Clinical

Microbiology
N e w s l e t

CMN

Stay Current...
Stay Informed.

t e r

Infectious Meningitis

Vol. 37, No. 6

March 15, 2015
www.cmnewsletter.com
I n Th is

CMN

Issu e

43 Infectious Meningitis

AbdelRahman M. Zueter, M.L.S., M.Sc., Ph.D.,1 and Amani Zaiter, M.Sc.,2 1Department of Medical
Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia,
2
Biological Sciences Department, Faculty of Science, Hashemite University, Zarqa, Jordan

Abstract
Infectious meningitis is a large public health concern, especially in children and immunocompromised
patients. Although the epidemiology of meningitis has shown significant decline in past decades, partly
due to the introduction of vaccines, outbreaks are still reported worldwide. Diagnosis of meningitis is
of critical importance, and it is considered to be one of the most urgent of the microbiological medical emergencies. In order to improve the treatment strategy, various diagnostic methods have been
developed to detect the presence of infectious agents that cause meningitis, as well as their antibiotic
resistance patterns. This article aims to enhance the understanding of meningitis and to highlight the
most current updates that describe outbreaks of meningitis and the subsequent investigations. We also
describe the current diagnosis and treatment options.

Introduction

Corresponding author:
AbdelRahman M. Zueter,
M.L.S., M.Sc., Ph.D., Department of Medical Microbiology
and Parasitology, School of
Medical Sciences, Universiti
Sains Malaysia, 16150 Kubang
Kerian, Kelantan, Malaysia.
Tel.: 0060136709343. Fax:
0060197676289. E-mail:
zueterabdelrahman@gmail.com

Meningitis is an inflammation of the meningeal

layers of the brain and spinal cord. The infection involves the arachnoid, the pia mater, and
the intervening cerebrospinal fluid (CSF). The
inflammatory process extends throughout the
subarachnoid space of the brain and spinal cord
and involves the ventricles. Meningitis can cause
necrosis, decreased blood and CSF flow, and
impaired central nervous system (CNS) functions. The early symptoms are headache, fever,
and chills; however, a combination of 2 to 4
symptoms (headache, fever, stiff neck, and altered
mental status) is found in 95% of patients. Death
occurs from shock and other serious complications within hours of the appearance of symptoms (1,2).
Meningitis is usually caused by an infection but
may also occur in response to noninfectious irritants introduced into the subarachnoid space
(1). Noninfectious cases are uncommon or rare
compared with the infectious type, particularly
with their inability to spread from one person
to another (3). Therefore, meningitis could be
divided into two categories according to the
nature of the causative agents: infectious and

noninfectious meningitis (2). Noninfectious

meningitis can be induced by certain drugs, autoimmune hypersensitivity disorders, neoplasms,
and chemical agents (Table 1). When present in
the CSF, noninfectious agents or their products,
such as tumor cell products, act as inflammatory
irritants that induce inflammatory processes that
can progress to meningitis.

Infectious Meningitis
Infectious meningitis is a serious disease of the
CNS that involves inflammation of the meninges
as a result of microbial infection, and it occurs in
all age groups. It is caused most commonly by
viruses and bacteria, rarely by fungi and parasites (9). The clinical presentation of meningitis
depends on the virulence of the causative agent,
the pathogenesis of spread to the CNS, and the
area of CNS involvement (3). Headache, fever,
stiff neck, confusion, vomiting, and pleocytosis
are features of meningeal inflammation and are
common to many types of meningitis (e.g., bacterial, fungal, viral, and chemical) and also to some
parameningeal processes. The CSF laboratory
findings are most helpful in distinguishing among
these processes (2).

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

43

The age of the host and other underlying host factors (head
trauma, neurosurgery, or presence of a CSF shunt) contribute to
the etiology and the routes of entry. Initially, infectious agents
colonize or establish localized infection in the skin, nasopharynx,
respiratory tract, gastrointestinal tract, or genitourinary tract of
the host. From these sites, the organisms invades by circumventing host defenses (e.g., physical barriers, local immunity, and
phagocytes/macrophages) and gains access to the CNS through
(i) hematogenous spread, the most common route of infection, in
which the organisms spread via the blood vessels of the brain to
enter the subarachanoid space; (ii) direct spread from an infected
neighboring site contiguous to the CNS; (iii) an anatomical defect
in the CNS structure that resulted from surgery, trauma, or congenital abnormalities, which can allow microorganisms to easily
access the CNS; or (iv) travel along nerves leading to the brain, as
occurs with some viruses. Of note, neonates have the highest risk
of infection because of their immature immune system and the
increased permeability of the blood brain barrier (10). Infectious
meningitis is grouped on the basis of pathogen type (bacterial,
viral, fungal, or parasitic), host age (neonate, pediatric, and adult),
health status (healthy or immunocompromised), and symptom
duration (acute, subacute, or chronic [recurrent]).
Meningitis is transmitted from person to person through respiratory secretions (saliva, sputum, or nasal mucus), through the fecaloral route, or vertically through the colonized vaginal canal. The
infection is considered to be acute during the period when signs
and symptoms of less than 24 hours duration are observed and
subacute when signs and symptoms have been present for 1 to 7
days. Most cases of meningitis are acute, but some are chronic due
to the invasion of pathogens from a neighboring infected site (10).
The common infectious agents of acute meningitis are viruses
(mainly enteroviruses and, to a lesser degree, HIV, herpes simplex viruses (HSV), and mumps virus), bacteria (Streptococcus
pneumoniae, Neisseria meningitidis, Streptococcus agalactiae (group B
streptococci), Haemophilus influenzae, and Listeria monocytogenes).
Less common causes of acute meningitis include parasites (Naegleria fowleri, Strongyloides stercoralis, and Acanthamoeba cantonensis).
Subacute or chronic meningitis is characterized by delayed symptoms over weeks to months or even years. These patients may
also have some acute meningitis symptoms, but the onset is more
gradual, with lower fever and possibly associated lethargy and
disability. This type of meningitis may be caused by Mycobacteria
spp., spirochetes, Cryptococcus neoformans, Candida spp., and Coccidioides spp. (1,3).
Bacterial meningitis

