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Child Meningitis Case Study

Child meningitis case study presentation, free google slides theme and powerpoint template.

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INTRODUCTION

Despite the effectiveness of antibiotics in clearing bacteria from the cerebrospinal fluid (CSF), bacterial meningitis in adults continues to cause significant morbidity and mortality worldwide. As an example, in the largest prospective study to date of 1412 episodes of community-acquired bacterial meningitis, the case-fatality rate was 17 percent, and unfavorable outcomes occurred in 38 percent [ 2 ]. (See "Neurologic complications of bacterial meningitis in adults" .)

The pathogenesis and pathophysiology of bacterial meningitis involve a complex interplay between virulence factors of the pathogens and the host immune response [ 3,4 ]. Much of the damage from this infection is believed to result from cytokines released within the CSF as the host mounts an inflammatory response. (See "Neurologic complications of bacterial meningitis in adults" .)

The clinically important issues related to the pathogenesis and pathophysiology of bacterial meningitis will be reviewed here. The clinical features, treatment, prognosis, and prevention of bacterial meningitis in adults and children and issues related to chronic and recurrent meningitis are discussed separately. (See "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Initial therapy and prognosis of community-acquired 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' .)

PATHOGENESIS

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Kenadeed Hersi ; Francisco J. Gonzalez ; Noah P. Kondamudi .

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Last Update: August 12, 2023 .

• Continuing Education Activity

In spite of breakthroughs in diagnosis, treatment, and vaccination, in 2015 there were 8.7 million reported cases of meningitis worldwide with 379,000 subsequent deaths. This activity reviews the cause, presentation, and diagnosis of meningitis and highlights the role of the interprofessional team in its management.

• Review the causes of meningitis.
• Describe the presentation of a patient with meningitis.
• Summarize the treatment of meningitis.
• Describe modalities to improve care coordination among interprofessional team members in order to improve outcomes for patients affected by meningitis.
• Introduction

Signs and symptoms of meningeal inflammation have been recorded in countless ancient texts throughout history; however, the term 'meningitis' came into general usage after surgeon John Abercrombie defined it in 1828.

Despite breakthroughs in diagnosis, treatment, and vaccination, in 2015, there were 8.7 million reported cases of meningitis worldwide, with 379,000 subsequent deaths. [1] [2] [3]

Meningitis is a life-threatening disorder that is most often caused by bacteria or viruses. Before the era of antibiotics, the condition was universally fatal. Nevertheless, even with great innovations in healthcare, the condition still carries a mortality rate of close to 25%.

Meningitis is defined as inflammation of the meninges. The meninges are the three membranes (the dura mater, arachnoid mater, and pia mater) that line the vertebral canal and skull enclosing the brain and spinal cord. Encephalitis, on the other hand, is inflammation of the brain itself. [4] [5]

Meningitis can be caused by infectious and non-infectious processes (autoimmune disorders, cancer/paraneoplastic syndromes, drug reactions).

The infectious etiologic agents of meningitis include bacteria, viruses, fungi, and less commonly parasites.

Risk factors for meningitis include:

• Chronic medical disorders (renal failure, diabetes, adrenal insufficiency, cystic fibrosis)
• Extremes of age
• Undervaccination
• Immunosuppressed states (iatrogenic, transplant recipients, congenital immunodeficiencies, AIDS)
• Living in crowded conditions
• Travel to endemic areas (Southwestern U.S. for cocci; Northeastern U.S. for Lyme disease)
• Vectors (mosquitoes, ticks)
• Alcohol use disorder
• Presence of ventriculoperitoneal (VP) shunt
• Bacterial endocarditis
• Dural defects
• IV drug use
• Sickle cell anemia
• Splenectomy
• Epidemiology

In the United States, the annual incidence of bacterial meningitis is approximately 1.38 cases/100,000 population with a case fatality rate of 14.3%. [6]

The highest incidence of meningitis worldwide is in an area of sub-Saharan Africa dubbed “the meningitis belt” stretching from Ethiopia to Senegal. [7] [2] [8]

Most common bacterial causes of meningitis in the United States are: [9]

• Streptococcus pneumoniae (incidence in 2010: 0.3/100,000)
• group B Streptococcus
• Neisseria meningitidis (incidence in 2010: 0.123/100,000)
• Haemophilus influenzae (incidence in 2010: 0.058/100,000)
• Listeria monocytogenes

Consider less common bacteria such as Staphylococcus aureus in patients with recent surgery, central lines, and trauma. Mycobacterium tuberculosis  should be considered in immunocompromised hosts. Borrelia burgdorferi in patients with travel to Lyme endemic areas. Treponema pallidum in HIV/AIDS and individuals with multiple sexual partners. Escherichia coli is an important pathogen in the neonatal period.

