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Adults and Children The early clinical effects of acute bacterial meningitis are fever, severe headache, and stiffness of the neck (resistance to passive movement on forward bending), sometimes
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with generalized convulsions and a disorder of consciousness (ie, drowsiness, confusion, stupor, and coma) Flexion at the hip and knee in response to forward exion of the neck (Brudzinski sign) and inability to completely extend the legs (Kernig sign) have the same signi cance as stiff neck but are less consistently elicitable Basically, all of these signs are part of a exor protective re ex (one of the nocifensive responses in Fulton s terms) Stiffness of the neck that is part of paratonic or extrapyramidal rigidity should not be mistaken for that of meningeal irritation The former is more or less equal in all directions of movement, in distinction to that of meningitis, which is present only or predominantly on forward exion Whether it is stiffness in the initial few degrees of exion of the neck or in the subsequent part of the movement that is more speci c for meningitis has been debated; our experience has been that the latter is more sensitive but also proves to be mistaken for other disorders; therefore the rst may be more speci c for meningitis Diagnosis of meningitis may be dif cult when the initial manifestations consist only of fever and headache, when stiffness
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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
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30-day period of life It poses a number of special problems Infants, of course, cannot complain of headache, stiff neck may be absent, and one has only the nonspeci c signs of a systemic illness fever, irritability, drowsiness, vomiting, convulsions and a bulging fontanel to suggest the presence of meningeal infection Signs of meningeal irritation do occur, but only late in the course of the illness A high index of suspicion and liberal use of the lumbar puncture needle are the keys to early diagnosis Lumbar puncture is ideally performed before any antibiotics are administered for other neonatal infections An antibiotic regimen suf cient to control a septicemia may allow a meningeal infection to smolder and to are up after antibiotic therapy for the systemic infection has been discontinued A number of other facts about the natural history of neonatal meningitis are noteworthy It is more common in males than in females, in a ratio of about 3:1 Obstetric abnormalities in the third trimester (premature birth, prolonged labor, premature rupture of fetal membranes) occur frequently in mothers of infants who develop meningitis in the rst weeks of life The most signi cant factor in the pathogenesis of the meningitis is maternal infection (usually a urinary tract infection or puerperal fever of unknown cause) The infection in both mother and infant is most often due to gram-negative enterobacteria, particularly E coli, and group B streptococci and less often to Pseudomonas, Listeria, Staph aureus or epidermidis (formerly albus), and group A streptococci Analysis of postmortem material indicates that in most cases infection occurs at or near the time of birth, although clinical signs of meningitis may not become evident until several days or a week later In infants with meningitis, one should be prepared to nd a unilateral or bilateral sympathetic subdural effusion regardless of bacterial type Young age, rapid evolution of the illness, low polymorphonuclear cell count, and markedly elevated protein in the CSF correlate to some extent with the formation of effusions, according to Snedeker and coworkers Also, these attributes greatly increase the likelihood of the meningitis being associated with neurologic signs Transillumination of the skull is the simplest method of demonstrating the presence of an effusion, but computed tomography (CT) and magnetic resonance imaging (MRI) are the de nitive diagnostic tests When aspirated, most of the effusions prove to be sterile If recovery is delayed and neurologic signs persist, a succession of aspirations is required In our experience and that of others, patients in whom meningitis is complicated by subdural effusions are no more likely to have residual neurologic signs and seizures than are those without effusions
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