Bacterial meningitis is a major cause of morbidity and mortality, especially among children less than 5 years of age. The rapid
progression of symptoms and potentially devastating effect of the
disease necessitate early recognition and immediate treatment.
Shock, coagulation disorders, endocarditis, pyogenic arthritis,
and prolonged fever are the most common bacterial meningitis
complications (2). Despite many new antibacterial agents, bacterial
meningitis fatality rates remain high, with reported rates between

44

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

Table 1. Noninfectious causes of meningitis

Noninfectious cause/agent Examplea Reference

Drug hypersensitivity
antimicrobials
Systemic diseases
Neoplastic diseases
Chemical agents
a

NSAID

4,5

SLE

Metastatic carcinoma

Anaesthetics

NSAID, nonsteroidal anti-inflammatory drug; SLE, Systemic lupus erythomatosis.

2% and 30%. Permanent sequelae, such as epilepsy, mental retardation, or sensorineural deafness, are observed in 10% to 20% of
those who survive (11,12).
In general, all human microbes can cause meningitis, but only
a few species account for most cases of bacterial meningitis. S.
agalactiae and Escherichia coli commonly infect neonates up to 3
months of age and are acquired during the passage of the baby
through a colonized vaginal canal. H. influenzae infects unvaccinated children between the age of 3 to 6 months and 6 years.
N. meningitidis infects children and young adults and is the only
organism that causes meningitis epidemics. S. pneumoniae occasionally infects children and increases in incidence with age. L.
monocytogenes appears to be foodborne (dairy products, processed
meat, and uncooked vegetables) and infects people with defective
immunity or those receiving certain therapies (1-3). Some studies
report a dramatic drop in developed countries as a result of the
introduction of vaccines against common bacterial agents, such
as S. pneumoniae, H. influenzae type b, and N. meningitidis (2,11).
Data for community-acquired acute bacterial meningitis suggest
that almost 50% of cases are due to S. pneumoniae, 25% to N. meningitidis, 13% to group B streptococci, 8% to L. monocytogenes, and
7% to H. influenzae. In contrast, nosocomial meningitis is associated with enteric gram-negative bacilli in up to 33% of cases. The
most common gram-negative bacterial agents in adults are E. coli
and Klebsiella/Enterobacter spp. Mortality rates of bacterial meningitis in adults remain at approximately 20% but rise to at least 40%
for those older than age 60 (13). In neonates, S. agalactiae and E.
coli are the most common agents of meningitis in North America
(11), Australasia (14), and Europe (15). The morbidity rate of
neonatal meningitis is up to 56%; if not treated, the mortality can
approach 100% (16). In rare situations, other bacterial pathogens
can cause acute meningitis, including coagulase-negative staphylococci, Burkholderia pseudomallei, Pseudomonas aeruginosa, miscellaneous gram-negative bacilli, Staphylococcus aureus, viridans
streptococci, and anaerobic bacteria. Mixed bacterial infections
might occur as complications of neurosurgical procedures (e.g.,
spinal puncture) and low immunity status. Meningitis caused by
group A streptococci is uncommon but occasionally occurs after
acute otitis media. In approximately 10% of patients with acute
bacterial meningitis, the bacterial cause cannot be defined but is
diagnosed on the basis of other differential laboratory findings (3).
Mycobacterium tuberculosis, Treponema pallidum and Borrelia burg
dorferi are considered to be the most common causes of chronic

bacterial meningitis (13); 1% of patients suffering from tuber

culosis progress to complicated CNS tuberculosis (17).
Viral meningitis

Viral meningitis is more common than bacterial meningitis but is

much less severe. The clinical course of viralmeningitis is usually
self-limited, with complete recovery in 7 to 10 days. Most cases of
community-acquired aseptic meningitis are the result of viruses.
Aseptic meningitis is suspected when CSF cultures for routine
bacteria are negative and there were no antibiotics given before
the lumbar puncture (16).
Enteroviruses account for 85 to 95% of aseptic meningitis (3,18).
Enteroviruses are single-stranded RNA viruses and, along with
rhinoviruses, represent a major group in the genus Enterovirus
in the family Picornaviridae. Recent classification systems rely on
RNA homology, which classifies the enteroviruses into four species designated human enteroviruses A through D, encompassing
many serotypes of group A and B coxsackieviruses and enteroviruses, echoviruses, and polioviruses (3).
Mumps virus, HIV-1, and HSV-2 may cause chronic recurrent
meningitis (2), a recurrent infection that occurs after full recovery.
The exact incidence of viral meningitis is known to be underestimated, due to poor reporting practices. In temperate regions,
seasonal aseptic meningitis usually peaks in summer and early
autumn, reflected by the seasonal pattern of outbreaks. Some
enteroviral serotypes (e.g., echoviruses 6, 9, 13, 18, and 30 and
coxsackievirus B5) cause widespread outbreaks, while coxsackieviruses A9, B3, and B4 are associated with endemic infection.
Echovirus 30 has been implicated in European outbreaks every
3 to 5 years. Its distribution covers large geographical areas, and
infections are more common in children. On the other hand, no
seasonal preference has been reported for HSV and HIV (18).
Table 2 describes the recently published surveys and outbreaks of
acute meningitis worldwide.
Fungal and parasitic meningitis

Fungal meningitis is rare but poses a significant challenge, spanning a wide array of hosts, including immunocompetent and
immunosuppressed individuals, patients undergoing neurosurgical
procedures, and those with implantable CNS devices. C. neoformansandAspergillusspp. are the most common fungal pathogens
(51). C. neoformansinfection is acquired by the inhalation route
and can be asymptomatic and limited to the lungs in immunocompetent hosts. Upon immunosuppression, hematogenous
dissemination to the meninges may occur, which can end with a
fatal outcome in the absence of prompt management. Lympho
proliferative malignancies, steroid therapy, diabetes mellitus, and
AIDS are the most common predisposing factors for cryptococcal meningitis (51). C. neoformans is the most common cause of
meningitis in immunosuppressed and AIDS patients; the mortality rate in that population ranges from 10 to 30% and from 13 to
44% in developed and developing countries, respectively (52,53).
In one retrospective study performed in India, the prevalence of
C. neoformans among HIV patients was 14.3% (53). Candida spp.
cause acute meningitis indistinguishable from bacterial meningitis

in patients with low immunity or after neurosurgery procedures.

