Core EM - Emergency Medicine Podcast

Episode 219: Meningitis 2.0

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We review diagnosing and managing bacterial meningitis in the ED.

Hosts:

Sarah Fetterolf, MD
Avir Mitra, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Meningitis_2_0.mp3
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Tags: CNS Infections, Infectious Diseases, Neurology
Show Notes
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  • Curriculum: Comprehensive coverage of Core Emergency Medicine,  with 12 modules spanning from Critical Care to Pediatrics.
  • Cost:
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      Patient Presentation & Workup
      • Patient: 36-year-old male, currently shelter-domiciled, presenting with 3 weeks of generalized weakness, fevers, weight loss, and headaches.
      • Vitals (Initial): BP 147/98, HR 150s, Temp 100.2°F, RR 18, O2 99% RA.
      • Clinical Evolution: Initial assessment noted cachexia and a large ventral hernia. Following initial workup, the patient became acutely altered (A&O x0) and febrile to 102.9°F.
      • Physical Exam Findings:
        • Brudzinski Sign: Positive (knees flexed upward upon passive neck flexion).
        • Kernig Sign: Discussed as highly specific (resistance/pain during knee extension with hip flexed at 90°).
        • Meningeal Triad: Fever, nuchal rigidity, and AMS (present in 40% of cases; 95% of patients have at least two of the four cardinal symptoms including headache).
        • Imaging:
          • Chest X-ray: Scattered opacities (pneumonia) and a small pneumothorax.
          • CT Abdomen/Pelvis: Confirmed asplenia (secondary to 2011 GSW/exploratory laparotomy).
          • Head CT: Ventricle enlargement concerning for obstructive hydrocephalus and diffuse sulcal effacement.
            • CSF Analysis & Microbiology
            • Bacterial Meningitis
              • Opening Pressure: Elevated (Normal is <170 mm H2​O).
              • Color: Cloudy or turbid.
              • Gram Stain: Positive in 60%–80% of cases before antibiotics; drops to 7%–41% after antibiotics.
              • Cell Count: Very high (>1000–2000/mm3 WBC); dominated by neutrophils (>80% PMN).
              • Glucose: Low (<40 mg/dL); CSF/blood glucose ratio is <0.3–0.4.
              • Protein: High (>200 mg/dL).
              • Cytology: Negative.
              • Viral Meningitis
                • Opening Pressure: Normal.
                • Color: Clear or bloody.
                • Gram Stain: Negative.
                • Cell Count: Slightly elevated (<300/mm3 WBC); dominated by lymphocytes (<20% PMN).
                • Glucose: Normal.
                • Protein: Moderately elevated (<200 mg/dL).
                • Cytology: Negative.
                • Fungal Meningitis
                  • Opening Pressure: Normal to elevated.
                  • Color: Clear or cloudy.
                  • Gram Stain: Negative.
                  • Cell Count: Elevated (<500/mm3 WBC).
                  • Glucose: Normal to slightly low.
                  • Protein: High (>200 mg/dL).
                  • Cytology: Negative.
                  • Neoplastic (Cancer-related) Meningitis
                    • Opening Pressure: Normal.
                    • Color: Clear or cloudy.
                    • Gram Stain: Negative.
                    • Cell Count: Elevated (<300/mm3 WBC).
                    • Glucose: Normal to slightly low.
                    • Protein: High (>200 mg/dL).
                    • Cytology: Positive (this is the key differentiator).
                      • Management Protocol
                      • Immediate Treatment: Early administration of antibiotics/antivirals is critical to reduce mortality.
                        • Antibiotics: Ceftriaxone 2g IV q12h + Vancomycin (or Rifampin in cephalosporin-resistant areas).
                        • Listeria Coverage: Add Ampicillin for patients > 50 years old.
                        • Antivirals: Acyclovir 10 mg/kg q8h.
                        • Steroids: Dexamethasone 10 mg IV q6h for 4 days (proven to reduce mortality and improve outcomes).
                        • Surgical Intervention: Neurosurgery performed an emergent EVD in the ED to relieve pressure from obstructive hydrocephalus.
                        • Post-Exposure Prophylaxis: Indicated only for N. meningitidis (not S. pneumoniae) for contacts < 24 hours from diagnosis.
                          • Regimens: Rifampin for 2 days, single-dose Ciprofloxacin, or IM Ceftriaxone (if pregnant).
                            • Stats & Clinical Pearls: Austrian Syndrome
                            • The Triad: Concurrent pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae.
                            • Risk Factors: Asplenia (due to the spleen’s role in filtering encapsulated bacteria), alcohol use disorder, and immunosuppression.
                            • Mortality Rate: Extremely high at 28%; mortality is highest when there is CNS involvement.
                            • Incidence: Worldwide, S. pneumoniae is the leading cause of bacterial meningitis, accounting for 3,000–6,000 cases annually.

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