eMedicine Specialties > Neurology > Neurological Infections

Meningococcal Meningitis: Differential Diagnoses & Workup

Author: Francisco de Assis Aquino Gondim, MD, MSc, PhD, Professor Adjunto II, Departments of Physiology and Pharmacology, Neurology Residency Program Director, Faculdade de Medicina, Universidade Federal do Ceará, Brazil
Coauthor(s): Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience; Sidney E Croul, MD, Director of Neuropathology, Professor, Department of Pathology and Laboratory Medicine, Medical College of Pennsylvania Hahnemann University
Contributor Information and Disclosures

Updated: Aug 11, 2009

Differential Diagnoses

Acute Disseminated Encephalomyelitis
Intracranial Epidural Abscess
Aseptic Meningitis
Leptomeningeal Carcinomatosis
Haemophilus Meningitis
Lyme Disease
Herpes Simplex Encephalitis
Neonatal Meningitis
HIV-1 Associated CNS Conditions: Meningitis
Staphylococcal Meningitis
HIV-1 Associated Opportunistic Infections: CNS Cryptococcosis
Subdural Empyema
HIV-1 Associated Opportunistic Infections: CNS Toxoplasmosis
Tuberculous Meningitis
HIV-1 Associated Opportunistic Infections: Cytomegalovirus Encephalitis
Viral Meningitis

Other Problems to Be Considered

Rocky Mountain spotted fever7
Streptococcal meningitis
Listerial meningitis
Adrenal failure
Sepsis
Multiorgan failure

Workup

Laboratory Studies

  • Laboratory examination of the cerebrospinal fluid (CSF) usually confirms the presence of meningitis. Typical CSF abnormalities in meningitis include the following:
    • Increased opening pressure (>180 mm water)
    • Pleocytosis of polymorphonuclear leukocytes (WBC counts between 10 and 10,000 cells/µL, predominantly neutrophils)
    • Decreased glucose concentration (<45 mg/dL)
    • Increased protein concentration (>45 mg/dL)
  • Gram stain and culture of CSF identify the etiological organism, N meningitides. In bacterial meningitis, Gram stain is positive in 70-90% of untreated cases, and culture results are positive in as many as 80% of cases.
  • More specialized laboratory tests, which may include culture of CSF and blood specimens, are needed for identification of N meningitidis and the serogroup of meningococci, as well as for determining its susceptibility to antibiotics.
  • Polymerase chain reaction (PCR)8 may be used to complement standard laboratory procedures for the diagnosis of meningococcal meningitis.9 The IS1106 PCR is a rapid and sensitive test for confirmation of the diagnosis; its sensitivity is not affected by prior antibiotic treatment.10 PCR of the nspA gene was also reported to be a fast diagnostic test.11

Imaging Studies

  • Perform a neuroimaging study (either MRI or CT scan) prior to lumbar puncture in all patients in whom meningitis is suspected. CT scan findings are usually normal. However, imaging is an important cause of delay of therapy.
  • MRI with contrast is preferred to CT scan because MRI better demonstrates meningeal lesions, cerebral edema, and cerebral ischemia. T1 may show obliterated cisterns. Contrast enhances the cisterns, and extension of enhancing subarachnoid exudate deep into the sulci may be seen in severe cases. Strokes can be seen with the development of vasculitis and cerebritis. CNS complications that can be visualized by MRI include hydrocephalus, aqueductal obstruction, ventriculitis (especially in neonates), choroid plexitis, subdural effusion, and empyema.
  • Indications for performing CT scan prior to lumbar puncture include altered level of consciousness, papilledema, focal neurological deficits, and/or focal or generalized seizure activity.


Head CT demonstrates enlargement of the temporal ...

Head CT demonstrates enlargement of the temporal horns indicating increased intracranial pressure (horizontal open large arrow). The closed arrowhead shows small intracerebral hemorrhage foci on the right temporal lobe, and the curved arrow shows the effect of increased intracranial pressure on the cerebellum.

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Head CT demonstrates enlargement of the temporal ...

Head CT demonstrates enlargement of the temporal horns indicating increased intracranial pressure (horizontal open large arrow). The closed arrowhead shows small intracerebral hemorrhage foci on the right temporal lobe, and the curved arrow shows the effect of increased intracranial pressure on the cerebellum.