Chronic cryptococcal and candidal meningitis may mimic chronic
meningitis that is caused by M. tuberculosis (52).
Parasites can infect the meninges and cause aseptic meningitis;
they can also infect brain tissue, causing acute meningoencephalitis. From warm freshwater, the free-living amoeba N. fowleri
(the most virulent) invades the brain via direct extension from the
nasal mucosa and causes meningoencephalitis that is lethal within
1 week in most cases, predominantly in children and young adults.
Acanthamoeba species are commonly found in soil and primarily
infect immunocompromised patients, usually through inhalation
or skin wounds, causing encephalitis, which can be acute or chronic
(3,10). A listing of uncommon pathogens is provided in Table 3.

Approaches for Laboratory Diagnosis

Diagnosis of an infection involving the CNS is considered to be
a medical emergency. Combining the physical examination with
confirmatory laboratory tests and a clinical history of the patient
provides the strongest evidence of meningitis. Over the last few
years, many approaches have been developed and used for the
diagnosis of meningitis. Currently, several diagnostic methods
were evaluated in order to achieve sensitive, rapid, and specific
detection of meningitis etiology (10), especially in the case of bacterial meningitis, which requires immediate diagnosis and rapid
institution of antimicrobial therapy (2). When meningitis occurs,
inflammatory immune cells flow into the CSF and are usually
detectable on examination of the fluid. Therefore, the collection
of CSF specimen via lumbar puncture is one of the first steps in
the workup of a patient with suspected meningitis (2,13).
CSF collection

Routinely, CSF is collected into three sterile tubes from the same
puncture after considering the proper intracranial pressure. The
first tube is used for chemical and immunological testing due to
the potential for cell contamination during collection. To avoid
surface flora contamination, the second tube is selected for microbiological and molecular testing. The last volume collected best
represents the actual cellular composition of the CSF and is ideal
for cytological testing. In cases where a low volume of CSF is
collected, the sample is triaged for microbiology, cytology, and
chemistry, respectively, to optimize findings. After collection, the
sample is assessed for normal color, clarity, and viscosity and then
sent for further laboratory examination (65).
Cytology

Direct microscopy provides a screening method of CSF samples.

Various cell types in CSF should be evaluated and studied, yet
few have established usefulness in diagnosing infectious meningitis. A microscopic examination includes total and differential
white blood cell (WBC) counts, as well as counts of red blood
cells (RBCs) and other cell types that could be uncommon or
abnormal (13).
A total CSF cell count is usually performed manually using a
hemacytometer chamber. Automated electronic-impedance-based
CSF cell counters increase precision and reduce turnaround time.

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

45

Table 2. Recent surveys and outbreaks of acute meningitis in selected countries worldwide
Age group

Predominant pathogensa

Study interval

Diagnostic methodc

Reference

India

Allb

S. aureus, Klebsiella spp., E. coli, Acinetobacter spp.,

N. meningitidis, S. pneumoniae

2009-2010

Culture

19

Japan

Neonates

H. influenzae, S. pneumoniae, S. agalactiae, E. coli

2008-2010

Culture

20

Japan

Adult

Enteroviruses, mumps virus, VZV, HSV

2004-2014

PCR, culture

21

China

All

S. pneumoniae, N. meningitidis, H. influenzae

2006-2009

Agglutination, culture

22

China

Pediatric

Enteroviruses, adenoviruses

2006-2012

PCR, culture

23

China

Pediatric

Enteroviruses (echovirus 30, coxsackievirus B5)

Outbreak
2008, 2012

PCR, culture,
genotyping

24

Australia

All

Enteroviruses (echoviruses 6, 4, 30, 25, and

coxsackievirus A9)

2007-2013

PCR, culture,
genotyping

25

Jordan

Pediatric

Enteroviruses

1999

Culture, IFA

26

Palestine

Adults

Enteroviruses (echovirus 27)

1978-2012

Culture, serology

27

Kuwait

Pediatric

Enteroviruses (echoviruses 9, 11, 30)

2006-2009

PCR, hybridization

28

France, Italy, Greece,

Finland, Bulgaria,
Serbia, Latvia, Spain,

All

Enteroviruses (echovirus 30)

Outbreak,
2009-2013

PCR, culture,
genotyping

29,30-32

Turkey

Children

S. pneumoniae, N. meningitidis, H. influenzae

2005-2006

PCR, culture

38

Denmark

All

S. pneumoniae, N. meningitidis,
streptococcus groups A, B, G

1998-2010

Agglutination,
culture

39

UK

Neonates

S. agalactiae, E. coli, S. pneumoniae, N. meningitidis

2010-2011

Gram stain, culture

40

Iceland

Children

N. meningitidis, H. influenzae
S. pneumoniae, S. agalactiae

1975-2010

Gram stain, culture

41

Spain

Adults,
Elderly

N. meningitidis, S. pneumoniae, L. monocytogenes

S. pneumoniae, L. monocytogenes,
Gram-negative bacilli

1982-2010

Gram stain, culture,

agglutination

42

Brazil, Panama

All

Enteroviruses (echovirus 30)

