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Other Laboratory Findings In addition to CSF cultures, blood cultures should be obtained because they are positive in 40 to 60 percent of patients with H in uenzae, meningococcal, and pneumococcal meningitis, and they may provide the only de nite clue as to the causative agent Routine cultures of the oropharynx are as often misleading as they are helpful, because pneumococci, H in uenzae, and meningococci are common inhabitants of the throats of healthy persons In contrast, cultures of the nasopharynx may aid in diagnosis, though often not in a timely way; the nding of encapsulated H in uenzae or groupable meningococci may provide the clue to the etiology of the meningeal infection Conversely, the absence of such a nding prior to antibiotic treatment makes an H in uenzae and meningococcal etiology unlikely The leukocyte count in the blood is generally elevated, and immature forms are usually present Meningitis may be complicated after several days by severe hyponatremia, the result of inappropriate secretion of antidiuretic hormone (ADH) Radiologic Studies In patients with bacterial meningitis, chest lms are essential because they may disclose an area of pneumonitis or abscess Sinus and skull lms may provide clues to the presence of cranial osteomyelitis, paranasal sinusitis, mastoiditis, or cranial osteomyelitis, but these structures are better visualized on CT scans, which have supplanted conventional lms in most cases The CT scan is particularly useful in detecting lesions that erode the skull or spine and provide a route for bacterial invasion, such as tumors or sinus wall defects, as well as in demonstrating a brain abscess or subdural empyema MRI with gadolinium enhancement may display the meningeal exudate and cortical reaction, and both types of imaging, with appropriate techniques, will demonstrate venous occlusions and adjacent infarctions

performed after the acute infection has subsided Persistence of CSF rhinorrhea usually requires surgical repair

.

The diagnosis of bacterial meningitis is not dif cult provided that one maintains a high index of suspicion Febrile patients with lethargy, headache, or confusion of sudden onset even those with low-grade fever should generally be subjected to lumbar puncture if no alternative explanation for the state is evident It is particularly important to recall the possibility of meningitis in drowsy, febrile, and septic patients in an intensive care unit when no obvious source of fever is apparent Overwhelming sepsis itself, or the multiorgan failure that it engenders, may cause an encephalopathy, but if there is a meningitis, it is imperative, in deciding on the choice of antibiotics, to identify it early The same can be said for the confused alcoholic patient Too often the symptoms are ascribed to alcohol intoxication or withdrawal, or to hepatic encephalopathy, until examination of the CSF reveals a meningitis Although this approach undoubtedly results in many negative spinal uid examinations, it is preferable to the consequence of overlooking a bacterial meningitis Viral meningitis (which is far more common than bacterial meningitis), subarachnoid hemorrhage, chemical meningitis (following lumbar puncture, spinal anesthesia, or myelography), and tuberculous, leptospiral, sarcoid, and fungal meningoencephalitis enter into the differential diagnosis as well, as discussed in later sections A number of nonbacterial meningitides must be considered in the differential diagnosis when the meningitis recurs repeatedly and all cultures are negative Included in this group are Epstein-Barr virus (EBV) infections; Behcet disease, which is characterized by recurrent oropharyngeal mucosal ulceration, uveitis, orchitis, and meningitis; so-called Mollaret meningitis, which consists of recurrent episodes of fever and headache in addition to signs of meningeal irritation (due in many cases to herpes simplex, as discussed in Chap 33); and the Vogt-Koyanagi-Harada syndrome, in which recurrent meningitis is associated with iridocyclitis and depigmentation of the hair and skin The CSF in these recurrent types may contain large numbers of lymphocytes or polymorphonuclear leukocytes but no bacteria, and the glucose content is not reduced (see discussion of chronic and recurrent meningitis on page 635) Carcinomatous and lymphomatous meningitis, discussed in Chap 31, rarely present in the fulminant manner of bacterial meningitis, but sometimes they do, and the CSF formulas can be similar Rarely, a fulminant case of cerebral angiitis or intravascular lymphoma will present with headache, fever, and confusion in conjunction with a meningeal in ammatory reaction The other intracranial suppurative diseases and their differentiation from bacterial meningitis are considered further on in this chapter.

TABLE 8-2

This is observed most frequently in patients who have had some type of ventriculovenous shunting procedure for the treatment of hydrocephalus or who have an incompletely closed dural opening after surgery When the origin of the recurrence is inapparent, one should always suspect a congenital neuroectodermal sinus or a stulous connection between the nasal sinuses and the subarachnoid space The stula in these latter cases is more often traumatic than congenital in origin (eg, a previous basilar skull fracture), although the interval between injury and the initial bout of meningitis may be several years The site of trauma is in the frontal or ethmoid sinuses or the cribriform plate, and Strep pneumoniae is the usual pathogen Often it re ects the predominance of such strains in nasal carriers These cases usually have a good prognosis; mortality is much lower than in ordinary cases of pneumococcal meningitis CSF rhinorrhea is present in most cases of posttraumatic meningitis, but it may be transient and dif cult to nd Suspicion of its presence is raised by the recent onset of anosmia or by the occurrence of a watery nasal discharge that is salty to the taste and increases in volume when the head is dependent One way of con rming the presence of a CSF leak is to measure the glucose concentration of nasal secretions; ordinarily they contain little glucose, but in CSF rhinorrhea the amount of glucose approximates that obtained by lumbar puncture (two-thirds of the serum value) The site of a CSF leak can sometimes be demonstrated by injecting a dye, radioactive albumin, or water-soluble contrast material into the spinal subarachnoid space and detecting its appearance in nasal secretions or its site of exit by CT scanning This testing is best

Bacterial meningitis is a medical emergency The rst therapeutic measures are directed to sustaining blood pressure and treating septic shock (volume replacement, pressor therapy) A premium is then placed on choosing an antibiotic that is known both to be bactericidal for the suspected organism and is able to enter the CSF in effective amounts Treatment should begin while awaiting the results of diagnostic tests and may be altered later in accordance with the laboratory ndings Whereas penicillin formerly suf ced