Clinical Presentation of Meningitis in Adults Prof. Dr. Serhat Ünal FACP, FEFIM Hacettepe University, Faculty of Medicine Department of© Infectious by author Diseases , ANKARA Meningitis Update ESCMIDESCMID PostgraduateOnline Lecture Educational Library Course September 2013, İzmir Why Is Clinical Examination Important? "If, in a fever, the neck be turned awry on a sudden, so that the sick can hardly swallow, and yet no tumour appear, it is mortal.- © by author ESCMID“Aphorism Online XXXV Lecture of Hippocrates Library” Meningitis • Meningitis is a clinical syndrome characterized by inflammation of the meninges • Infectious Meningitis – caused by a variety of infectious agents • bacteria, viruses, fungi, and parasites. • Clinical signs and symptoms at presentation may predict prognosis • Only 25% of adults© by have author a classic presentation and are not a diagnostic dilemma. • ESCMIDMany patients Online have a Lecture less obvious Library presentation Mace SE, Emerg Med Clin N Am 2008;38:281 Spanos A et al JAMA 1998;262:2700 Clinicians Suspecting Meningitis • While taking the patient's history • Examine for – General symptoms of infection • such as fever, chills, and myalgias – Symptoms suggesting central nervous system infection © by author • photophobia, headache, nausea and vomiting, focal neurologic symptoms, or changes in mental status ESCMID Online Lecture Library Clinical Presantation of Meningitis (Dept. Of Emergency) The suspicion of ABM is critically dependent on the early recognition of the meningitis syndrome. • 156 patients with meningitis -Taiwan – I nitial ED diagnosis was correct in only 58% of the cases. • The 3 most common© by alternative author diagnoses – Nonmeningeal infection ESCMID– Metabolic encephalopathy Online Lecture Library – Nonspecific conditions Chern CH, Ann Emerg Med. 2001;38. Causes of Fever and Headache Viral infections without meningitis Meningitis Encephalitis Cerebral abscess Severe sepsis Non-specific symptoms of other infections, e.g. pneumonia, urinary tract infection (UTI), Dengue,© by malaria, author typhoid Local head and neck infections, e.g. sinusitis, tooth abscess, tonsillitisESCMID Online Lecture Library Non-infectious conditions, e.g. sub-arachnoid haemorrhage, cerebral venous thrombosis, pontine haemorrhage © by author ESCMID Online Lecture Library Mace SE, Emerg Med Clin N Am 2008;38:281 Risk Factors © by author ESCMID Online Lecture Library Clues Patient’s History • During late summer and • Enteroviruses infections early fall in temperate climates. • During winter and • Mumps, measles, and spring seasons. © by authorvaricella zoster viruses • Arthropod-borne viruses (eg, • During the warmer ESCMID Online LectureSt. Louis encephalitis, Library California months). encephalitis virus group ) Clues Patient’s History • A history of exposure to a • N. menigitidis patient with a similar illness ( eg close contact with an index case of meningococcemia ) • A history of sexual contact and high-risk behavior© by author• HSV, HIV • The geographic location and • Endemic mycosis ESCMIDa travel history Online Lecture– Histoplasma Library capsulatum and Blastomyces dermatitidis – Borrelia burgdorferi Clues Patient’s History • intake of unpasteurized • L. monocytogenes, milk and cheese Brucellosis • Animal contacts • Rabies (aseptic meningitis) – Animal bite eg, skunk, raccoon, dog, fox, bat © by author• Lymphocytic – Exposure to rodents choriomeningitis (LCM) virus and Leptospira infection ESCMID Online Lecture Library • Laboratory workers • LCM Is the Duration of Symptoms Important ? • Acute or subacute /chronic. – Acute meningitis denotes the evolution of symptoms within hours to several days • Median duration of symptomps before admission – 24 h ( 1h-14 d) – Subacute / chronic meningitis has an onset and duration of weeks to months.© by author • 2-4 wks - subacute ESCMID• > 4 wks chronic Online Lecture Library – The manifestations of subacute and chronic meningitis may be similar to those of acute meningitis, but the illness evolves more slowly. (3) Etiology and Classification • Acute bacterial meningitis is usually characterized by an acute onset of meningeal symptoms and neutrophilic pleocytosis. – Streptococcus pneumoniae meningitis, meningococcal meningitis, or Haemophilus influenzae meningitis. • Fungal and parasitic causes of meningitis are also termed according© to by their author specific etiologic agent, – such as Cryptococcal meningitis, Histoplasma ESCMIDmeningitis, andOnline Amebic Lecturemeningoencephalitis. Library Etiology and Classification • Aseptic meningitis – Clinical and laboratory evidence for meningeal inflammation BUT negative routine bacterial cultures. – In many cases, a cause is not apparent after initial evaluation – The presentation© isby