The most common viral agents of meningitis are non-polio enteroviruses (group b coxsackievirus and echovirus). Other viral causes: mumps, Parechovirus, Herpesviruses (including Epstein Barr virus, Herpes simplex virus, and Varicella-zoster virus), measles, influenza, and arboviruses (West Nile, La Crosse, Powassan, Jamestown Canyon)

Fungal meningitis typically is associated with an immunocompromised host (HIV/AIDS, chronic corticosteroid therapy, and patients with cancer).

Fungi causing meningitis include:

• Cryptococcus neoformans
• Coccidioides immitis
• Aspergillus
• Mucormycosis (more common in patients with diabetes mellitus and transplant recipients; direct extension of sinus infection)
• Pathophysiology

Meningitis typically occurs through two routes of inoculation:

Hematogenous seeding

• Bacteria colonize the nasopharynx and enter the bloodstream after mucosal invasion. Upon making their way to the subarachnoid space, the bacteria cross the blood-brain barrier, causing a direct inflammatory and immune-mediated reaction.

Direct contiguous spread

• Organisms can enter the cerebrospinal fluid (CSF) via neighboring anatomic structures (otitis media, sinusitis), foreign objects (medical devices, penetrating trauma), or during operative procedures.

Viruses can penetrate the central nervous system (CNS) via retrograde transmission along neuronal pathways or by hematogenous seeding.

• History and Physical

Meningitis can have a varied clinical presentation depending on age and immune status of the host. Symptoms typically include fever, neck pain/stiffness, and photophobia. More non-specific symptoms include headache, dizziness, confusion, delirium, irritability, and nausea/vomiting. Signs of increased intracranial pressure (altered mental status, neurologic deficits, and seizures) portend a poor prognosis.

The following risk factors should increase clinical suspicion:

• Close contact exposures (military barracks, college dorms)
• Incomplete vaccinations
• Immunosuppression
• Children younger than five years and adults older than 65 years

One should try to determine a history of exposures, sexual contact, animal contact, previous neurosurgical intervention, recent travel, and the season. Most viral cases tend to occur in the warmer months.

In adults, the physical exam is centered on identifying focal neurologic deficits, meningeal irritation (Brudzinski and Kernig signs), and particularly in meningococcal meningitis, characteristic skin lesions (petechiae and purpura). Cranial nerve abnormalities are seen in 10%-20% of patients. 

Signs and symptoms are less evident in neonates and infants. They can present with and without fever or hypothermia, decreased oral intake, altered mental status, irritability, bulging fontanelle. It is important to obtain a full perinatal history and vaccine records. Some causes of meningitis are vaccine-preventable such as Pneumococcus, Haemophilus influenzae type B, Meningococcus, Measles, and Varicella-virus.

Meningitis is diagnosed through cerebrospinal fluid (CSF) analysis, which includes white blood cell count, glucose, protein, culture, and in some cases, polymerase chain reaction (PCR). CSF is obtained via a lumbar puncture (LP), and the opening pressure can be measured.  [10] [11] [12]

Additional testing should be performed tailored on suspected etiology:

• Viral: Multiplex and specific PCRs
• Fungal: CSF fungal culture, India ink stain for Cryptococcus
• Mycobacterial: CSF Acid-fast bacilli smear and culture
• Syphilis: CSF VDRL
• Lyme disease: CSF burgdorferi antibody

The CSF findings expected in bacterial, viral, and fungal meningitis are listed in the chart: Expected CSF findings in bacterial versus viral versus fungal meningitis.

Ideally, the CSF sample should be obtained before initiating antimicrobials. However, when the diagnosis of bacterial meningitis is seriously considered, and the patient is severely ill, antibiotics should be initiated before performing the LP.

Computed Tomography (CT) of the Head before Lumbar Puncture

There is controversy regarding the adage that the lumbar puncture is the inciting event causing brain herniation and death in the setting of increased intracranial pressure caused by acute bacterial meningitis.

Currently, guidelines recommend empiric antibiotics and supportive care, while forgoing the lumbar puncture if there is clinical suspicion of increased intracranial pressure or impending brain herniation.

Signs and symptoms of impending herniation include:

• Glasgow coma scale (GCS) less than 11
• Altered mental status
• New-onset seizures
• Focal neurologic deficit

It is important to note that a normal head CT does not preclude increased intracranial pressure or impending brain herniation. If the clinical symptoms are consistent with impending herniation, regardless of whether or not the CT head is normal, avoid the LP and start treatment.

Blood work should include blood culture, serum electrolytes as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is not uncommon, serum glucose, renal and liver function, and testing for HIV.

• Treatment / Management

Antibiotics and supportive care are critical in all cases of bacterial meningitis. [13] [14] [15]

Managing the airway, maintaining oxygenation, giving sufficient intravenous fluids while providing fever control are parts of the foundation of meningitis management.