2005, 2008

PCR, culture,
genotyping

43,44

Brazil

All

N. meningitidis, S. pneumoniae
H. influenzae

2004-2006
2000-2010

Gram stain
PCR, agglutination

45,46

USA

All

S. pneumoniae, N. meningitidis

1998-2007

Culture

11

USA

All

Enteroviruses (echoviruses 30, 6)

5 yr

PCR, culture,
genotyping

47

Malawi

Neonates

S. agalactiae, S. pneumoniae, S. enterica

2002-2008

Gram stain, culture

12

Burkina Faso

Children

H. influenzae, S. pneumoniae, N. meningitidis

2004-2012

Gram stain,
PCR, culture

48

Niger

All

N. meningitidis, S. pneumoniae, H. influenzae

2002-2010

PCR, culture,
agglutination

49

South Africa

Pediatric

Enteroviruses (echoviruses 4, 9, and

coxsackievirus B5

2010-2011

PCR, culture,
genotyping

18

Kenya

Pediatric

S. pneumoniae, N. meningitidis, H. influenzae

2014

Culture, Gram stain

50

Country

Asia

Middle East

Europe

Americas

Africa

Pathogens are listed in the order of highest frequency to lowest frequency. VZV, varicella-zoster virus.
All includes pediatric patients, adults, and the elderly.
IFA, immunofluorescence assay.

b
c

46

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

Moreover, the nature of normal CSF cell constituents represent

cells in low density, which interferes with the working principle
of the automated counter, thus resulting in values higher than
normal cell counts. Therefore, the impedance-based technology
may not be routinely applicable, since most CSF samples tested in
the laboratory are in the normal/low cell count range (65). Some
studies have reported agreement of cell counts performed on
automated analyzers that use flow cytometry and flow cell digitalimaging principles with those from the manual hemacytometer
method (66). Unfortunately, automated systems cannot identify
pathologic cell types, such as neoplastic cells, lipophages, and siderophages. A differential cell count is best performed by Wrights
stain of CSF sediment smear prepared by cytocentrifugation. The
normal CSF does not contain RBCs; however, normal adult CSF
contains a total of 0 to 5 WBCs/l, specifically, lymphocytes and
monocytes. In children, the total WBC count is 0 to 10 WBCs/
l; in healthy neonates, counts as high as 30 WBCs/l, with a predominance of monocytes, can be normal (2,65).
Chemical examination

Numerous chemical constituents in the CSF sample are evaluated, but few give useful diagnostic data for meningitis etiology. Since result values differ in response to the different types
of microorganisms involved, assays such as glucose, lactate, and
various proteins assays can provide diagnostic information (Table
4) and help classify the type of meningitis, but results from cytology and chemistry laboratories cannot conclusively determine
whether the infection is bacterial, viral, fungal, or parasitic due to
similarity of results that may be obtained in response to infections

by different microorganism types. Confirmatory tests should be

performed (2,18).
Normal CSF glucose levels range from 50 to 80 mg/dl, which is
approximately 60% to 70% of the plasma concentration. In contrast, CSF lactate is unrelated to plasma and is present in normal
concentrations of 10 to 22 mg/dl. More than 50% of infectious
meningitis cases cause decreases in the CSF glucose level due
to defects in glucose transport across the blood brain barrier or
increased glucose consumption within the CNS. Increased lactate
is an indicator of anaerobic metabolism within the CNS due to
decreased oxygenation and blood supply.
The CSF total protein assay assesses the integrity of the blood
brain barrier. The total CSF protein level varies with the age and
the site from which the CSF is obtained and is higher when collected from the lumbar region. A CSF total protein level of 15 to
45 mg/dl is considered normal. Protein screens include assessment
of CSF proteins and immunoglobulins by electrophoresis, and the
definitive concentrations are measured by nephelometry (2,65).
Microbiological examination

Microbiological staining is used for visual detection of causative

agents in the CSF sediments. The sediment could be concentrated or smeared, dried, and stained with Gram stain, India ink,
and Ziehl-Neelsen stain for bacteria and yeast, Cryptococcus spp.,
and Mycobacteria spp., respectively. Wet-mount preparation can
be used for parasite detection (10). Direct microscopy and staining of concentrated CSF sediment provide rapid presumptive
diagnosis of meningitis in 60% to 80% of untreated patients and

Table 3. Recent cases of meningitis of chronic and uncommon etiologies

Age/gender

Meningitis etiology

Risk factora

Diagnostic methodb

50 yr/male

Rhodotorula glutinis

AIDS

Outcome

Reference

Gram stain, culture

Cured

54

34 yr/male

C. neoformans

AIDS

Culture

Cured

55

42 yr/male

C. neoformans

HIV-induced IRIS

Relapsed

56

19 mo/male

A. cantonensis

Poor hygiene

Microscopy

Cured

68

64 yr/male

Abiotrophia defectiva

Neurosurgical
procedures

Culture, genotyping

Cured

57

17 mo/male

M. tuberculosis

Disseminated
tuberculosis

PCR

Cured

59

18 mo/male

M. tuberculosis

Disseminated
tuberculosis

CT scan

Cured

52 yr/female

Pantoea calida

Post surgery

Culture, genotyping

Cured

60

36 yr/male

Salmonella enterica
serovar Virchow

Salmonella Virchow
carrier

Culture

Cured

61

21 yr/female

Mycobacterium chelonae

Culture, RFLP

Cured

62

6 yr/male

N. fowleri

Contaminated water
reservoir

Microscopy

Cured

63

8 mo/male

Methicillin-resistant
S. aureus (MRSA)

MRSA sepsis

Culture

Cured

64

Complication

Reversible blindness

Agglutination
Permanent
neurological sequelae

Communicating
hydrocephalus

IRIS, immune reconstitution inflammatory syndrome.

CT, computed tomography; RFLP, restriction fragment length polymorphism.

