Meningitis Clinical Manifestation History The classic history of acute meningitis is that of severe headache, fever, altered mental

status and symptoms of meningeal irritation such as neck stiffness. The severity of symptoms is such that patients generally seek medical care within 24 hours of symptom onset. Although one or more of these signs and symptoms may be absent in a given patient, if none of the three classic symptoms of fever, altered mental status, and neck stiffness are present, the diagnosis of meningitis is virtually ruled out. Other symptoms to inquire about include photophobia, seizures, and rash. An exposure history including travel, animal exposures, and ill contacts should be obtained. Two elements of the history may help distinguish the likelihood of ABM versus AVM: (a) Patients with bacterial meningitis are more likely to be younger than 5 or older than 50 years, and (b) AVM has a peak incidence in the summer months. Physical Examination Eliciting signs of meningeal inflammation has been a classic aspect in working up suspected meningitis. Nuchal rigidity, or neck stiffness, is one typical finding. Other signs are the so-called Kernig sign and Brudzinski sign. Although these classic tests were first described over 100 years ago, a recent study showed that they have low sensitivity (~5%) in most patients. Other elements of the physical examination include examination of the fundi (to look for papilledema indicative of increased intracranial pressure); skin examination for rashes (seen in meningococcal meningitis as well as viral meningitis); and neurologic examination (in particular cranial nerve examination, where deficits can be seen with herniation). Give the lack of specific physical examination findings for meningitis, suspicion needs to be based on the complete clinical picture and then proceed with the diagnosis via CSF examination when appropriate. Differential Diagnosis As mentioned at the outset, the key distinction is between ABM and other inflammatory processes. A number of other conditions can also present with fever, headache, and meningeal irritation, including: - Brain abscess - Cerebral and spinal epidural abscess - Septic intracranial thrombophlebitis - Infective endocarditis with cerebral embolization Diagnostic Evaluation Analysis of CSF obtained by LP is the main diagnostic test used in the evaluation of possible meningitis. The fear of triggering brain herniation following LP has prompted some to recommend universal CT for patients prior to LP. However, this can lead to a delay in administration of antibiotic therapy, and therefore, the Infectious Disease Society of America (IDSA) has published criteria outlining conditions/findings that identify patients in whom CT should be performed prior to LP:

Immunocompromised state (HIV or immunosuppressive therapy) History of CNS disease (mass, stroke, focal infection) New onset seizure (within 1 week) Papilledema Abnormal level of consciousness Focal neurologic deficit (dilated nonreactive pupil, abnormal ocular motility, visual field deficits, arm or leg drift)

When an LP is performed, the following routine date should be obtained: - Opening pressure (normally between 70 and 180 mm H2O) - Cell counts (often opening and closing) and WBC differential - Glucose and protein determination - Gram stain and culture for bacterial organisms Gram stain of CSF permits a rapid, accurate identification of the causative agent in approximately 60% to 90% of patients with bacterial meningitis, with nearly 100% specificity. If other patient characteristics are present (e.g. H