- Bacterial Meningitis
- How Meningitis Is Diagnosed in Its Early Stages
Your child was recently diagnosed with viral meningitis. This infection causes swelling of the lining of the brain. Your child may have symptoms such as fever, headache, neck pain or stiffness, pain when looking at bright lights, nausea, vomiting, poor appetite, tiredness and sleepiness. The virus may also infect other parts of the body and cause symptoms such as skin rash, runny nose, sore throat, ear ache, cough, difficulty breathing and diarrhea. Let your doctor know if your child has any of these symptoms.
To diagnose viral meningitis, the doctor performs a lumbar puncture or ‘spinal tap’ to obtain some of the fluid that normally surrounds the brain and spinal cord. Laboratory tests on this fluid help the doctor decide whether the infection is caused by a virus or other germ such as bacteria. Most cases of viral meningitis are not very serious. Children recover in about one or two weeks. However, it is very important to recognize meningitis caused by bacteria because it is more serious but can be treated with antibiotics. Antibiotic treatment is not effective against viral meningitis.
If your child has mild symptoms from viral meningitis, and is doing well at home, the doctor will not admit him or her to hospital. However, if your child is quite sick from the viral infection (especially young infants), the doctor may hospitalize your child temporarily for further care until he or she is better.
Occasionally, a doctor is unable to distinguish viral and bacterial meningitis on the basis of the test results. This may be because your child was taking an oral antibiotic before the spinal tap was completed. An antibiotic does not prevent the meningitis from happening but can make the spinal fluid results confusing. Some viral infections can also give spinal fluid results that falsely resemble bacterial meningitis. In that case, your doctor may decide to hospitalize your child and start intravenous antibiotic(s) while waiting for other test results. If the diagnosis of viral meningitis becomes apparent in the next several days, the antibiotic(s) will be stopped. Sometimes this involves repeating the spinal tap in one or two days.
In Canada viral meningitis occurs most commonly during the summer when the two most common viruses that cause meningitis, coxsackievirus and echovirus, are in the community. These viruses frequently infect many children and adults at the same time, but few will actually develop viral meningitis. The meningitis resolved its own, usually without any complications. The viruses spread easily from one person to another. The viruses are carried in the stool or feces, making it very important for all family members to wash their hands with soap and water after using the washroom (or changing dirty diapers), and before food preparation and eating to prevent spread of the virus. Viral meningitis may also occur at other seasons during the year but may be caused by other types of viruses. Your doctor can explain more about the type of viral infection that your child has.
Viral meningitis is inflammation of the leptomeniges due to a viral agent. It is the most common cause of meningitis, with an annual incidence of 10 to 11 people per 100,000. Viral meningitis occurs most commonly in those under the age of 30, with a predominance in neonates and children. The disease is usually self-limiting, rarely requires hospitalization, and symptoms typically resolve in 7-10 days. Enterovirus is the most common etiologic agent and is responsible for 85 percent of viral meningitis cases. The peak season for enterovirus is during the summer months when it is hypothesized that warm weather aids in its spread .
The symptoms of viral meningitis are indistinguishable from those of bacterial meningitis or aseptic causes of meningitis. Classic symptoms are fever, headache, and neck stiffness (nuchal rigidity). Young children or infants may simply present with fever and irritability. Other symptoms include photophobia, myalgias, nausea and vomiting, diarrhea, lethargy, and even upper respiratory symptoms (which may precede or occur concomitantly with the classic symptoms) .
Physical exam maneuvers for nuchal rigidity include the Kernig and Brudzinski signs. Kernig’s is performed by having the supine patient, with hips and knees flexed, extend the leg passively. The test is positive if the leg extension causes pain. The Brudzinski’s sign is positive when passive forward flexion of the neck causes the patient to involuntarily raise his knees or hips in flexion. Despite their historical significance, a positive result from either test has not been shown to be reliable indicators of meningitis.
It is critical to distinguish between bacterial and viral etiologies because the course of bacterial meningitis is rapid and potentially deadly. History and physical exam alone are not sufficient to confirm the diagnosis, especially in young children or infants. Meningitis is definitively diagnosed with a lumbar puncture, which in viral meningitis typically reveals clear cerebral spinal fluid (CSF) with elevated white blood cell counts predominated by lymphocytes, in contrast to the PMNs (polymorphonuclear leukocytes) that typify bacterial etiologies. CSF glucose levels are characteristically normal; protein may be normal or slightly elevated.