often author similar to that of ABM – Generally benign course that resolves without ESCMIDspecific therapy. Online Lecture Library Mace SE, Emerg Med Clin N Am 2008;38:281 Sadoun T et al. Emergency Med 2009; Emergency Medicine Practice 11:9:1 Aseptic Meningitis • Aseptic meningitis is most commonly a result of viral infection –viral meningitis – The most common cause is enterovirus – It can also be due to a fungal, parasitic, or atypical bacterial infection. • Other causes – Medications, reactions© by toauthor vaccines, and specific systematic diseases with meningeal or ESCMIDparameningeal Online involvement. Lecture Library Mace SE, Emerg Med Clin N Am 2008;38:281 Sadoun T et al. Emergency Med 2009; Emergency Medicine Practice 11:9:1 Meningitis Encephalitis The presence or absence of normal brain function is the important distinguishing feature • Abnormalities in brain • Brain function remains function are common normal • Altered mental status, • Uncomfortable, lethargic, or motor or sensory deficits, distracted by headache altered behavior and personality changes, and speech or movement © by authordisorders SeizuresESCMID, postictal Online states, hemiparesis Lecture, flaccidLibrary paralysis, and paresthesias with clinical features of both Meningitis Encephalitis The presence or absence of normal brain function is the important distinguishing feature The distiction between the two entities is frequently blurred since some patients may have both a parenchymal and meningeal process with clinical features of both. © by author • L abeled as having meningitis or encephalitis based ESCMIDupon which Online features predominateLecture Library in the illness • These patients can best be described as having meningoencephalitis Intracranial Abscess • A focal infection that begins as a localized area of inflammation • The presenting signs and symptoms of a brain abscess – Often nonspecific – Vary according to the location – Severity of the primary infection – Virulence of the bacterium© by author – Size and location(s) of the cerebral abscess ESCMID– P atient’s ability Online to mount Lecture an adequate Libraryimmune response. Zeidman SM, et al. Neurosurgery. 1995;36(1):189-193. Lee TH, et al. J Neurol Neurosurg Pscychiatry. 2007;78(3):303-309. Seydoux C, et al. Clin Infect Dis. 1992;15(3):394-401. Intracranial Abscess • Headache is the most common presenting symptom – Gradual in onset, constant and progressive in nature, and moderate to severe in intensity • Sudden worsening of the headache with new meningismus – rupture of the abscess into the intraventricular space, a life-threatening complication • Fever – only half of patients© andby low author-grade in a significant number. • Focal neurologic deficits – variably present depending on the size and location of the ESCMIDbrain abscess Online. Lecture Library Zeidman SM, et al. Neurosurgery. 1995;36(1):189-193. Lee TH, et al. J Neurol Neurosurg Pscychiatry. 2007;78(3):303-309. Seydoux C, et al. Clin Infect Dis. 1992;15(3):394-401. Factors Affecting Clinical Presentations • Encephalitis vs meningitis • Meningitis vs brain abcsess • İmmunocompromised ( HIV, cancer ) • Underlying diseases (SLE, DM, Chronic renal failure) • Extreme age© (by very author young or elderly ) ESCMID• Prior antimicrobial Online Lecture treatment Library Mace SE, Emerg Med Clin N Am 2008;38:281 Sadoun T et al. Emergency Med 2009; Emergency Medicine Practice 11:9:1 Factors Affecting Clinical Presentations • Elderly individuals, especially those with underlying comorbidities (eg, diabetes, renal and liver disease) – present with lethargy and an absence of meningeal symptoms. • Patients with neutropenia – subtle symptoms© of bymeningeal author irritation. • Other immunocompromised hosts, including organ and tissue transplant recipients and ESCMIDpatients with Online HIV and AIDS Lecture Library – an atypical presentation. Mace SE, Emerg Med Clin N Am 2008;38:281 Sadoun T et al. Emergency Med 2009; Emergency Medicine Practice 11:9:1 Physical Examination • More clinically useful than history • Classic triad (fever, neck stiffness, and altered mental status) – comm-aqc M %44 • + headache – 95% of all patients had at least two of four symptoms – 99% for the presence© by of author 1 of these findings – The absence of fever, neck stiffness, and altered ESCMIDmental status Online effectively Lecture eliminates meningitisLibrary Atta J et al JAMA 1999;282:175 van de Beek D N Engl J Med 2004;351(18):1849–59 Mace SE, Emerg Med Clin N Am 2008;38:281. Physical Examination • Positive Kernig’s and Brudzinski’s signs are hallmarks of meningitis. • Kernig’s and Brudzinski’s signs were present in only about half of adults with meningitis. © by author ESCMID Online Lecture Library Atta J et al JAMA 1999;282:175 van de