(For brain infections, see Brain Infections; for neonatal meningitis, see Infections in Neonates: Neonatal Bacterial Meningitis.)
Meningitis is inflammation of the meninges and subarachnoid space. It may result from infections, other disorders, or reactions to drugs. Severity and acuity vary. Findings typically include headache, fever, and nuchal rigidity, Diagnosis is by CSF analysis. Treatment includes antimicrobial drugs as indicated plus adjunctive measures.
Meningitis may be classified as acute, subacute, chronic, or recurrent. It may also be classified by its cause: bacteria, viruses, fungi, protozoa, or, occasionally, noninfectious conditions. But the most clinically useful categories of meningitis are
Acute bacterial meningitis is particularly serious and rapidly progressive. Viral and noninfectious meningitides are usually self-limited. Subacute and chronic meningitides usually follow a more indolent course than other meningitides, but determining the cause can be difficult.
Aseptic meningitis, an older term, is sometimes used synonymously with viral meningitis; however, it usually refers to acute meningitis caused by anything other than the bacteria that typically cause acute bacterial meningitis. Thus, aseptic meningitis can be caused by viruses, noninfectious conditions (eg, drugs, disorders), or, occasionally, other organisms (eg, Borrelia burgdorferi in Lyme disease, Treponema pallidum in syphilis).
Symptoms and Signs
Symptoms and signs of the different types of meningitis may vary, particularly in severity and acuity. However, all types tend to cause the following (except in infants):
Patients may appear lethargic or obtunded.
Nuchal rigidity, a key indicator of meningeal irritation, is resistance to passive or volitional neck flexion. Nuchal rigidity may take time to develop. Clinical tests for it, from least to most sensitive, are
Nuchal rigidity can be distinguished from neck stiffness due to cervical spine osteoarthritis or influenza with severe myalgia: in these disorders, neck movement in all directions is usually affected. In contrast, nuchal rigidity due to meningeal irritation affects mostly neck flexion; thus, the neck can usually be rotated but cannot be flexed.
Diagnosis is mainly by CSF analysis. Because meningitis can be serious and lumbar puncture is a safe procedure, lumbar puncture should usually be done if there is any suspicion of meningitis. CSF findings tend to differ by the type of meningitis but can overlap.
If patients have signs suggesting increased intracranial pressure (ICP) or a mass (eg, focal neurologic deficits, papilledema, deterioration in consciousness, seizures, especially if patients have HIV infection or are immunocompromised), neuroimaging—typically, contrast-enhanced CT or MRI—is done before lumbar puncture. In such patients, lumbar puncture may cause brain herniation. When lumbar puncture is deferred, blood cultures should be obtained, followed immediately by empiric treatment with antibiotics. After ICP, has been lowered and if no mass is detected, lumbar puncture can be done. Also, if a bleeding disorder is suspected, lumbar puncture is not done until the bleeding disorder is excluded or controlled. If the skin over the needle insertion site is infected, the needle is inserted at a different site.
Infectious meningitis is treated with antimicrobial therapy as indicated clinically. Adjunctive treatments can include supportive measures, treatment of complications or of associated disorders, removal of causative drugs, and, for bacterial meningitis, corticosteroids.
Last full review/revision February 2013 by John E. Greenlee, MD