Head CT shows small intracerebral hemorrhage foci...

Head CT shows small intracerebral hemorrhage foci (vertical closed arrow). Basal ganglia can also not be visualized because of diffuse edema (oblique closed arrow). The black arrow head on the left shows soft tissue edema.

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Head CT shows small intracerebral hemorrhage foci...

Head CT shows small intracerebral hemorrhage foci (vertical closed arrow). Basal ganglia can also not be visualized because of diffuse edema (oblique closed arrow). The black arrow head on the left shows soft tissue edema.

Other Tests

An electroencephalogram (EEG) study is sometimes useful to document irritable electrical patterns that may predispose the patient to seizures. Periodic complexes and periodic lateralizing epileptiform discharges (PLEDs) may be suggestive of encephalitis caused by herpes simplex virus.

Histologic Findings

During the first few days, the subarachnoid and ventricular exudate contains large numbers of neutrophils and necrotic debris. Intracellular and extracellular bacteria can be demonstrated. The exudate extends along the perivascular spaces into the cortex and cerebral cortex. Purulent material usually is observed in the choroid plexus. With time, the number of mononuclear leukocytes increases, and they predominate by the end of the first week. Fibroblasts also proliferate.

Inflammatory cells infiltrate leptomeningeal and cortical arteries and veins and accumulate in the intima. Thrombosis of small vessels leads to infarction. This pattern is common in autopsied cases.

More on Meningococcal Meningitis

Overview: Meningococcal Meningitis
Differential Diagnoses & Workup: Meningococcal Meningitis
Treatment & Medication: Meningococcal Meningitis
Follow-up: Meningococcal Meningitis
Multimedia: Meningococcal Meningitis
References
Further Reading
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References

  1. Stephens DS. Neisseria meningitidis. Infect Control. Jan 1985;6(1):37-40. [Medline].

  2. Jackson LA, Schuchat A, Reeves MW, Wenger JD. Serogroup C meningococcal outbreaks in the United States. An emerging threat. JAMA. Feb 1 1995;273(5):383-9. [Medline].

  3. Ahlawat S, Kumar R, Roy P, et al. Meningococcal meningitis outbreak control strategies. J Commun Dis. Dec 2000;32(4):264-74. [Medline].

  4. Andersen J, Backer V, Voldsgaard P, et al. Acute meningococcal meningitis: analysis of features of the disease according to the age of 255 patients. Copenhagen Meningitis Study Group. J Infect. May 1997;34(3):227-35. [Medline].

  5. Heckenberg SG, de Gans J, Brouwer MC, Weisfelt M, Piet JR, Spanjaard L, et al. Clinical features, outcome, and meningococcal genotype in 258 adults with meningococcal meningitis: a prospective cohort study. Medicine (Baltimore). 2008;87:185-92. [Medline].

  6. Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. Jan 2005;90(1):66-9. [Medline].

  7. Helmick CG, Bernard KW, D'Angelo LJ. Rocky Mountain spotted fever: clinical, laboratory, and epidemiological features of 262 cases. J Infect Dis. Oct 1984;150(4):480-8. [Medline].

  8. Kotilainen P, Jalava J, Meurman O, et al. Diagnosis of meningococcal meningitis by broad-range bacterial PCR with cerebrospinal fluid. J Clin Microbiol. Aug 1998;36(8):2205-9. [Medline].

  9. Pardo F, Juncal R, Rajo C, Perez del Molino ML. [Usefulness of polymerase chain reaction (PCR) in the diagnosis of meningococcal meningitis]. Enferm Infecc Microbiol Clin. Feb 1999;17(2):74-7. [Medline].

  10. Ni H, Knight AI, Cartwright K, et al. Polymerase chain reaction for diagnosis of meningococcal meningitis. Lancet. Dec 12 1992;340(8833):1432-4. [Medline].

  11. de Filippis I, do Nascimento CR, Clementino MB, et al. Rapid detection of Neisseria meningitidis in cerebrospinal fluid by one-step polymerase chain reaction of the nspA gene. Diagn Microbiol Infect Dis. Feb 2005;51(2):85-90. [Medline].

  12. Talan DA, Guterman JJ, Overturf GD, et al. Analysis of emergency department management of suspected bacterial meningitis. Ann Emerg Med. Aug 1989;18(8):856-62. [Medline].

