Doctors Revision

Neurological System

Meningitis (Overview)

Acute inflammation of the meninges, the membranes surrounding the brain and spinal cord. Most commonly caused by bacterial infection (medical emergency), but can also be viral, fungal (esp. cryptococcal in HIV), or tuberculous. Requires prompt diagnosis and treatment.

Also known as: Brain Fever

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Referral and warning signs

When to refer

ALL suspected cases of meningitis require URGENT referral to Hospital (HC4/H) for lumbar puncture, CSF analysis, appropriate antibiotic administration (often IV), and monitoring for complications.

Red flags

  • Fever with severe headache and neck stiffness
  • Altered mental status (confusion, lethargy, coma)
  • Photophobia
  • Seizures
  • Petechial or purpuric rash
  • Bulging fontanelle in infant
  • Positive Kernig's or Brudzinski's sign

Signs and symptoms

  • Classic Triad (often not all present, esp. in young/elderly): Fever, Severe Headache, Neck Stiffness (nuchal rigidity).
  • Other common symptoms: Photophobia (sensitivity to light), Nausea, Vomiting, Altered mental status (confusion, lethargy, irritability, delirium, coma).
  • Specific signs:
  • - Kernig's sign: Resistance/pain on extending knee when hip is flexed.
  • - Brudzinski's sign: Involuntary flexion of hips/knees when neck is passively flexed.
  • - Bulging fontanelle (infants).
  • - Seizures.
  • - Focal neurological deficits (cranial nerve palsies, hemiparesis - less common).
  • - Petechial or purpuric rash (characteristic of Neisseria meningitidis - meningococcemia, medical emergency).
  • Onset typically acute (hours to days) for bacterial/viral.
  • Subacute onset (days to weeks) possible with TB or Cryptococcal meningitis (headache, fever, malaise progressing to confusion/stiffness).

Risk factors

  • Age extremes (infants, elderly).
  • Immunocompromise (HIV/AIDS, malnutrition, cancer, immunosuppressive drugs).
  • Lack of vaccination (Hib, Pneumococcus, Meningococcus).
  • Recent respiratory infection or otitis media/sinusitis (can precede bacterial meningitis).
  • Skull fracture / Neurosurgery / CSF leak.
  • Crowded living conditions (meningococcal outbreaks).
  • Splenectomy.
  • Active Tuberculosis (for TB meningitis).
  • Low CD4 count (<100) for Cryptococcal meningitis.

Diagnosis

Clinical assessment

High index of suspicion based on clinical presentation (fever, headache, neck stiffness, altered mental status, photophobia). Assess for Kernig's/Brudzinski's signs, rash, focal deficits, papilledema (contraindication to immediate LP).

Investigations

  • Lumbar Puncture (LP) and Cerebrospinal Fluid (CSF) Analysis: CRITICAL diagnostic test. Perform promptly unless contraindicated (signs of markedly raised ICP like papilledema, focal signs, coma GCS<8 - get CT Head first if available/suspected; severe coagulopathy). Send CSF for: Opening pressure, Cell count and differential (Neutrophils high in bacterial; Lymphocytes high in viral, TB, fungal), Glucose (low in bacterial, TB, fungal; normal in viral), Protein (high in bacterial, TB, fungal; normal/mildly high in viral), Gram stain (identify bacteria), Bacterial culture & sensitivity, India Ink stain (for Cryptococcus), Ziehl-Neelsen stain / GeneXpert (for TB), Viral PCR (if available), Cryptococcal Antigen (CrAg) test (rapid test, highly sensitive/specific in CSF/blood).
  • Blood Cultures: Obtain before starting antibiotics.
  • Complete Blood Count (CBC) with differential.
  • Blood Glucose (compare with CSF glucose).
  • Renal function, electrolytes.
  • Consider Malaria test (RDT/smear) as differential for fever/altered mental status.
  • Consider HIV test (esp. if Cryptococcal or TB meningitis suspected).
  • Consider Chest X-ray (primary TB site).

Diagnostic criteria

Clinical suspicion + Confirmatory CSF findings (e.g., pleocytosis, low glucose, high protein, positive gram stain/culture/CrAg/India Ink/ZN/PCR).

