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The classic triad of meningitis consists of fever, nuchal rigidity, and altered mental status, but not all
patients have all 3, and almost all patients have headache. Altered mental status can range from irritability
to somnolence, delirium, and coma. The examination reveals no focal neurologic deficits in the majority of
cases. Furthermore, the majority of patients with bacterial meningitis have a stiff neck, but the meningeal
signs are insensitive for diagnosis of meningitis.[13]
Acute bacterial meningitis in otherwise healthy patients who are not at the extremes of age presents in a
clinically obvious fashion. In contrast, most patients with subacute bacterial meningitis pose a diagnostic
challenge. Systemic examination occasionally reveals a pulmonary or otitis media coinfection.
Systemic findings can also be present. Extracranial infection (eg, sinusitis, otitis media, mastoiditis,
pneumonia, or urinary tract infection [UTI]) may be noted. Endotoxic shock with vascular collapse is
characteristic of severe N meningitidis(meningococcal) infection.
General physical findings in viral meningitis are common to all causative agents, but some viruses
produce unique clinical manifestations that help focus the diagnostic approach. Enteroviral infection is
suggested by the presence of the following:
Exanthemas
Symptoms of pericarditis, myocarditis, or conjunctivitis
Syndromes of pleurodynia, herpangina, and hand-foot-and-mouth disease
Increased blood pressure with bradycardia can also be present. Vomiting occurs in 35% of patients.
Nonblanching petechiae and cutaneous hemorrhages may be present in meningitis caused by N
meningitidis (50%), H influenzae, S pneumoniae, or S aureus.[14] Arthritis is seen with meningococcal
infection and with M pneumoniaeinfection but is less common with other bacterial species.
Infants
Infants may have the following:
Chronic meningitis
It is essential to perform careful general, systemic, and neurologic examinations, looking especially for the
following:
Lymphadenopathy
Papilledema and tuberculomas during funduscopy
Meningismus
Cranial nerve palsies
Tuberculous meningitis
The presentation of chronic tuberculous meningitis may be acute, but the classic presentation is subacute
and spans weeks. Patients generally have a prodrome consisting of fever of varying degrees, malaise,
and intermittent headaches. Cranial nerve palsies (III, IV, V, VI, and VII) often develop, suggesting basilar
meningeal involvement.
Clinical staging of tuberculous meningitis is based on neurologic status, as follows:
Headache is the most common symptom of Lyme diseaseassociated chronic meningitis, with
photophobia, nausea, and neck stiffness occurring less frequently. Somnolence, emotional lability, and
impaired memory and concentration may occur. Facial nerve palsy is the most common cranial nerve
deficit. These symptoms of meningitis usually fluctuate and may last for months if left untreated.
Fungal meningitis
Meningitis from C neoformans usually develops in patients with defective cell-mediated immunity
(see CNS Cryptococcosis in HIV). It is characterized by the gradual onset of symptoms, the most
common of which is headache.
Coccidioidal meningitis is the most serious form of disseminatedcoccidioidomycosis; it usually is fatal if
left untreated. These patients may present with headache, vomiting, and altered mental function
associated with pleocytosis, elevated protein levels, and decreased glucose levels. Eosinophils may be a
prominent finding on CSF analysis.
Patients infected with B dermatitidis may present with an abscess or fulminant meningitis. Patients
infected with H capsulatum may present with headache, cranial nerve deficits, or changes in mental
status months before diagnosis.
Aseptic meningitis
In contrast to patients with bacterial meningitis, patients with aseptic meningitis syndrome usually appear
clinically nontoxic, with no vascular instability. (SeeAseptic Meningitis.) In many cases, a cause for
meningitis is not apparent after initial evaluation, and the condition is therefore classified as aseptic
meningitis. These patients characteristically have an acute onset of meningeal symptoms, fever, and CSF
pleocytosis that is usually prominently lymphocytic.
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