The type of antibiotic is based on the presumed organism causing the infection. The clinician must take into account patient demographics and past medical history in order to provide the best antimicrobial coverage.

Current Empiric Therapy

Neonates - Up to 1 month old

• Ampicillin intravenously (IV) and
• Cefotaxime (or equivalent, usually ceftazidime or cefepime) IV or gentamicin IV and
• Acyclovir IV

More than 1 month old

• Ampicillin IV and
• Ceftriaxone IV

Adults (18 to 49 years old)

• Ceftriaxone IV and
• Vancomycin IV

Adults older than 50 years old and the immunocompromised

• Vancomycin IV and
• Ampicillin IV

Meningitis associated with a foreign body (post-procedure, penetrating trauma)

• Cefepime IV or ceftazidime IV or meropenem IV and

Meningitis with severe penicillin allergy

• Moxifloxacin IV and

Fungal (Cryptococcal) meningitis

• Amphotericin B IV and
• Flucytosine by mouth

Antibiotics

Ceftriaxone

• Third-generation cephalosporin
• Gram-negative coverage
• Very effective against  Streptococcus pneumoniae and  Neisseria meningitidis
• Better CNS penetration than piperacillin-tazobactam (typically used in gram-negative sepsis coverage)
• Gram-positive coverage (MRSA)
• Also used for resistant pneumococcus
• Listeria coverage (gram-positive bacilli)
• Fourth-generation cephalosporin
• Increased activity against pseudomonas
• Equivalent to ceftriaxone
• Safe for neonates

Steroid Therapy

There is insufficient evidence to support the widespread use of steroids in bacterial meningitis. Some studies report a reduction in mortality for Streptococcus pneumoniae meningitis, but not in Haemophilus influenzae or Neisseria meningitidis meningitis. In children, steroids were associated with a reduction of severe hearing impairment only in cases of Haemophilus influenzae meningitis. [16]

Increased Intracranial Pressure

If the patient develops clinical signs of increased intracranial pressure (altered mental status, neurologic deficits, non-reactive pupils, bradycardia), interventions to maintain cerebral perfusion include:

• Elevating the head of the bed to 30 degrees
• Inducing mild hyperventilation in the intubated patient
• Osmotic diuretics such as 25% mannitol or 3% saline

Chemoprophylaxis

Chemoprophylaxis is indicated for close contacts of a patient diagnosed with N. meningitidis and H. influenzae type B meningitis.

Close contacts include housemates, significant others, those who have shared utensils, and health care providers in proximity to secretions (providing mouth-to-mouth resuscitation, intubating without a facemask).

Antibiotic chemoprophylaxis for N. meningitidis includes rifampin, ciprofloxacin, or ceftriaxone, and for H. influenzae type B: rifampin.

• Differential Diagnosis
• Subdural hematoma
• Subarachnoid hemorrhage
• Metastatic brain disease
• Brain abscess (might coexist with meningitis)

Outcomes depend on patient characteristics such as age and immune status, but also vary depending on the etiologic organism. In the United States, for overall bacterial meningitis, the annual case fatality rate in 2010 was 14.3%.

Pathogen-specific mortality: [6]

• Streptococcus pneumoniae meningitis: case fatality rate, 17.9%
• Neisseria meningitidis meningitis: case fatality rate, 10.1%
• Group B Streptococcus meningitis: case fatality rate, 11.1%
• H. i nfluenzae meningitis: case fatality rate, 7%
• Listeria monocytogenes meningitis: case fatality rate, 18.1%
• Complications

A metaanalysis published in 2010 from a cohort of pediatric patients reported that the median risk of sequelae post-discharge was 19.9%. In this study, the most common organism isolated was H. influenzae , followed by S. pneumoniae . The most common sequelae were hearing loss (6%), followed by behavioral (2.6%) and cognitive difficulties (2.2%), motor deficit (2.3%), seizure disorder (1.6%) and visual impairment (0.9%). [17]

Other complications include:

• Increased intracranial pressure from cerebral edema caused by increased intracellular fluid in the brain. Several factors are involved in the development of cerebral edema: increased in blood-brain barrier permeability, cytotoxicity from cytokines, immune cells, and bacteria.
• Hydrocephalus
• Cerebrovascular complications
• Focal neurologic deficits
• Consultations
• Infectious diseases specialist in case of unidentified or rare pathogen
• Neurology to aid in seizure management
• Neurosurgery when there is suspicion of progression to brain abscess
• Rheumatology and heme/oncology in case of non-infectious cause
• Pearls and Other Issues

Differentiating between bacterial, viral, and fungal meningitis may be difficult. CSF analysis may not be conclusive, and cultures do not immediately yield an answer. Multiplex and specific PCR panels are available and provide information in a few hours. Given the morbidity and mortality, it is prudent to initiate empiric antibiotic therapy and admit all those with suspected meningitis to the hospital on droplet precautions, until pathogen is identified, and appropriate antibiotics have been given for 24 hours.