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

47

in 40% to 60% of treated patients (65). Culture is considered the

gold standard for several protocols. The organism could be grown
on special nutritive medium that supports its growth after proper
incubation under suitable atmosphere and temperature. Culture is
routinely used for bacterial and fungal diagnosis. Traditional laboratory diagnostic culture methods for the identification of bacterial meningitis pathogens take up to 36 hours or more and enable
the isolation of common types of bacteria in 80% to 90% of cases
(65,67). Unfortunately, in many clinical settings, the administration of short-course antibiotic therapy prior to lumbar puncture
reduces the chance of isolation of bacteria in CSF culture, decreasing the diagnostic accuracy for bacterial meningitis to only 30%.
Therefore, a growing discrepancy exists between the numbers of
clinically suspected and culture-confirmed cases of bacterial meningitis. Thus, negative CSF cultures in patients suspected to have
meningitis can be confirmed by other methods that are not affected
by antibiotic administration (67), such as PCR (3).
Cell lines for viral culture are part of routine laboratory diagnosis
for viral meningitis in countries where viral meningitis outbreaks
are endemic. In some cases, the purpose of viral culture is more
often focused on molecular genotyping applications that require
isolation of the viral genome than on primary diagnosis (3,25).
Enteroviruses are isolated in cell line culture with sensitivities of 65
to 75% and takes 4 to 8 days. HSV-2 can be cultured from CSF in
approximately 75% of patients with aseptic meningitis (2). Development of CSF PCR panels for diagnostic purposes is ongoing.
Immunodiagnostics

Immunoassays are based on the principle of antigen-antibody reaction for identification of microbial agents. Microbial structures,
such as capsules, can be targeted as an antigen and then detected
by a reagent antibody. Rapid antigen detection from CSF has been
largely accomplished by the principles of latex agglutination, coagglutination, immunoassay, and counter-immunoelectrophoresis.
Immunoassays represent a screening tool for primary diagnosis,
along with other screens for microbial detection and cell counting.
Currently, immunologic tests are applicable for the detection of
several types of bacteria and fungi that cause meningitis, including S. pneumoniae, S. agalactiae, H. influenzae, N. meningitidis, Coccidioides immitis, M. tuberculosis, and C. neoformans. Additionally,
certain kits are used to detect either antibodies or antigens that

are specific for some viruses (10,65). The latex slide agglutination
test for C. neoformans antigen shows moderate to high sensitivity (60% to 99%) and specificity (80% to 99%). In addition, the
antigen titer serves as a good prognostic indicator (65). However,
CSF serology for detection of bacterial antigens is not widely used
because it has lower sensitivity and specificity than Gram stain and
culture (3,10,65).
Molecular methods and applications

Molecular assays have become widely applied in the microbiology field as diagnostic and research tools. Molecular techniques
are used for confirmatory diagnosis and have been gradually
introduced for routine primary diagnosis of viral meningitis (10).
Nucleic acid assays, mainly PCR and its variants, have been used
in diagnosis involving direct detection of microorganisms in CSF
specimens, confirmation of bacteria and viruses grown in culture
media and cell lines, genotyping of viruses beyond identification
for molecular epidemiology and phylogenetic purposes, and identification of antimicrobial resistance for certain bacteria.
Molecular methods shorten diagnosis time (up to 4 hours) and
have increased specificity and sensitivity of diagnosis. Additionally, they solve the discrepancy problems in suspected patients who
show culture-negative results. These combined characteristics provide advantages for PCR over any other laboratory test (10,23).
Reverse transcription (RT)-PCR targeting the 5' non-translated
region (NTR) of the enteroviral genome, which is the most conserved genomic region, is essential for enteroviral-meningitis diagnosis and delivers results in as little as 5 hours, thereby shortening
inpatient hospital stays and minimizing the unnecessary use of
empirical antimicrobial agents. In comparison with cell line culture, RT-PCR sensitivity and specificity in CSF are 85 to 100%
and 90 to 100%, respectively. PCR for HSV-2 DNA is usually
positive in the CSF of patients with initial episodes of meningitis. PCR is also is positive in approximately 80% of patients with
benign recurrent meningitis caused by lymphocytic choriomeningitis virus (2,18).
A systematic review and meta-analysis study was performed to
evaluate the accuracy of broad-range 16S rRNA PCR in the diagnosis of bacterial meningitis. The study judged the benefit of PCR
for diagnosis in emergency departments (68). Fourteen articles
were analyzed, in which 488/2,780 CSF samples were proven to

Table 4. Common laboratory results in meningitis in children and adultsa

Clinical status

WBCs (cells/l)

Normal
Bacterial meningitis
Tuberculosis-meningitis

0-5
>1,000
100-500

Predominant cell type

Glucose (mg/dl)

Protein (mg/dl)

45-100

15-50

Neutrophils; lymphocytes in early infection

<40

>100

Lymphocytes, monocytes

40

>50

Normal

50-150

None

Viral meningitis

5-500

Lymphocytes

Fungal meningitis

5-500

All differential cells

40

>100

Parasitic meningitis

2-200

Eosinophils, neutrophils

40

>50

Modified from references 2, 10, and 65.

48

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

be culture positive. Pooled analysis showed a sensitivity of 92%

(95% confidence interval [CI], 75 to 98%), a specificity of 94%
(95% CI, 90 to 97%), a positive likelihood ratio of 16.26 (95% CI,
9.07 to 29.14), and a negative likelihood ratio of 0.09 (95% CI,
0.03 to 0.28). PCR also amplified 30% of culture-negative cases
(68). Many recent studies applied and evaluated various PCRbased methods, showed their utility, and compared them with
other detection methods to investigate for common meningitis
infectious agents, but they are beyond the scope of this review.
Recently, molecular typing approaches to enteroviruses targeting
the VP1 region of the enteroviral genome that encodes serotypespecific neutralization epitopes have been successfully applied
during enteroviral-meningitis outbreak investigations in many
countries worldwide (18,23,24,25,27,33,34,44,47). They have
provided details of enteroviral molecular phylogeny that help us
to understand its association with specific disease manifestations
and possible clonal geographical clustering (34) (Table 2).

