- Always think of this diagnosis in patients with Fever + headache or Fever + altered mental status. The ABSENCE of fever+neck stiffness+altered LOC has high sensitivity (ie none of these 3 = no meningitis). Also in this JAMA rational Clinical exam paper much is made of the jolt accentuation (worsening headache when shaking head side to side at 1Hz). However, the evidence for this comes from only one small study. When considering this serious diagnosis an LP is required to rule out!
- Look at the Tangents TWH Blog for some recommendations on LP!
- Common organisms include Steptococcus pneumoniae, Neisseria meningitidis. In older adults also consider Listeria. Contrary to some sources older adults seem to present quite typically. Given the epidemiology, in those over 50 y/o with community acquired meningitis we treat empirically with Ceftriaxone 2g iv q12h (for Neisseria and sensitive pneumococci), Vanco 1.5-2g iv q12h (for resistant pneumococci) and Ampicillin 2g iv q4h (for Listeria). Note the high doses for CSF penetration.
- Adjunctive steroids are recommended, chiefly based on this trial and this metanalysis. But interestingly a 2010 Cochrane Metanalysis puts this recommendation into question, perhaps more so in developing countries.
- Lastly, with Neisseria meningitis always think of the public health implications.
Cheers
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