Management

Non-pharmacological management

  • Immediate Stabilization: ABCDE approach.
  • Isolation (Droplet precautions): For suspected/confirmed meningococcal meningitis until 24h of effective antibiotics.
  • Supportive Care: IV fluids for hydration (use cautiously to avoid cerebral edema). Control fever (paracetamol). Manage seizures (benzodiazepines). Nutritional support (NGT if needed). Monitor fluid balance, vital signs, neurological status.
  • Management of Raised Intracranial Pressure (ICP) if present (Hospital level): Head elevation, osmotic therapy (mannitol), hyperventilation (temporary measure).

Pharmacological treatment

  • Empirical Antibiotics: Start IMMEDIATELY after LP (or before LP if LP delayed and high suspicion). Choice depends on age and likely pathogens.
  • - UCG Empirical Regimen (Adult/Child): Ceftriaxone (Adult: 2g IV/IM q12h; Child: 100mg/kg/day divided q12h or given once daily) for 10-14 days.
  • - Alternative if Ceftriaxone unavailable/not improving: Chloramphenicol (Adult: 1g IV q6h; Child: 25mg/kg/dose q6h). Switch to oral when clinically improved to complete course.
  • Specific Antibiotics (Once pathogen identified/suspected):
  • - Streptococcus pneumoniae: Benzylpenicillin high dose (Adult: 3-4MU IV q4h; Child: 100,000 IU/kg/dose q4h) OR Ceftriaxone (as above). Duration 10-14 days.
  • - Haemophilus influenzae: Ceftriaxone (as above) OR Chloramphenicol OR Ampicillin (if susceptible). Duration 10 days.
  • - Neisseria meningitidis: Benzylpenicillin high dose OR Ceftriaxone OR Chloramphenicol. Duration up to 14 days. Chemoprophylaxis for close contacts: Ciprofloxacin 500mg PO single dose (Adult/>12y) or 10mg/kg (Child<12y); OR Ceftriaxone 250mg IM single dose (Adult/Pregnancy) or 150mg IM (Child<12y).
  • - Listeria monocytogenes (Neonates, Immunosuppressed): Ampicillin high dose OR Benzylpenicillin. Duration at least 3 weeks.
  • Adjunctive Dexamethasone: Consider in suspected bacterial meningitis (esp. Pneumococcal, Hib) in adults/children >6 weeks. Give 0.15mg/kg IV q6h for 2-4 days, starting *before or with* first antibiotic dose. Benefit controversial, potential harm if delayed start. Not typically used in neonates.
  • Management of Specific Types:
  • - Neonatal Meningitis: See NEU010.
  • - Cryptococcal Meningitis: See NEU011.
  • - TB Meningitis: See NEU012.

Monitoring

Monitor vital signs, neurological status (GCS, pupils, focal signs), seizure activity. Monitor fluid balance, urine output. Monitor response to antibiotics (fever resolution, improving mental status). Monitor for complications (hearing loss, hydrocephalus, seizures). Repeat LP may be considered if poor clinical response.

Complications

  • Hearing loss (common sequela)
  • Seizures / Epilepsy
  • Cognitive impairment / Learning difficulties
  • Motor deficits (weakness, spasticity)
  • Hydrocephalus
  • Cranial nerve palsies
  • Cerebral edema / Raised ICP
  • Subdural effusion/empyema
  • Cerebral infarcts (vasculitis)
  • Sepsis / Septic shock
  • Death

Prevention

  • Vaccination: Hib (Haemophilus influenzae type b), Pneumococcal conjugate vaccine (PCV), Meningococcal vaccine (ACWY, B - depending on prevalence/outbreaks). Included in Ugandan EPI.
  • Chemoprophylaxis for close contacts of meningococcal meningitis.
  • Prompt treatment of preceding infections (otitis media, sinusitis, pneumonia).
  • Avoid overcrowding (meningococcal).
  • Good hygiene practices.
  • HIV prevention and treatment (reduces risk of cryptococcal/TB meningitis).

Patient education

  • Explain the seriousness of the infection.
  • Explain the need for lumbar puncture and prompt antibiotic treatment.
  • Discuss potential complications and need for follow-up (e.g., hearing check).
  • Educate on importance of completing antibiotic course.
  • Explain need for isolation (if meningococcal) and contact prophylaxis.
  • Emphasize importance of vaccinations for prevention.

Uganda-specific notes

Common bacterial causes include S. pneumoniae, N. meningitidis (esp. during epidemics in meningitis belt), and H. influenzae (reduced due to Hib vaccine). Cryptococcal and TB meningitis are major considerations, especially in HIV-positive individuals. Empirical treatment with Ceftriaxone is standard. LP capacity and CSF analysis capabilities vary. Bacterial meningitis is a notifiable disease.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.1.5

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