• Enhancing Healthcare Team Outcomes

Meningitis is a serious disorder with high morbidity and mortality. The majority of patients with meningitis first present to the emergency department and a streamlined interprofessional approach is vital if one wants to lower the high morbidity. The triage nurse must be fully aware of the signs and symptoms of the illness and refer the patient immediately to the emergency department clinician. Other specialists who are usually involved in the care of these patients are neurologists, pediatricians, intensivists, infectious disease specialists, and pharmacists. If bacterial meningitis is suspected, prompt antibiotics should be started even in the absence of laboratory results. The pharmacist, preferably specializing in infectious diseases, should assist the clinical team in choosing the appropriate antibiotics based on the age of the patient and local sensitivities and correct dosing to ensure penetration into the central nervous system.

To prevent this infection, the education of the public is vital. All healthcare workers (nurses, physicians, and pharmacists) should educate patients and parents in regards to vaccine-preventable meningitis ( H. influenzae type B, S. pneumoniae , N. meningitidis , Measles, and Varicella). Across the board, the incidence of meningitis has decreased with the implementation of generalized vaccination. Family members should be educated about the need for prophylaxis when there is a family member with Neisseria and H. influenzae type B meningitis. All contacts should be educated about the signs and symptoms of the infection and when to return to the emergency department. [18]

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Neuropathology specimen, Purulent meningitis, HE Stain, Hematoxylin and Eosin stain Contributed by Wikimedia Commons, Jens Florian (CC by 4.0) https://creativecommons.org/licenses/by/4.0/

Culture Plate, Meningitis; Fungal, Ascomycota, Lab Contributed by James Gathany, The Centers for Disease Control and Prevention (CDC)

Expected CSF Findings in Bacterial versus Viral versus Fungal Meningitis 2 Contributed by Kenadeed Hersi

Figure 3 has a reference of PMID 22844374, A case of carcinomatous meningitis despite prophylactic cranial irradiation in small cell lung cancer during treatment with amrubicin. Contributed by Ayesha Anwar, MBBS

Disclosure: Kenadeed Hersi declares no relevant financial relationships with ineligible companies.

Disclosure: Francisco Gonzalez declares no relevant financial relationships with ineligible companies.

Disclosure: Noah Kondamudi declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Hersi K, Gonzalez FJ, Kondamudi NP. Meningitis. [Updated 2023 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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10 Best Meningitis-Themed Templates for PowerPoint & Google Slides

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Company Info

• Patient Care & Health Information
• Diseases & Conditions

A health care provider can diagnose meningitis based on a medical history, a physical exam and certain tests. During the exam, your provider may check for signs of infection around the head, ears, throat and skin along the spine.

Common tests to diagnose meningitis include:

• Blood cultures. A blood sample is placed in a special dish to see if it grows microorganisms such as bacteria. This is called a blood culture. A sample also may be placed on a slide and stained. Then it will be studied under a microscope to see whether bacteria are present.
• Imaging. Computerized tomography (CT) or magnetic resonance imaging (MRI) scans of the head may show swelling or inflammation. X-rays or CT scans of the chest or sinuses may show an infection that may be associated with meningitis.

Spinal tap. A definitive diagnosis of meningitis requires a spinal tap to collect cerebrospinal fluid. In people with meningitis, the fluid often shows a low sugar level along with an increased white blood cell count and increased protein.

Analyzing the fluid also may help identify which bacterium caused the meningitis. If viral meningitis is suspected, you may need a DNA-based test known as a polymerase chain reaction amplification. Or you may be given a test to check for antibodies against certain viruses to determine the specific cause and proper treatment.

More Information

• Lumbar puncture (spinal tap)

The treatment depends on the type of meningitis you or your child has.

Bacterial meningitis

Acute bacterial meningitis must be treated right away with intravenous antibiotics and sometimes corticosteroids. This helps to ensure recovery and reduce the risk of complications, such as brain swelling and seizures.

The antibiotic or combination of antibiotics depends on the type of bacteria causing the infection. Your health care provider may recommend a broad-spectrum antibiotic until the exact cause of the meningitis is known.

Your provider may drain any infected sinuses or mastoids — the bones behind the outer ear that connect to the middle ear.

Viral meningitis

Antibiotics can't cure viral meningitis, and most cases improve on their own in several weeks. Treatment of mild cases of viral meningitis usually includes:

• Plenty of fluids.
• Pain medicine to help reduce fever and relieve body aches.

Your health care provider may prescribe corticosteroids to reduce swelling in the brain and a medicine to control seizures. If a herpes virus caused your meningitis, an antiviral medicine is available.

Other types of meningitis

If the cause of your meningitis is unknown, you may start antiviral and antibiotic treatment while the cause is determined.