CSF analysis should include a gram stain, acid-fast stain, and culture to further aid in diagnosis. If available, polymerase chain reaction (PCR) for presence of genomic material from likely viral pathogens can quickly assist in determining whether a patient’s meningitis is bacterial or viral. PCR tests are currently available for enterovirus, cytomegalovirus, herpes simplex virus, and HIV pathogens. A positive PCR test for enterovirus in the emergency room can save a patient with mild symptoms from an unnecessary hospital admission, assuming proper support and provisions at home. Keep in mind that mild meningeal symptoms in the setting of prior antibiotic use may mask a fulminant cause. As with any potentially infectious picture, it is important to clarify immune status, inasmuch as mycobacterial and fungal causes are more likely in those with compromised immune systems.
Treating Viral Meningitis
Treatment for viral meningitis is primarily supportive, especially in the case of enterovirus. Some patients require hospitalization for fluid administration and pain relief, while others can be safely treated at home. Exceptions include varicella and herpes simplex virus meningitis, which, if severe, are treated with antiviral agents such as acyclovir.
- Evidence-based practice/Effectiveness
The bacterial form of meningitis can be life-threatening and needs to be treated quickly. Your teen will likely stay in a hospital to get antibiotics put into his veins through an IV until the doctor gets the results of a spinal tap.
If the spinal fluid tests show your teen has bacterial meningitis, he’ll need to keep up with the antibiotics until the infection goes away, possibly for as long as 2 weeks. Because bacterial meningitis can spread easily to others, he’ll probably stay in an isolated room for at least 48 hours.
Meningitis can make the eyes sensitive to light, so your teen may prefer a darkened room. He’ll get plenty of liquids and drugs to relieve headache and fever. To keep him from getting reinfected, doctors will look for a source of the infection, such as an infected sinus.
If your teen has a type of bacterial meningitis called meningococcal meningitis, there’s a risk that people close to him can get infected. The doctor may suggest they take an antibiotic to prevent them from getting the disease.
A lack of understanding
I woke up at about 5am on March 9th 2012 with a severe headache in the back of my neck. I thought I had woken up too early and tried to get back to sleep. By 7.30am I was feeling sick and had pins and needles in my arms. Two weeks previously I had had a bad dose of flu, probably the worst I have ever had, and was off work for a week.
As there was no one at home I called a friend as I just didn’t know what to do, and she told me to call an ambulance. An emergency car arrived within five minutes, but the medic didn’t seem too concerned, thought I was having a migraine (which I have never had before) and told me the pins and needles in my arms were due to me hyper-ventilating. The ambulance arrived a few minutes later and took me to hospital. On arrival they tried to give me painkiller tablets but I felt too sick to take them, and was given morphine in liquid form. Within an hour of being in hospital I had had a brain scan.
Meningitis had not crossed my mind
Meningitis had not crossed my mind at this point. I thought perhaps it was ‘only’ a migraine, but my worst fear was a stroke due to the pins and needles and strange sensations in my arms. Throughout the morning I was kept in A&E with a string of doctors performing various tests on me. I think they all shone a torch in my eyes and asked me if the light affected me. I think, meningitis or not, if you are feeling that ill with a severe headache, a torch shone in your eyes would be uncomfortable.
They also asked me if I had any rash on my body, which I didn’t, and kept checking my reflexes which were normal. I was aware of the symptoms of meningitis, and assumed their references to light and rash were to exclude meningitis. Even at this stage I didn’t for one moment think that it would be meningitis.
When the results of my scan came back normal, they said I would need to have a lumbar puncture. It was explained to me that this would be performed 12 hours after my onset of symptoms, because if there was any bleeding (i.e. a stroke) it may take this long to show up. By mid afternoon I was moved to a ward and starting to feel a bit better.
The lumbar puncture was performed at about 7pm and I was told the results would be ready by midnight. This was a Friday, so by the evening I guess only weekend staff were on duty. Despite me constantly asking, I didn’t see a doctor or get my results until Saturday afternoon. By this time I was feeling fine and assuming I would be allowed home. I was up and about, no headache, and eating normally. The results of the lumbar puncture showed no bleeding, so it wasn’t a stroke, but my white blood cell count was high indicating an infection. I was told I needed to stay in hospital another night whilst they did further tests.