Therapeutic Management
The ideal antibiotic for CNS infection would be inexpensive and
would cover a broad range of gram-positive and -negative bacteria
(13). If the infecting organism is observed on examination of the
Gram-stained smear of the CSF sediment collected from a patient
with suspected bacterial meningitis, specific therapy is initiated;
otherwise, empirical antimicrobial therapy should be initiated.
Prompt treatment of bacterial meningitis usually results in rapid
recovery of neurologic function.
Bacterial meningitis is treated using various antibacterial families
such as beta-lactams, cephalosporins, aminoglycosides, fluoroquinolones, and other drugs, like trimethoprim-sulfamethoxazole
and vancomycin; the type of antibiotic, its dose and duration, and
whether to combine it with other antibiotics are all decided by
the physician according to the causative agent, patients age, and
other clinical considerations.
Effective vaccines are now available for many subtypes of H. influenzae type b, meningococcal serogroups (A, C, Y, and W-135),
S. pneumoniae, M. tuberculosis, and S. agalactiae (2). Adherence to
recommended vaccination schedules substantially reduces meningitis from each of those organisms. Previous studies indicated that
five bacteria, namely, H. influenzae, N. meningitidis, S. pneumoniae,
L. monocytogenes, and S. agalactiae, accounted for almost 80% of
cases of meningitis. However, upon the introduction of conjugate
vaccines, substantial reduction in the prevalence of cases due to
these five pathogens was achieved (59,69). Another study reported
a 31% decline in the incidence of bacterial meningitis during the
surveillance periods 1998-1999 and 2006-2007 (11).
Most viral-meningitis cases are self-limited, but some cause
chronic or recurrent illness. Treatment of acute viral meningitis
is directed at relief of symptoms, supportive care, and prevention and management of complications. Full recovery from viral
meningitis usually occurs within 1 to 2 weeks of onset, although
some patients describe persistence of fatigue, lightheadedness,

and asthenia for months. Introduction of mumps vaccine reduces

aseptic meningitis due to mumps virus.
No approved antiviral chemotherapy is available for enteroviral meningitis. Intravenous acyclovir is used to treat hospitalized, symptomatic patients with HSV-2 meningitis. In patients
with frequent recurrences of HSV meningitis, it is reasonable to
attempt prophylaxis with oral antivirals: valacyclovir, famciclovir,
or acyclovir (2). For patients with cryptococcal CNS infection,
amphotericin B plus flucytosine, followed by fluconazole, is the
ideal treatment. Most experiences with therapy of Candida meningitis have been with amphotericin B, often in combination with
flucytosine because of the latter agents ability to penetrate the
blood brain barrier (70).
For patients with cryptococcal CNS infection, amphotericin B plus
flucytosine, followed by fluconazole, is the ideal treatment. Most
experiences with therapy of Candida meningitis have been with
amphotericin B, often in combination with flucytosine because of
the latter agents ability to penetrate the blood brain barrier (70).
Many cases of fungal meningitis and meningioencephalitis are fatal
because of the course of the disease, the considerable toxic effects
of amphotericin B, and other anti-fungals, such as miconazole,
ketoconazole, and flucytosine (2,18).

Conclusion
Infectious meningitis is a large public health concern. Continuous diagnosis improvement is necessary to minimize disease mortality and life-threatening complications. Continued updates to
describe prevalence and expanded reporting of outbreaks will help
to evaluate vaccination outcomes and impact. Viral genotyping in
outbreaks provides a clearer picture for virus epidemiology and
geographical distribution and helps predict the emergence of new
strains by phylogenetic studies.

References
1. Matthew, P.F. 2007. The nervous system, p. 873-881. In A.K. Abbas,
V. Kumar, N. Fausto, and R. Mitchell (ed.), Robbins basic pathology.
Saunders Elsevier, Philadelphia, PA.
2. Morton, N.S. and A. Nath. 2012. Meningitis: bacterial, viral, and
other, p. 2355-2370. In Lee Goldman (ed.), Goldmans Cecil medicine. Saunders Elsevier, Philadelphia, PA.
3. Tunkel, A.R. 2015. Central nervous system infections, p. 1091-1093.
In R.D. John, E. Bennett, and M.J. Blaser (ed.), Mandell, Douglas
and Bennetts principles and practice of infectious diseases. Saunders
Elsevier, Philadelphia, PA.
4. Davison, S.P. and M.S. Marion. 1998. Sensorineural hearing loss
caused by NSAID-induced aseptic meningitis. Ear Nose Throat J.
77:820-821.
5. Lockwood, J.R. and D. Carr. 2014. Drug-induced aseptic meningitis
secondary to trimethoprim/sulfamethoxazole: a headache to be aware
of. CJEM 16:421-424.
6. Al-Shareef, A. and S.M. Atar. 2014. Central nervous system manifestation in patients with SLE: A 12-year retrospective chart review at a
tertiary center. Kuwait Med. J. 46:14-20.
7. Silvani, A. et al. 2013. Neoplastic meningitis from solid tumors: a
prospective clinical study in lombardia and a literature review on
therapeutic approaches. J. Drug Deliv. 2013:147325.
8. Akhtaruzzaman, A. et al. 2014. Outbreak of bacterial meningitis after

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

49

spinal anaesthesia in Bangladesh. J. Bangladesh Soc. Anaesthesiol.