Treatment for chronic meningitis is based on the underlying cause. Antifungal medicines treat fungal meningitis. A combination of specific antibiotics can treat tuberculous meningitis. However, these medicines can have serious side effects, so treatment may be deferred until a laboratory can confirm that the cause is fungal.

Noninfectious meningitis due to allergic reaction or autoimmune disease may be treated with corticosteroids. In some cases, no treatment may be required because the condition can resolve on its own. Cancer-related meningitis requires therapy for the specific cancer.

Preparing for your appointment

Meningitis can lead to death, depending on the cause. If you've been exposed to bacterial meningitis and you develop symptoms, go to an emergency room and tell the health care providers that you may have meningitis.

If you're not sure what you have and you call your provider for an appointment, here's how to prepare for your visit.

What you can do

• Be aware of any pre- or post-appointment restrictions. Ask if there's anything you need to do in advance, such as restrict your diet. Also ask if you may need to stay at your health care provider's office for observation following your tests.
• Write down symptoms you're having, including changes in your mood, thinking or behavior. Note when you developed each symptom and whether you had cold- or flu-like symptoms.
• Write down key personal information, including any recent moves, vacations or interactions with animals. If you're a college student, your provider likely will ask questions about any similar signs or symptoms in your roommates and dorm mates. Your provider also will want to know your vaccination history.
• Make a list of all medicines, vitamins or supplements you're taking.
• Take a family member or friend along. Meningitis can be a medical emergency. Take someone who can help remember all the information you may receive and who can stay with you if needed.
• Write down questions to ask your health care provider.

For meningitis, some basic questions to ask your health care provider include:

• What kinds of tests do I need?
• What treatment do you recommend?
• Am I at risk of long-term complications?
• If my condition is not treatable with antibiotics, what can I do to help my body recover?
• Am I contagious? Do I need to be isolated?
• What is the risk to my family? Should they take preventive medicine?
• Is there a generic alternative to the prescription medicine you're recommending?
• Do you have any printed information I can have? What websites do you recommend?

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, such as:

• When did you begin experiencing symptoms?
• How severe are your symptoms? Do they seem to be getting worse?
• Does anything seem to improve your symptoms?
• Have you been exposed to anyone with meningitis?
• Does anyone in your household have similar symptoms?
• What is your vaccination history?
• Do you take any immunosuppressant medicines?
• Do you have other health problems, including allergies to any medicines?

What you can do in the meantime

When you call your health care provider's office for an appointment, describe the type and severity of your symptoms. If your provider says you don't need to come in immediately, rest as much as possible while you're waiting for your appointment.

Drink plenty of fluids and take acetaminophen (Tylenol, others) to reduce your fever and body aches. Also avoid any medicines that may make you less alert. Don't go to work or school.

• Meningitis and encephalitis fact sheet. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Meningitis-and-Encephalitis-Fact-Sheet. Accessed Oct. 10, 2022.
• Bacterial meningitis. Centers for Disease Control and Prevention. https://www.cdc.gov/meningitis/bacterial.html. Accessed Oct. 20, 2022.
• Ferri FF. Meningitis, bacterial. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Oct. 21, 2022.
• Viral meningitis. Centers for Disease Control and Prevention. https://www.cdc.gov/meningitis/viral.html. Accessed Oct. 10, 2022.
• Fungal meningitis. Centers for Disease Control and Prevention. https://www.cdc.gov/meningitis/fungal.html. Accessed Oct. 20, 2022.
• Ferri FF. Meningitis, viral. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Oct. 21, 2022.
• Loscalzo J, et al., eds. Acute meningitis. In: Harrison's Principals of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Oct. 10, 2022.
• Acute bacterial meningitis. Merck Manual Professional Version. https://www.merckmanuals.com/professional/neurologic-disorders/meningitis/acute-bacterial-meningitis. Accessed Oct. 25, 2022.
• Prevention — Listeria (listeriosis). Centers for Disease Control and Prevention. https://www.cdc.gov/listeria/prevention.html. Accessed Oct. 20, 2022.
• Subacute and chronic meningitis. Merck Manual Professional Version. https://www.merckmanuals.com/professional/neurologic-disorders/meningitis/subacute-and-chronic-meningitis. Accessed Oct. 20, 2022.
• Ferri FF. Meningitis, fungal. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed Oct. 25, 2022.
• Recommended immunization schedules for children and adolescents aged 18 years or younger, United States, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed Oct. 20, 2022.
• Recommended adult immunization schedule for adults aged 19 or older, United States, 2020. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed Oct. 20, 2022.
• Meningococcal vaccination: What everyone should know. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/vpd/mening/public/index.html. Accessed Oct. 26, 2022.
• Sexton D, et al. Approach to the patient with chronic meningitis. https://www.uptodate.com/contents/search. Accessed Oct. 25, 2022.
• Tunkel A. Aseptic meningitis in adults. https://www.uptodate.com/contents/search. Accessed Oct. 25, 2022.
• Di Pentima C. Viral meningitis: Management, prognosis, and prevention in children. https://www.uptodate.com/contents/search. Accessed Oct. 25, 2022.
• Parasitic meningitis. Centers for Disease Control and Prevention. https://www.cdc.gov/meningitis/parasitic.html. Accessed Oct. 26, 2022.
• Kobayashi M, et al. Use of 15-valent pneumococcal conjugate vaccine among U.S. Children: Updated recommendations of the advisory committee on immunization practices – United States, 2022. MMWR Morbidity and Mortality Weekly Report. 2022; doi:10.15585/mmwr.mm7137a3.
• Summary of WHO position papers — Recommendations for routine immunization. World Health Organization. https://www.who.int/immunization/policy/immunization_tables/en/. Accessed Oct. 26, 2022.
• ACIP recommendations. Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/acip/recommendations.html#meeting-recommendations. Accessed Sept. 20, 2023.
• Kobayashi M, et al. Pneumococcal vaccine for adults aged 19 years: Recommendations of the advisory committee on immunization practices, United States, 2023. MMWR Morbidity and Mortality Weekly Report. 2023; doi:10.15585/mmwr.rr7203a1.
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Chapter 133:  Acute Meningitis