Told to go home and rest
On the Sunday morning I woke up feeling dreadful and could not lift my head off the pillow. I had a severe headache and my head felt so heavy and uncoordinated, a really strange feeling. I couldn’t eat anything and struggled to get out of bed. In the afternoon they started a course of intra-venous Acyclovir ‘as a precaution’. On Monday morning, still feeling dreadful, a doctor came around and informed me I had viral meningitis. I was told to go home and rest, and that it may take up to a month until I felt better.
A friend came to pick me up from hospital and had to double check with the staff that I was allowed home. I think she was shocked that I was being allowed home when I was struggling to even sit up in bed. Walking to her car took so much effort and I really struggled to sit upright for the two mile journey home. I remember sitting in the passenger seat and trying to put my head down as low as possible. Being upright was intolerable.
When I got home I went straight to bed and stayed there for about five days. I couldn’t even get downstairs. Every time I sat up or moved my head felt so heavy and I was dizzy and uncoordinated. I was also finding breathing difficult whenever I tried to move or do anything other than lie still. By this time I had read up on meningitis and lumbar puncture and thought that the symptoms I was now experiencing were due to the lumbar puncture, as side effects can take 24-48 hours to develop. I still cannot understand why the day after I was admitted to hospital I felt fine and then the next day felt so ill again.
Over the next few weeks I gradually started to try and do a little more each day. The first time I walked down my street my head felt terrible, it felt as if my head was pulling me one way and my legs were going in a different direction (vertigo?), and with every attempt my breathing became more difficult. I could only walk really slowly and to walk to the end of my street (50m) felt like a marathon.
Although feeling so rough, I was still quite relaxed within myself and not feeling stressed or panicky. I started to do a few vestibular rehabilitation exercises for the vertigo and this did help a bit, throwing a ball and catching it, and walking down the street looking alternately at front doors on opposite sides of the street, although these hadn’t been prescribed for me. I knew about the vestibular rehabilitation exercises from my sister as she had been prescribed them for vertigo previously.
I couldn’t bear any sensory stimulation – more than one noise, i.e. a conversation in the room and the phone ringing; busy visual environments; looking around for something, and bright un-natural lighting. The first time I went to a supermarket was awful. You don’t realise how much visual stimulation there is and your eyes try and glance over everything in one go, and the lighting is so harsh. I gradually set myself challenges to go to Tesco every day and buy one thing. I had to know where it was before going as I couldn’t look around the shelves to find what I needed. It’s surprising how much harsher the lighting was in Morrison’s compared to Tesco, something you would typically never notice, but shopping in Morrison’s was so much worse.
After about six weeks I booked an appointment with a neurologist. He didn’t seem concerned, said all my symptoms were typical for viral meningitis, just give it time. I asked him if I should be referred for vestibular rehabilitation but he wouldn’t refer me, just told me to relax a bit more.
Supportive work colleagues and employer
I returned to work after ten weeks, on reduced hours, but was limited to what I could do at work. I just wanted a sense of normality. My work colleagues and company were supportive and I was allowed to work at my own pace. With hindsight I probably went back too soon and struggled with everyday tasks. After two weeks back at work I contracted food poisoning and with this a return of my previous symptoms (feeling dizzy, irregular breathing, aversion to sensory stimuli), and had another four to five weeks off work. At this stage I had to cancel a holiday to Jamaica as I knew I would not be able to cope with the travelling.
Over the next few months I gradually improved. Some days were better than others. By the end of 2012 I was beginning to feel reasonably okay, as long as I didn’t do too much and wasn’t in a very busy environment with lots of noise and bright lighting. Christmas was a busy time and I returned to work in the New Year.
The first week of January I contracted conjunctivitis followed by a throat infection. I was feeling quite ill and once again many of my previous symptoms returned and I was struggling to even walk to the doctors. It took two courses of antibiotic eye creams and a course of antibiotics to clear the infections.
Over the course of the next few months I was very up and down and had taken more time off work. I was starting to feel a bit panicky and anxious and was getting quite worked up about taking so much time off work. This became a bit of a vicious circle and the more anxious I became the worse my symptoms were. I made several visits to my GP and spoke with Meningitis Now.
I pushed for a referral for vestibular rehabilitation and was finally referred. The physio who I saw was excellent and I think she really understood what I was going through, more so than any of the doctors I had seen. She did a range of tests on me to try and provoke dizziness, but none of these worked e.g. changing direction quickly, turning around and looking from side to side. I explained to her that if I was moving in a controlled way and thinking about what I was doing it didn’t really affect me.
