Meningococcal Meningitis Workup

  • Author: Francisco de Assis Aquino Gondim, MD, MSc, PhD; Chief Editor: Karen L Roos, MD   more...
 
Updated: Oct 17, 2011
 

Approach Considerations

Laboratory examination of the cerebrospinal fluid (CSF) usually confirms the presence of meningitis.

Perform a neuroimaging study (either magnetic resonance imaging [MRI] or computed tomography [CT] scanning) prior to lumbar puncture in all patients in whom meningitis is suspected.

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CSF Examination

Typical CSF abnormalities in meningitis include the following:

  • Increased opening pressure (>180 mm water)
  • Pleocytosis of polymorphonuclear leukocytes (white blood cell [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 etiologic 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.

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Polymerase Chain Reaction

The polymerase chain reaction (PCR)[10] may be used to complement standard laboratory procedures for the diagnosis of meningococcal meningitis.[11] The IS1106 PCR is a rapid and sensitive test for confirmation of the diagnosis; its sensitivity is not affected by prior antibiotic treatment.[12] PCR of the nspA gene was also reported to be a fast diagnostic test.[13]

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CT Scanning and MRI

CT scan findings are usually normal. However, imaging is an important cause of delay of therapy.

Indications for performing CT scanning prior to lumbar puncture include altered level of consciousness, papilledema, focal neurological deficits, and/or focal or generalized seizure activity. Intracerebral hemorrhage foci and diffuse edema are seen below in a patient with meningitis.

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.

MRI with contrast is preferred to CT scanning, 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 with MRI include hydrocephalus, aqueductal obstruction, ventriculitis (especially in neonates), choroid plexitis, subdural effusion, and empyema.

Head CT demonstrates enlargement of the temporal hHead 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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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. The image below shows purulent exudate in the leptomeninges.

Grossly purulent exudate is seen in the leptomeninGrossly purulent exudate is seen in the leptomeninges.
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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.

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Contributor Information and Disclosures
Author

Francisco de Assis Aquino Gondim, MD, MSc, PhD  Associate Professor of Neurology, Department of Neurology and Psychiatry, St Louis University School of Medicine

Francisco de Assis Aquino Gondim, MD, MSc, PhD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Movement Disorders Society

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

Norman C Reynolds Jr, MD  Neurologist, Veterans Affairs Medical Center of Milwaukee; Clinical Professor, Medical College of Wisconsin

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

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: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Karen L Roos, MD  John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine

Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Sidney E Croul, MD, to the development and writing of the source article.

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. 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].

  5. 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].

  6. 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].

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

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. 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].

  13. 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].

  14. 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].

  15. 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].

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

  17. [Guideline] CDC. Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. Jan 28 2011;60(3):72-6. [Medline]. [Full Text].

  18. [Guideline] CDC. Recommendation of the Advisory Committee on Immunization Practices (ACIP) for Use of Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D) Among Children Aged 9 Through 23 Months at Increased Risk for Invasive Meningococcal Disease. MMWR Morb Mortal Wkly Rep. Oct 14 2011;60:1391-2. [Medline]. [Full Text].

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

  20. 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].

 
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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 (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.
Grossly purulent exudate is seen in the leptomeninges.
 
 
 
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