Karen L. Roos; Kenneth L. Tyler

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Epidemiology.

• PATHOPHYSIOLOGY
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• SPECIFIC ANTIMICROBIAL THERAPY
• ADJUNCTIVE THERAPY
• INCREASED INTRACRANIAL PRESSURE
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BACTERIAL MENINGITIS

Bacterial meningitis is an acute purulent infection within the subarachnoid space (SAS). It is associated with a CNS inflammatory reaction that may result in decreased consciousness, seizures, raised intracranial pressure (ICP), and stroke. The meninges, SAS, and brain parenchyma are all frequently involved in the inflammatory reaction ( meningoencephalitis ).

Bacterial meningitis is the most common form of suppurative CNS infection, with an annual incidence in the United States of >2.5 cases/100,000 population. The organisms most often responsible for community-acquired bacterial meningitis are Streptococcus pneumoniae (~50%), Neisseria meningitidis (~25%), group B streptococci (~15%), and Listeria monocytogenes (~10%). Haemophilus influenzae type b accounts for <10% of cases of bacterial meningitis in most series. N. meningitidis is the causative organism of recurring epidemics of meningitis every 8–12 years.

S. pneumoniae (Chap. 143) is the most common cause of meningitis in adults >20 years of age, accounting for nearly half the reported cases (1.1 per 100,000 persons per year). There are a number of predisposing conditions that increase the risk of pneumococcal meningitis, the most important of which is pneumococcal pneumonia. Additional risk factors include coexisting acute or chronic pneumococcal sinusitis or otitis media, alcoholism, diabetes, splenectomy, hypogammaglobulinemia, complement deficiency, and head trauma with basilar skull fracture and CSF rhinorrhea. The mortality rate remains ~20% despite antibiotic therapy.

The incidence of meningitis due to N. meningitidis (Chap. 150) has decreased with the routine immunization of 11- to 18-year-olds with the quadrivalent (serogroups A, C, W-135, and Y) meningococcal glycoconjugate vaccine. The vaccine does not contain serogroup B, which is responsible for one-third of cases of meningococcal disease. The Advisory Committee on Immunization Practices (ACIP) recommends that adolescents and young adults aged 16–23 years may be vaccinated with the serogroup B meningococcal (MenB) vaccine. The presence of petechial or purpuric skin lesions can provide an important clue to the diagnosis of meningococcal infection. In some patients the disease is fulminant, progressing to death within hours of symptom onset. Infection may be initiated by nasopharyngeal colonization, which can result in either an asymptomatic carrier state or invasive meningococcal disease. The risk of invasive disease following nasopharyngeal colonization depends on both bacterial virulence factors and host immune defense mechanisms, including the host’s capacity to produce antimeningococcal antibodies and to lyse meningococci by both classic and alternative complement pathways. Individuals with deficiencies of any of the complement components, including properdin, are highly susceptible to meningococcal infections.

Gram-negative bacilli cause meningitis in individuals with chronic and debilitating diseases such as diabetes, cirrhosis, or alcoholism and in those with chronic urinary tract infections. Gram-negative meningitis can also complicate neurosurgical procedures, particularly craniotomy, and head trauma associated with CSF rhinorrhea or otorrhea.

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• Second Opinion

Meningitis in Children

What is meningitis in children?

Meningitis is a swelling (inflammation) of the thin membranes that cover the brain and the spinal cord. These membranes are called the meninges.

What causes meningitis in a child?