22:5-11.
9. Torpy, J.M., C. Lynn, and R.M. Glass. 2007. JAMA patient page.
Meningitis. JAMA 297:122.
10. Tille, P.M. 2014. Bailey & Scotts diagnostic microbiology, 13th ed.,
p. 899-909. Elsevier Mosby, St. Louis, MO.
11. Thigpen, M.C. et al. 2011. Bacterial meningitis in the United States,
1998-2007. N. Engl J. Med. 364:2016-2025.
12. Swann, O. et al. 2014. Bacterial meningitis in Malawian infants <2
months of age: etiology and susceptibility to World Health Organization first-line antibiotics. Pediatr. Infect. Dis. J. 33:560-565.
13. Gantz, N.M. et al. 2006. Manual of clinical problems in infectious
diseases, 5th ed., p. 170-223. Lippincott Williams & Wilkins, Hagerstown, MD.
14. Heath, P.T., I.O. Okike, and C. Oeser. 2011. Neonatal meningitis:
can we do better? Adv. Exp. Med. Biol. 719:11-24.
15. Gaschignard, J. et al. 2011. Neonatal bacterial meningitis: 444 cases
in 7 years. Pediatr. Infect. Dis. J. 30:212-217.
16. Richard, G.C. and M. Lepe. 2013. Meningitis in children: diagnosis
and treatment for the emergency clinician. Clin. Pediatr. Emerg. Med.
14:146-156.
17. Rock, R.B. et al. 2008. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin. Microbiol. Rev. 21:243-261.
18. Wolfaardt, M. et al. 2014. Molecular characterisation of enteroviruses
and clinical findings from a cluster of paediatric viral meningitis cases
in Tshwane, South Africa 2010-2011. J. Clin. Virol. 61:400-405.
19. Bhagawati, G. et al. 2014. Bacteriological profile of acute meningitis:
a one year study in a tertiary care centre in Assam. Indian J. Public
Health. Res. Dev. 5:210-214.
20. Shinjoh, M. et al. 2014. Recent trends in pediatric bacterial meningitis
in Japana country where Haemophilus influenzae type b and Streptococcus pneumoniae conjugated vaccines have just been introduced. J.
Infect. Chemother. 20:477-483.
21. Takeshima, S. et al. 2014. Clinical, epidemiological, and etiological
studies of aseptic meningitis in adults. Rinsho Shinkeigaku 54:791797.
22. Li, Y, et al. 2014. Population-based surveillance for bacterial neningitis
in China, September 2006-December 2009. Emerg. Infect. Dis. 20:61.
23. Tao, Z. et al. 2014. Molecular epidemiology of human enterovirus
associated with aseptic meningitis in Shandong Province, China,
2006-2012. PLoS One 9:e89766.
24. Liu, N. et al. 2014. An outbreak of aseptic meningitis caused by a
distinct lineage of coxsackievirus B5 in China. Int. J. Infect. Dis.
23:101-104.
25. Papadakis, G. et al. 2014. Detection and genotyping of enteroviruses
in cerebrospinal fluid in patients in Victoria, Australia, 2007-2013. J.
Med. Virol. 45:950-957.
26. Meqdam, M.M., M.M. Khalousi, and A. Al-Shurman. 2002. Enteroviral meningitis in northern Jordan: prevalence and association with
clinical findings. J. Med. Virol. 66:224-228.
27. Levine, H. et al. 2014. Time trends of viral meningitis among young
adults in Israel: 1978-2012. Eur. J. Clin. Microbiol. Infect. Dis.
33:1149-1153.
28. Dalwai, A., S. Ahmad, and W. Al-Nakib. 2010. Echoviruses are a
major cause of aseptic meningitis in infants and young children in
Kuwait. Virol. J. 7:236.
29. Nougairede, A. et al. 2014. Widespread circulation of a new echovirus
30 variant causing aseptic meningitis and non-specific viral illness,
South-East France, 2013. J. Clin. Virol. 61:118-124.
30. Milia, M.G. et al. 2013. Recent outbreak of aseptic meningitis in
Italy due to Echovirus 30 and phylogenetic relationship with other
European circulating strains. J. Clin. Virol. 58:579-583.

