Failure To Diagnose Meningitis

Meningitis is an inflammation of the meninges (i.e., the pia, arachnoid and dura mater), which are the membranes that cover the brain and the spinal cord.  In most cases, the inflammation is due to a virus, bacteria, microorganism (e.g., fungi or parasite), or drug.  If left untreated, meningitis can be fatal - especially in infants.

The types of bacteria that cause meningitis depend upon the age group.  For newborns, the most common bacterial agents are group B streptococci (which may inhabit the vagina and pass to a baby during childbirth), Escherichia coli and Lysteria monocytogenes.  Older children and adults are more often affected by Neisseria meningitidis (meningococcus) and Streptococcus pneumoniae. 

Aseptic meningitis is a diagnosis attached to a meningeal infection that cannot be attributed to a bacteria.  Cases of aseptic meningitis are usually caused by a virus, or a bacterial condition that has partially resolved.  Viruses known to cause meningitis include: enteroviruses, herpes simplex type 2, varicella zoster, mumps and HIV.  Endocarditis may also cause aseptic meningitis.  Other potential causes for meningitis include trauma that enables organisms to invade the bloodstream, head trauma that puts the meninges into direct contact with the nasal cavity or skin, and parasites in the cerebral spinal fluid.

In adults, signs and symptoms of meningitis include:
  • severe headache;
  • neck stiffness (nuchal rigidity);
  • high fever (rapid onset);
  • photophobia;
  • phonophobia;
  • altered mental status;
  • positive Kernig's sign; and
  • positive Brudzinski's sign.
In infants, signs and symptoms of meningitis are less obvious, but may include:
  • bulging fontanel;
  • high fever;
  • abnormal skin color;
  • seizure activity;
  • inconsolable crying; and
  • high-pitched shriek.
Prompt diagnosis of meningitis, including the type of meningitis, is critical because it is well-known that a delay in treatment is associated with a poor outcome.  Typically, a blood test is ordered to identify markers of inflammation (e.g., C-reactive protein).  A blood culture and, where appropriate (and not contraindicated), a lumbar puncture may also be ordered.  While laboratory studies are being performed, a physician (most often an emergency room physician) should order the administration of wide-spectrum antibiotics to prevent harm from progression of the disease, e.g., death, hearing loss, epilepsy, decreased intelligence and behavioral difficulties. 

Treatment for meningitis depends on the type of inflammation.  Generally, viral meningitis does not respond to specific treatments.  It is commonly treated at home with fluid and bed rest.  Whereas, bacterial meningitis is treated by empiric antibiotics (e.g. cefalosporin, cefotaxime, vancomycin) and adjuvant treatment with corticosteroids (e.g., dexamathasone) to mitigate inflammation.

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