Meningitis is most often caused by a bacterial or viral infection that moves into the cerebral spinal fluid (CSF). CSF is the fluid that protects and cushions the brain and spinal cord. A fungus or parasite may also cause meningitis. This is more common only in children with a weak immune system.

Meningitis caused by a virus is more common and usually less severe. Bacterial meningitis is usually more severe and may lead to long-term complications or death.

Viruses that can cause meningitis include polioviruses, the mumps virus (paramyxovirus), the flu virus, and West Nile virus.

Bacteria that can cause meningitis include group B streptococcus, E. coli, Haemophilus influenzae type b (Hib), and a strep bacteria that causes pneumonia. Syphilis, tuberculosis, and Lyme disease bacteria can also cause meningitis. The bacteria, viruses, and fungi that cause meningitis usually grow in a person’s respiratory tract. A child may have no symptoms at all, but may carry the organism in his or her nose and throat. They may be spread by:

Close contact with someone carrying the infection

Touching infected objects, such as doorknobs, hard surfaces, or toys, and then touching nose, mouth, or eyes

Droplets from a sneeze, close conversation, or kissing

An infection usually starts in the respiratory tract. In a child, it may first cause a cold, sinus infection, or ear infection. It can then go into the bloodstream and reach the brain and spinal cord.

Which children are at risk for meningitis?

A child is more at risk for meningitis if he or she has an infection caused by a number of viruses, bacteria, or fungi. Children with a weakened immune system are at great risk.

What are the symptoms of meningitis in a child?

The symptoms of meningitis vary depending on what causes the infection. The symptoms may start several days after your child has had a cold and runny nose, or diarrhea and vomiting. Symptoms can occur a bit differently in each child. Symptoms may appear suddenly. Or they may develop over several days.                                                                                                                                         

In babies, symptoms may include:

Irritability

Sleeping more than usual

Poor feeding

Crying that can’t be soothed

High-pitched cry

Arching back

Bulging soft spots on the head (fontanelles)

Changed temperament

Purple-red splotchy rash

In children age 1 or older, symptoms may include:

Refusing to eat

Reduced level of consciousness

Eyes sensitive to light (photophobia)

Nausea and vomiting

Neck stiffness

A purple-red splotchy rash

The symptoms of meningitis can be like other health conditions. Make sure your child sees his or her healthcare provider for a diagnosis.

How is meningitis diagnosed in a child?

The healthcare provider will ask about your child’s symptoms and health history. He or she may also ask about your family’s health history. He or she will give your child a physical exam. Your child may also have tests, such as:

Lumbar puncture (spinal tap).  This is the only test that diagnoses meningitis. A needle is placed into the lower back, into the spinal canal. This is the area around the spinal cord. The pressure in the spinal canal and brain is measured. A small amount of cerebral spinal fluid (CSF) is removed and sent for testing to see if there is an infection or other problems.

Blood tests. These can help diagnose infections that cause meningitis. 

CT scan or MRI.  These are tests that show images of the brain. A CT scan is sometimes done to look for other conditions that may cause similar symptoms as meningitis. An MRI may show inflammatory changes in the meninges. These tests give more information. But meningitis can’t be diagnosed using these tests alone.

Nasal, throat, or rectal swabs. These tests help diagnose viral infections that cause meningitis.

How is meningitis treated in a child?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.                                         

Treatment varies by type of meningitis. The treatments by type include:

Bacterial meningitis.  Treatment is started as quickly as possible. The healthcare provider will give your child IV (intravenous) antibiotics, which kill bacteria. Your child will also get a corticosteroid medicine. The steroid works by decreasing the swelling (inflammation) and reducing pressure that can build up in the brain. Steroids also reduce the risk for hearing loss and brain damage. 

Viral meningitis.  Most children get better on their own without treatment. In some cases, treatment may be done to help ease symptoms. There are no medicines to treat the viruses that cause viral meningitis. The only exception is herpes simplex virus, which is treated with IV antiviral medicine. Babies and children with a weakened immune system may need to stay in the hospital.

Fungal meningitis.  Your child may get IV antifungal medicine.

Tuberculous (TB) meningitis.  Your child will be treated with a course of medicines over 1 year. Treatment is done with several medicines for the first few months. This is followed by other medicines for the remaining time.

While your child is recovering from meningitis, he or she may also need:

Increased fluid intake by mouth or IV fluids in the hospital

Medicines to reduce fever and headache. Don’t give aspirin or medicine that contains aspirin to a child younger than age 19 unless directed by your child’s provider. Taking aspirin can put your child at risk for Reye syndrome. This is a rare but very serious disorder. It most often affects the brain and the liver.

Supplemental oxygen or breathing machine (respirator) if your child has trouble breathing

Talk with your child’s healthcare providers about the risks, benefits, and possible side effects of all treatments.

What are the possible complications of meningitis in a child?