  13. Cuevas LE, Hart CA. Chemoprophylaxis of bacterial meningitis. J Antimicrob Chemother. Feb 1993;31 Suppl B:79-91. [Medline].

  14. Shao PL, Chang LY, Hsieh SM, Chang SC, Pan SC, Lu CY, et al. Safety and immunogenicity of a tetravalent polysaccharide vaccine against meningococcal disease. J Formos Med Assoc. Jul 2009;108(7):539-47. [Medline].

  15. Hart CA, Cuevas LE, Marzouk O, et al. Management of bacterial meningitis. J Antimicrob Chemother. Jul 1993;32 Suppl A:49-59. [Medline].

  16. Bhatt KM, Bhatt SM, Mirza NB. Meningococcal meningitis. East Afr Med J. Jan 1996;73(1):35-9. [Medline].

  17. Schwartz B, Al-Tobaiqi A, Al-Ruwais A, et al. Comparative efficacy of ceftriaxone and rifampicin in eradicating pharyngeal carriage of group A Neisseria meningitidis. Lancet. Jun 4 1988;1(8597):1239-42. [Medline].

  18. Kutz JW, Simon LM, Chennupati SK, et al. Clinical predictors for hearing loss in children with bacterial meningitis. Arch Otolaryngol Head Neck Surg. Sep 2006;132(9):941-5. [Medline].

  19. Blazer S, Berant M, Alon U. Bacterial meningitis. Effect of antibiotic treatment on cerebrospinal fluid. Am J Clin Pathol. Sep 1983;80(3):386-7. [Medline].

  20. Caugant DA, Hoiby EA, Magnus P, Scheel O, Hoel T, Bjune G, et al. Asymptomatic carriage of Neisseria meningitidis in a randomly sampled population. J Clin Microbiol. Feb 1994;32(2):323-30. [Medline].

  21. Coll MT, Uriz MS, Pineda V, et al. Meningococcal meningitis with 'normal' cerebrospinal fluid. J Infect. Nov 1994;29(3):289-94. [Medline].

  22. Durand ML, Calderwood SB, Weber DJm, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. Jan 7 1993;328(1):21-8. [Medline].

  23. Edwards MS, Baker CJ. Complications and sequelae of meningococcal infections in children. J Pediatr. Oct 1981;99(4):540-5. [Medline].

  24. Feske SK. Coma and confusional states: emergency diagnosis and management. Neurol Clin. May 1998;16(2):237-56. [Medline].

  25. Galimand M, Gerbaud G, Guibourdenche M, et al. High-level chloramphenicol resistance in Neisseria meningitidis. N Engl J Med. Sep 24 1998;339(13):868-74. [Medline].

  26. Gjini AB, Stuart JM, Cartwright K, Cohen J, Jacobs M, Nichols T. Quality of in-hospital care for adults with acute bacterial meningitis: a national retrospective survey. QJM. Nov 2006;99(11):761-9. [Medline].

  27. Greenfield S, Sheehe PR, Feldman HA. Meningococcal carriage in a population of "normal" families. J Infect Dis. Jan 1971;123(1):67-73. [Medline].

  28. Greenwood BM, Bradley AK, Wall RA. Meningococcal disease and season in sub-Saharan Africa. Lancet. Oct 12 1985;2(8459):829-30. [Medline].

  29. Hodgson A, Smith T, Gagneux S, et al. Risk factors for meningococcal meningitis in northern Ghana. Trans R Soc Trop Med Hyg. Sep-Oct 2001;95(5):477-80. [Medline].

  30. Hui L, Tokeshi J. Dexamethasone use in adult meningococcal meningitis. Hawaii Med J. Jul 2000;59(7):308-9. [Medline].

  31. Jong EC. Travel immunizations. Med Clin North Am. Jul 1999;83(4):903-22, vi. [Medline].

  32. Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. Nov 2001;108(5):1169-74. [Medline].

  33. Kirsch EA, Barton RP, Kitchen L, Giroir BP. Pathophysiology, treatment and outcome of meningococcemia: a review and recent experience. Pediatr Infect Dis J. Nov 1996;15(11):967-78; quiz 979. [Medline].

  34. Leedom JM, Underman AE. Epidemiology of central nervous system infections. Neuroimaging Clin N Am. May 2000;10(2):297-308. [Medline].