Problems with bending down and turning around
But I would have problems with things like emptying the dishwasher (bending down and turning around), looking around for my keys, sitting at a table with other people so I had to turn my head, flicking through a magazine so I wasn’t focusing on each word, just glancing over items. I had to do everything at the pace my head would allow. If I was walking down the road with friends I had to dictate the pace we were walking as even trying to walk at a pace somebody else set was overwhelming.
Just speaking with her was like a good counselling session (nothing to do with the vestibular rehabilitation) – to finally speak to someone who listened to what I was saying. She said there would be no point in prescribing traditional vestibular rehabilitation exercises as she could not trigger my dizziness. She recommended that whatever made me feel dizzy to try and do it little and often and as ‘normally’ as possible. I know that I had begun to move my head less and slower to minimise any dizziness. As I didn’t like busy visual images and looking around I started playing Mah-jong, which involves images of lots of busy tiles that you have to match up. I also put a very busy screen saver on my PC and spent ages just watching it, trying to ‘recalibrate’ my brain. I persevered with both of these and think they did help.
I now feel well. Some things are still a bit strange, and I think the way my brain processes certain information has changed. I’m still a bit slow looking around for things, e.g. in a supermarket I still sometimes have to stand back and look slowly for an item rather than glancing over all the shelves, and crossing busy roads that I am unfamiliar with can be a bit awkward, but on the whole I am fine.
How Meningitis Is Diagnosed in Its Early Stages
Meningitis is an extremely serious, often life-threatening disease — yet its early symptoms often resemble the flu, and that can make it difficult to diagnose.
There are five types of meningitis, each caused by different factors. The two most common forms of the disease are viral meningitis and bacterial meningitis. Viral meningitis often resolves on its own without treatment. But if you have bacterial meningitis, early diagnosis and treatment is vital. If treatment is delayed because symptoms are mistaken for the flu, there can be devastating consequences.
Symptoms such as sudden fever, severe headache, and a stiff neck are possible indications of meningitis. Anyone experiencing these symptoms should seek immediate medical attention — it’s definitely a case of better safe than sorry. “The onset may be very sudden, and the progression even faster,” says Malcolm Thaler, MD, an internist with One Medical Group in New York City.
Making a Meningitis Diagnosis
The first step of diagnosing meningitis is a physical exam, and there are specific indicators for which your doctor can check. Your doctor may look for Brudzinski’s sign, an indicator in which stiffness in your neck causes you to automatically flex your knees and hips when your doctor forces you to flex your neck. “The doctor may also look for Kernig’s sign,” says Dr. Thaler. This means you could feel severe pain in your thigh if you try to extend your leg,
If meningitis is suspected, may start you on antibiotics right away, even before determining the type of meningitis you have. “Since the culture for virus and bacterial growth often takes a few days to come back, it would be very dangerous to wait for that information,” says Cathy Clements, MD, a primary care physician and internist at Mercy Medical Center in Baltimore. “That’s why the most important thing a doctor can do when a patient comes in with suspected meningitis is to go ahead and initiate treatment.” Antibiotics are prescribed based on the most common pathogens known to cause meningitis in certain age groups, Dr. Clements explains.
Additional Diagnostic Tests for Meningitis
When a meningitis diagnosis is suspected, there are several tests your doctor can run to confirm a diagnosis:
Blood tests. Standard blood tests to analyze antibodies and foreign proteins can alert your doctor to the presence of infection.
CT scan. A scan of the brain can reveal inflammation, internal bleeding, or other abnormalities. It can also detect conditions such as brain swelling, abscess, or hemorrhage, which could make a lumbar puncture unsafe.
Lumbar puncture. The inflammation associated with meningitis is most often caused by an infection of the cerebral spinal fluid, which surrounds the brain and spinal cord. A lumbar puncture, also known as a spinal tap, enables your doctor to collect a sample of this cerebrospinal fluid from a small area in your lower back. This fluid is sent to the lab and analyzed to determine if there is an infection. “We look for white blood cells, blood, protein, and glucose,” Clements says. “The results of these tests — and their ratios to each other — can give us an idea if the meningitis is bacterial, viral, or fungal.” She explains that bacterial meningitis tends to have more neutrophils (a certain type of white blood cell) and lower glucose levels. Viral meningitis tends to have more lymphocytes (another type of white blood cell) and more protein. “We also send it for culture for viruses and bacteria growth, which often takes a few days to come back,” she says.
Once all the results are in, the medical team should have the information needed for a more precise diagnosis and further treatment.