50

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

31. Mantadakis, E. et al. 2013. Echovirus 30 outbreak associated with a

high meningitis attack rate in Thrace, Greece. Pediat. Infect. Dis. J.
32:914-916.
32. Savolainen-Kopra, C. et al. 2011. A large Finnish echovirus 30 outbreak was preceded by silent circulation of the same genotype. Virus
Genes 42:28-36.
33. Mladenova, Z. et al. 2014. Aseptic meningitis outbreak caused by
echovirus 30 in two regions in Bulgaria, May-August 2012. Epidemiol.
Infect. 142:2159-2165.
34. Mantadakis, E. et al. 2013. Echovirus 30 outbreak associated with a
high meningitis attack rate in Thrace, Greece. Pediatr. Infect. Dis. J.
32:914-916.
35. Cosic, G. et al. 2010. Ongoing outbreak of aseptic meningitis associated with echovirus type 30 in the City of Novi Sad, Autonomous
Province of Vojvodina, Serbia, June-July 2010. Euro. Surveill.
15:19638.
36. Julia, M.L. et al. 2009. Meningitis outbreak caused by echovirus
serotype 30 in the Valencian community. Enferm. Infec. Microbiol.
Clin. 27:263-268. [In Italian.]
37. Perevoscikovs, J. et al. 2010. Ongoing outbreak of aseptic meningitis
in south-eastern Latvia, June-August 2010. Euro. Surveill. 15:9-11.
38. Ceyhan, M. et al. 2008. A prospective study of etiology of childhood
acute bacterial meningitis, Turkey. Emerg. Infect. Dis. 14:1089-1096.
39. Bodilsen, J. et al. 2014. Stroke in community-acquired bacterial meningitis: a Danish population-based study. Int. J. Infect. Dis. 20:18-22.
40. Snaebjarnardttir, K. et al. 2013. Bacterial meningitis in children in
Iceland, 1975-2010: a nationwide epidemiological study. Scand. J.
Infect. Dis. 45:819-824.
41. Okike, I.O. et al. 2014. Incidence, etiology, and outcome of bacterial meningitis in infants aged <90 Days in the United Kingdom and
Republic of Ireland: prospective, enhanced, national population-based
surveillance. Clin. Infect. Dis. 59:e150-e157.
42. Domingo, P. et al. 2013. The spectrum of acute bacterial meningitis
in elderly patients. BMC Infect. Dis. 13:108.
43. Pinto, V.L., Jr. et al. 2009. Description of a widespread outbreak of
aseptic meningitis due to echovirus 30 in Rio de Janeiro State, Brazil.
Braz. J. Infect. Dis. 13:367-370.
44. Martinez, A.A. et al. 2012. Molecular diagnosis of echovirus 30 as
the etiological agent in an outbreak of aseptic meningitis in Panama:
May-June 2008. J. Infect. Dev. Ctries. 6:836-841.
45. Tuyama, M. et al. 2008. The utility of the polymerase chain reaction
assay for aetiologic definition of unspecified bacterial meningitis cases.
Mem. Inst. Oswaldo Cruz 103:138-142.
46. Azevedo, L.C.P., C.M. Toscano, and A.L. Bierrenbach. 2013. Bacterial
meningitis in Brazil: baseline epidemiologic assessment of the decade
prior to the introduction of pneumococcal and meningococcal vaccines. PLoS One 8:e64524.
47. Volle, R. et al. 2014. Variations in CSF viral loads by virus genotype
in patients hospitalized with laboratory-confirmed enterovirus meningitis. J. Infect Dis. 210:576-584
48. Sanou, I. et al. 2014. Hospital-based sentinel surveillance of Haemophilus influenzae type B among children in Burkina Faso, 2004-2012:
impact of vaccine introduction. J. Med. Microb. Diagn. 3: 10001301000130.
49. Manassara, H.B. et al. 2014. Epidemiological patterns of bacterial
meningitis in Niger from 2002 to 2010. Science 2:58-63.
50. Karanja, B.W. et al. 2014. Prevalence of hearing loss in children following bacterial meningitis in a tertiary referral hospital. BMC Res.
Notes 7:138.
51. Kourbeti, I.S. and E. Mylonakis. 2014. Fungal central nervous system
infections: prevalence and diagnosis. ExpertRev.Anti.Infect. Ther.
12:265-273.
52. Bicanic, T. and T.S. Harrison. 2004. Cryptococcal meningitis. Br.

Med. Bull. 72:99-118.

53. Dash, M. et al. 2014. Prevalence of cryptococcal meningitis among
people living with human immunodeficiency virus/acquired immunodeficiency syndrome in a tertiary care hospital, Southern Odisha,
India. J. Nat. Sci. Biol. Med. 5:324-328.
54. Menon, S. et al. 2014. Rhodotorula glutinis meningitis: a case report
and review of literature. Mycoses 57:447-451.
55. Ghatalia, P.A. et al. 2014. Reversible blindness in cryptococcal meningitis with normal intracranial pressure: case report and review of the
literature. Clin. Infect. Dis. 59:310-313.

62. Salmanzadeh, S. et al. 2014. Chronic mycobacterial meningitis due

to Mycobacterium chelonae: a case report. Int. J. Infect. Dis. 27:67-69.
63. Sood, A. et al. 2014. Prompt diagnosis and extraordinary survival
from Naegleria fowleri meningitis: a rare case report. Indian J. Med.
Microbiol. 32:193-196.
64. Spini, R.G. et al. 2014. Methicillin resistant Staphylococcus aureus
community acquired meningitis: a case report. Arch. Argent. Pediatr.
112:e266-e268.
65. Brunzel, N.A. 2013. Fundamentals of urine and body fluid analysis,
3rd ed., p. 313-331. Saunders Elsevier, Philadelphia, PA.

56. Nunnari, G. et al. 2013. Cryptococcal meningitis in an HIV-1infected person: relapses or IRIS? Case report and review of the literature. Eur. Rev. Med. Pharmacol. Sci. 17:1555-1559.

66. Walker, T.J. et al. 2009. Comparative evaluation of the Iris iQ200
body fluid module with manual hemacytometer count. Am. J. Clin.
Pathol. 131:333-338.

57. Evans-Gilbert, T. et al. 2014. Severe eosinophilic meningitis owing

to Angiostrongylus cantonensis in young Jamaican children: case report
and literature review. Paediatr. Int. Child Health 34:148-152.

67. Corless, C.E. et al. 2001. Simultaneous detection of Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae in
suspected cases of meningitis and septicemia using real-time PCR. J.
Clin. Microbiol. 39:1553-1558.

58. Tena, D. et al. 2013. Meningitis caused by Abiotrophia defectiva: case

report and literature review. Infection 41:571-574.
59. Smith, B.B. et al. 2013. Disseminated tuberculosis and tuberculous
meningitis in Australian-born children; case reports and review of
current epidemiology and management. J. Paediatr. Child Health
49:E246-E250.
60. Fritz, S. et al. 2014. Postsurgical Pantoea calida meningitis: a case
report. J. Med. Case Rep. 8:195.
61. Lombardi, D. et al. 2014. Salmonella enterica serovar Virchow meningitis in a young man in Italy: a case report. J. Med. Case Rep. 8:139.

68. Srinivasan, L. et al. 2012. Can broad-range 16S ribosomal ribonucleic

acid gene polymerase chain reactions improve the diagnosis of bacterial meningitis? A systematic review and meta-analysis. Ann. Emerg.
Med. 60:609-620 e2.
69. Thigpen, M.C. et al. 2011. Bacterial meningitis in the United States,
1998-2007. N. Engl. J. Med. 364:2016-2025.
70. Dismukes, W.E. and J.D. Sobel. 2003. Clinical mycology, 1st ed,
Oxford University Press, New York, NY.

Clinical Microbiology Newsletter 37:6,2015 | 2015 Elsevier

51