  35. Memish ZA. Meningococcal disease and travel. Clin Infect Dis. Jan 1 2002;34(1):84-90. [Medline].

  36. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jun 30 2000;49(RR-7):1-10. [Medline].

  37. Pruitt AA. Infections of the nervous system. Neurol Clin. May 1998;16(2):419-47. [Medline].

  38. Quagliarello V, Scheld WM. Bacterial meningitis: pathogenesis, pathophysiology, and progress. N Engl J Med. Sep 17 1992;327(12):864-72. [Medline].

  39. Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med. Mar 6 1997;336(10):708-16. [Medline].

  40. Roos KL. Acute bacterial meningitis. Semin Neurol. 2000;20(3):293-306. [Medline].

  41. Rosenberg DH, Arling PA. Penicillin in the treatment of meningitis. JAMA. 1944;125:1011-1017.

  42. Rosenstein NE, Perkins BA, Stephens DS, et al. Meningococcal disease. N Engl J Med. May 3 2001;344(18):1378-88. [Medline].

  43. Rosenstein NE, Perkins BA, Stephens DS, et al. The changing epidemiology of meningococcal disease in the United States, 1992-1996. J Infect Dis. Dec 1999;180(6):1894-901. [Medline].

  44. Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med. Oct 2 1997;337(14):970-6. [Medline].

  45. Snape MD, Pollard AJ. Meningococcal polysaccharide-protein conjugate vaccines. Lancet Infect Dis. Jan 2005;5(1):21-30. [Medline].

  46. Stephens DS, Hajjeh RA, Baughman WS, et al. Sporadic meningococcal disease in adults: results of a 5-year population-based study. Ann Intern Med. Dec 15 1995;123(12):937-40. [Medline].

  47. [Best Evidence] Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?. JAMA. Oct 25 2006;296(16):2012-22. [Medline].

  48. Suri M, Kabra M, Singh S, et al. Group B meningococcal meningitis in India. Scand J Infect Dis. 1994;26(6):771-3. [Medline].

  49. Tikhomirov E, Santamaria M, Esteves K. Meningococcal disease: public health burden and control. World Health Stat Q. 1997;50(3-4):170-7. [Medline].

  50. Tunkel AR, Wispelwey B, Scheld WM. Bacterial meningitis: recent advances in pathophysiology and treatment. Ann Intern Med. Apr 15 1990;112(8):610-23. [Medline].

  51. Tzeng YL, Stephens DS. Epidemiology and pathogenesis of Neisseria meningitidis. Microbes Infect. May 2000;2(6):687-700. [Medline].

  52. Van Scoy RE, Wilkowske CJ. Prophylactic use of antimicrobial agents in adult patients. Mayo Clin Proc. Mar 1992;67(3):288-92. [Medline].

  53. Wang VJ, Malley R, Fleisher GR, et al. Antibiotic treatment of children with unsuspected meningococcal disease. Arch Pediatr Adolesc Med. Jun 2000;154(6):556-60. [Medline].

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Keywords

Neisseria meningitidis, N meningitidis, meningococcal disease, meningococci, meningococcal infections, Neisseria lactamica, N lactamica, bacterial meningitis, Waterhouse-Friderichsen syndrome, meningococcal septicemia

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Contributor Information and Disclosures

Author

Francisco de Assis Aquino Gondim, MD, MSc, PhD, Professor Adjunto II, Departments of Physiology and Pharmacology, Neurology Residency Program Director, Faculdade de Medicina, Universidade Federal do Ceará, Brazil
Francisco de Assis Aquino Gondim, MD, MSc, PhD is a member of the following medical societies: American Academy of Neurology and Movement Disorders Society
Disclosure: Boehringer-Ingelheim Honoraria Speaking and teaching

Coauthor(s)

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Sidney E Croul, MD, Director of Neuropathology, Professor, Department of Pathology and Laboratory Medicine, Medical College of Pennsylvania Hahnemann University
Sidney E Croul, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuropathologists, and Society for Neuroscience
Disclosure: Nothing to disclose.

Medical Editor

Norman C Reynolds Jr, MD, Neurologist, Veterans Affairs Medical Center of Milwaukee; Professor Medical College of Wisconsin (retired)
Norman C Reynolds Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, Movement Disorders Society, Sigma Xi, and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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