Bacterial meningitis is usually more severe and may lead to long-term complications. Some children may have long-term problems with seizures, brain damage, hearing loss, and disability. Bacterial meningitis can also cause death.

How can I help prevent meningitis in my child?

Several vaccines are available to prevent some of the bacterial infections that can cause meningitis. These include:

H. influenzae type b vaccine (Hib). This is given as a 3- or 4-part series during your child's routine vaccines starting at 2 months old.

PCV13 pneumococcal vaccine. The American Academy of Pediatrics recommends this vaccine for all healthy children younger than age 2. PCV13 can be given along with other childhood vaccines. It is recommended at ages 2 months, 4 months, 6 months, and 12 to 15 months. One dose is also advised for older children who did not get the 4-dose series, and for those at high risk for pneumococcal disease.

PPSV23 pneumococcal vaccine . This vaccine is also recommended for older children at high risk for pneumococcal disease.

Meningococcal vaccine. This vaccine is part of the routine vaccine schedule. It is given to children ages 11 to 12, with a booster given at age 16. It is given to teens entering high school if they were not vaccinated at age 11 or 12. A booster is also given at age 16 to 18, or up to 5 years later. Babies and young children at increased risk may also have this vaccine. Ask your child's healthcare provider about the number of doses and when they should be given.

Vaccines that protect against viruses such as measles, mumps, chickenpox, and the flu can prevent viral meningitis.                                                    

Talk with your child’s healthcare provider if you have questions about the vaccines. 

You and your child can do other things to prevent the spread of infections. Proper handwashing and staying away from people who are sick can help prevent meningitis.

When should I call my child’s healthcare provider?

Call the healthcare provider if your child has:

Not received vaccines

Contact with someone who has meningitis

Symptoms that don’t get better, or get worse

New symptoms

Key points about meningitis in children

Meningitis is an inflammation of the thin membranes that cover the brain and the spinal cord.

It is most often caused by a bacterial or viral infection that moves into the cerebral spinal fluid. A fungus or parasite may also cause meningitis.

A lumbar puncture (spinal tap) is the only test that diagnoses meningitis. A needle is placed into the lower back, into the spinal canal.

Several vaccines are available to prevent some of the bacterial and viral infections that can cause meningitis.

Tips to help you get the most from a visit to your child’s healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child’s condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

Related Links

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• Encephalitis in Children
• Meningococcal Infections in Children

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Virginia health officials are responding to a statewide meningococcal disease outbreak . For the latest information about the outbreak and vaccine recommendations, visit the Virginia Department of Health’s website.

Meningitis is an inflammation (swelling) of the protective membranes covering the brain and spinal cord. A bacterial or viral infection of the fluid surrounding the brain and spinal cord usually causes the swelling. However, injuries, cancer, certain drugs, and other types of infections also can cause meningitis. It is important to know the specific cause of meningitis because the treatment differs depending on the cause.

Meningitis caused by bacteria can be deadly and requires immediate medical attention. Vaccines are available to help protect against some kinds of bacterial meningitis.

Meningitis caused by viruses is serious but often is less severe than bacterial meningitis. People with normal immune systems who get viral meningitis usually get better on their own. There are vaccines to prevent some kinds of viral meningitis.

Meningitis caused by fungi is rare, but people can get it by inhaling fungal spores from the environment. People with certain medical conditions, like diabetes, cancer, or HIV, are at higher risk of fungal meningitis.

Various parasites can cause meningitis or can affect the brain or nervous system in other ways. Overall, parasitic meningitis is much less common than viral and bacterial meningitis.

Primary amebic meningoencephalitis (PAM) is a rare and devastating infection of the brain caused by Naegleria fowleri . Naegleria fowleri is a free-living microscopic ameba that lives in warm water and soil.

Bacterial Meningitis

Generally, the germs that cause bacterial meningitis spread from one person to another. Certain germs can spread through food. How people spread the germs often depends on the type of bacteria. Read about common examples of how people spread the different types of bacteria to each other.

Viral Meningitis

People can spread the viruses that cause viral meningitis to other people. If you have close contact with someone who has viral meningitis, they may spread the virus to you. However, you are not likely to develop meningitis. That’s because most people infected with these viruses will not develop meningitis.

Having meningitis doesn’t always mean you have meningococcal disease. And having meningococcal disease doesn’t necessarily mean you have meningitis. Meningococcal disease is any illness caused by a type of bacteria called Neisseria meningitidis . These illnesses are serious and include meningitis and bloodstream infections (septicemia).  More about meningococcal disease…

• Did you know October 5th is World Meningitis Day? Learn about this year’s event .
• You can also find out more about a Technical Task Force that will develop a strategic global meningitis control road map as part of “ Defeating meningitis by 2030 .”
• Meningitis bacteriana
• Meningitis viral
• Meningitis micótica

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