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of the neck has not yet developed, or when there is only pain in the neck or abdomen or a febrile confusional state or delirium Also, stiffness of the neck may not be apparent in the deeply stuporous or comatose patient or in the infant or the elderly, as indicated further on The symptoms comprised by the meningitic syndrome are common to the three main types of bacterial meningitis, but certain clinical features and the setting in which each of them occurs correlate more closely with one type than another Meningococcal meningitis should be suspected when the evolution is extremely rapid (delirium and stupor may supervene in a matter of hours), when the onset is attended by a petechial or purpuric rash or by large ecchymoses and lividity of the skin of the lower parts of the body, when there is circulatory shock, and especially during local outbreaks of meningitis Since a petechial rash accompanies approximately 50 percent of meningococcal infections, its presence dictates immediate institution of antibiotic therapy, even though a similar rash may be observed with certain viral (echovirus serotype 9 and some other enteroviruses) as well as Staph aureus infections and rarely with other bacterial meningitides Pneumococcal meningitis is often preceded by an infection in the lungs, ears, sinuses, or heart valves In addition, a pneumococcal etiology should be suspected in alcoholics, in splenectomized patients, in the very elderly, and in those with recurrent bacterial meningitis, dermal sinus tracts, sickle cell anemia ( autosplenectomized ), and basilar skull fracture On the other hand, H in uenzae meningitis usually follows upper respiratory and ear infections in the child Other speci c bacterial etiologies are suggested by particular clinical settings Meningitis in the presence of furunculosis or following a neurosurgical procedure should direct attention to the possibility of a coagulase-positive staphylococcal infection Ventriculovenous shunts, inserted for the control of hydrocephalus, are particularly prone to infection with coagulase-negative staphylococci HIV infection, myeloproliferative or lymphoproliferative disorders, defects in cranial bones (tumor, osteomyelitis), collagen diseases, metastatic cancer, and therapy with immunosuppressive agents are clinical conditions that favor invasion by such pathogens as Enterobacteriaceae, Listeria, A calcoaceticus, Pseudomonas, and occasionally by parasites Focal cerebral signs in the early stages of the disease, although seldom prominent, are most frequent in pneumococcal and H in uenzae meningitides Some of the transitory focal cerebral signs may represent postictal phenomena (Todd s paralysis); others may be related to an unusually intense focal meningitis for example, purulent material collected in one sylvian ssure Seizures are encountered most often with H in uenzae meningitis Although this has happened most often in infants and children, it is dif cult to judge the signi cance, since young children may convulse with fever of any cause Persistent focal cerebral lesions or intractable seizures usually develop in the second week of the meningeal infection and are caused by an infectious vasculitis, as described earlier usually with occlusion of surface cerebral veins and consequent infarction of cerebral tissue Cranial nerve abnormalities are particularly frequent with pneumococcal meningitis, the result of invasion of the nerve by purulent exudate and possibly ischemic damage as the nerve traverses the subarachnoid space Infants and Newborns Acute bacterial meningitis during the rst month of life is said to be more frequent than in any subsequent. ean 128 parser c# EAN-128 C# DLL - Create EAN-128 barcodes in C# with valid data
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