 2006; 6:64.
- Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache 1991; 31:167.
- Nakao JH, Jafri FN, Shah K, Newman DH. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med 2014; 32:24.
- Tamune H, Takeya H, Suzuki W, et al. Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med 2013; 31:1601.
- Kaplan SL. Clinical presentations, diagnosis, and prognostic factors of bacterial meningitis. Infect Dis Clin North Am 1999; 13:579.
- Kornelisse RF, Westerbeek CM, Spoor AB, et al. Pneumococcal meningitis in children: prognostic indicators and outcome. Clin Infect Dis 1995; 21:1390.
- Brouwer MC, van de Beek D, Heckenberg SG, et al. Hyponatraemia in adults with community-acquired bacterial meningitis. QJM 2007; 100:37.
- Geiseler PJ, Nelson KE, Levin S, et al. Community-acquired purulent meningitis: a review of 1,316 cases during the antibiotic era, 1954-1976. Rev Infect Dis 1980; 2:725.
- Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art. Rev Infect Dis 1988; 10:365.
- Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics 2001; 108:1169.
- Brouwer MC, Thwaites GE, Tunkel AR, van de Beek D. Dilemmas in the diagnosis of acute community-acquired bacterial meningitis. Lancet 2012; 380:1684.
- Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001; 345:1727.
- Gopal AK, Whitehouse JD, Simel DL, Corey GR. Cranial computed tomography before lumbar puncture: a prospective clinical evaluation. Arch Intern Med 1999; 159:2681.
- Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.
- Joffe AR. Lumbar puncture and brain herniation in acute bacterial meningitis: a review. J Intensive Care Med 2007; 22:194.
- Glimåker M, Johansson B, Grindborg Ö, et al. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis 2015; 60:1162.
- Blazer S, Berant M, Alon U. Bacterial meningitis. Effect of antibiotic treatment on cerebrospinal fluid. Am J Clin Pathol 1983; 80:386.
- Spanos A, Harrell FE Jr, Durack DT. Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations. JAMA 1989; 262:2700.
- Huy NT, Thao NT, Diep DT, et al. Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: a systemic review and meta-analysis. Crit Care 2010; 14:R240.
- Sakushima K, Hayashino Y, Kawaguchi T, et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infect 2011; 62:255.
- Tunkel AR. Approach to the Patient with Central Nervous System Infection. In: Principles and Practice of Infectious Diseases, 7th ed., Mandell GL, Bennett JE, Dolin R. (Eds), Churchill Livingstone Elsevier, Philadelphia 2010. Vol 1, p.1183.
- Bonadio WA. The cerebrospinal fluid: physiologic aspects and alterations associated with bacterial meningitis. Pediatr Infect Dis J 1992; 11:423.
- Schmidley JW, Simon RP. Postictal pleocytosis. Ann Neurol 1981; 9:81.
- Edwards R, Schmidley JW, Simon RP. How often does a CSF pleocytosis follow generalized convulsions? Ann Neurol 1983; 13:460.
- Tumani H, Jobs C, Brettschneider J, et al. Effect of epileptic seizures on the cerebrospinal fluid--A systematic retrospective analysis. Epilepsy Res 2015; 114:23.
- Fitch MT, van de Beek D. Emergency diagnosis and treatment of adult meningitis. Lancet Infect Dis 2007; 7:191.
- Elmore JG, Horwitz RI, Quagliarello VJ. Acute meningitis with a negative Gram's stain: clinical and management outcomes in 171 episodes. Am J Med 1996; 100:78.
- Saha SK, Darmstadt GL, Yamanaka N, et al. Rapid diagnosis of pneumococcal meningitis: implications for treatment and measuring disease burden. Pediatr Infect Dis J 2005; 24:1093.
- Werno AM, Murdoch DR. Medical microbiology: laboratory diagnosis of invasive pneumococcal disease. Clin Infect Dis 2008; 46:926.
- Tzanakaki G, Tsopanomichalou M, Kesanopoulos K, et al. Simultaneous single-tube PCR assay for the detection of Neisseria meningitidis, Haemophilus influenzae type b and Streptococcus pneumoniae. Clin Microbiol Infect 2005; 11:386.
- Negrini B, Kelleher KJ, Wald ER. Cerebrospinal fluid findings in aseptic versus bacterial meningitis. Pediatrics 2000; 105:316.
- CLINICAL FEATURES
- Presenting manifestations
- - Examination for nuchal rigidity
- Assessment of risk
- LABORATORY FEATURES
- Laboratory studies
- Blood cultures
- LUMBAR PUNCTURE
- Indications for CT scan before LP
- If LP is delayed
- Relative contraindications
- Opening pressure
- CSF analysis
- - Overview
- - Pleocytosis
- - Gram stain
- - Rapid tests
- - Polymerase chain reaction
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Epidemiology of bacterial meningitis
- Clinical manifestations
- Laboratory findings
- Lumbar puncture