Meningitis (inflammation of the meninges): symptoms, causes, therapy

Brief overview

• What is meningitis? An inflammation of the membranes that surround the brain – not to be confused with encephalitis. However, both inflammations can occur simultaneously (as meningoencephalitis).
• Causes: Mostly viruses (TBE viruses, Coxsackie viruses, herpes viruses etc.) or bacteria (pneumococci, meningococci etc.). More rarely, other pathogens (such as fungi, protozoa), cancer or inflammatory diseases (such as sarcoidosis) are the cause of meningitis.
• Signs & Symptoms: flu-like complaints (such as high fever, headache and aching limbs, nausea and vomiting), painful neck stiffness, sensitivity to noise and light, possibly clouding of consciousness up to unconsciousness, possibly neurological deficits (such as speech and walking disorders) and epileptic seizures.
• Diagnosis: Taking a medical history (anamnesis), physical examination, blood sample, taking and analysis of cerebrospinal fluid (liquor puncture), computer tomography (CT), magnetic resonance imaging (MRT)
• Treatment: With bacterial meningitis antibiotics and possibly dexamthesone (a cortisone). In case of viral meningitis, symptomatic treatment (fever and painkillers) and possibly viral medication (antivirals).
• Prognosis: Untreated meningitis can become life-threatening within hours, especially bacterial meningitis. However, it can often be cured with early treatment. However, some patients suffer permanent damage (such as hearing loss).

Meningitis: Symptoms

In general, at the beginning of meningitis, symptoms similar to those of influenza appear. These include high fever, headaches, nausea and vomiting.

In the further course of the disease a painful neck stiffness (menigism) is added. It is a very typical meningitis symptom: the meninges are (in contrast to the brain) equipped with pain receptors. They therefore react to inflammation and irritation, as in meningitis, with pain. The neck also stiffens. The pain is particularly noticeable during head movements, because the meninges and spinal cords are slightly stretched. It hurts most when the chin is guided to the chest. The pain also causes the neck muscles to tense. It increases the stiffness of the neck.

Meninges and the brain itself can also be inflamed at the same time. This combination of meningitis and encephalitis is called meningoencephalitis.

The following is an overview of all the important meningitis symptoms in adults:

Meningitis: symptoms of bacterial meningitis

The symptoms of meningitis are particularly severe in bacterial meningitis: within hours, the initially mild symptoms can worsen massively and even lead to death! It is therefore vital to recognise the signs of bacterial meningitis at an early stage and to alert the doctor.

The first symptoms of meningitis appear here two to five days (in the case of meningococcus about two to ten days) after one has been infected with the bacteria. As with other forms of meningitis, it begins with unspecific, flu-like symptoms. In the course of hours or a few days a highly acute clinical picture can develop. Those affected usually have severe headaches, extreme neck stiffness and fever. Neurological deficits are also possible, such as clouding of consciousness and slurred speech.

Complications

A possible complication of meningococcal meningitis is “blood poisoning” (sepsis): large numbers of the bacteria flood the patient’s blood. In severe cases, this meningococcal sepsis (meningitis sepsis) can develop into the so-called Waterhouse-Friderichsen syndrome (especially in children and people without a spleen):

The meningococci carry harmful sugar chains (endotoxins) on their surface. When the bacteria decay, these toxins are released into the blood in large quantities. This triggers an uncontrolled blood clotting reaction in the body: Numerous blood clots (thrombi) form, which can clog smaller vessels. In addition, the massive clot formation means that the coagulation factors necessary for blood coagulation are used up (consumption coagulopathy). This can cause severe bleeding in the skin, mucous membranes and internal organs.

For example, small bleedings in the skin and mucous membrane, so-called petechiae, occur initially. At first, they only appear as pin-sized, red or brownish dots. These become larger and larger as they progress and look like “bruises”. Bleeding into internal organs also occurs, for example in the adrenal glands. They are severely damaged by this, so that they fail as hormone producers. Doctors then speak of adrenal weakness (adrenal insufficiency). The heavy bleeding causes the blood pressure to drop, a state of shock can develop and even a coma. The mortality rate for Waterhouse-Friderichsen syndrome is high!

The Waterhouse-Friderichsen syndrome can occur with various bacterial diseases. Most often, however, it is the result of meningococcal meningitis.

Meningitis: symptoms of viral meningitis

Meningitis caused by viruses is generally milder than bacterial meningitis. Signs appear for the first time about two to fourteen days after infection: flu-like symptoms, followed by a painful stiffness of the neck. In contrast to bacterial meningitis, the symptoms do not usually worsen within hours, but rather in the course of several days.

For people with a healthy immune system, the symptoms usually subside on their own within a few days. However, the recovery phase can take quite a long time. In smaller children the disease can also be severe. The same applies to people with a weakened immune system (for example, due to medication, cancer or infections such as HIV).

Meningitis: symptoms in infants and young children

Many infants and toddlers show very unspecific meningitis symptoms. The meningitis is then often difficult to diagnose, especially in the early stages of the disease.

The first signs of meningitis in infants and toddlers include fever, weakness in drinking and noticeable fatigue. The little patients are unusually irritable and apathetic. Later on, stomach aches, cramps and shrill screams may be added. The fontanel (a gap in the bone of the child’s skull covered with connective tissue and skin) may be bulging. The painful stiffness of the neck (meningismus), which is normally a typical sign of meningitis, is often absent in infants and babies.

Tip: Since meningitis symptoms can develop rapidly and become dangerous, especially in small children, you should consult a doctor if you have a vague suspicion of the disease.

Meningitis: Symptoms in special forms of meningitis

Special forms of meningitis include tuberculous meningitis (caused by tuberculosis bacteria) and meningitis in neuroborreliosis (caused by borreliosis bacteria). Both start slowly – above ground fever can be the only symptom of meningitis. Later, other signs of meningitis may be added, such as stiff neck and headaches.

Overall, these two special forms are very rare. However, they should be considered if the course of the disease is long lasting.

Meningitis: examinations and diagnosis

If meningitis is suspected, there is no time to lose. You must see a doctor without delay! Consult your family doctor, a pediatrician (for small patients), a neurologist or the emergency department of a hospital. Rapidly diagnosing and treating meningitis can save lives under certain circumstances!

An experienced doctor can make a diagnosis of meningitis based on the symptoms and the physical examination. However, it is essential to clarify whether it is a bacterial or viral meningitis. Because the treatment depends on it.

The most important steps in diagnosing meningitis are:

Medical history (anamnesis)

During the consultation, the doctor will first take your or your sick child’s medical history (anamnesis). Possible questions from the doctor are included:

• Do you currently have a cold (sore throat, cough, chronic cold)?
• Do headaches, fever and/or painful neck stiffness occur?
• Are any basic or previous illnesses known (HIV, sarcoidosis, borreliosis etc.)?
• Do you or your child take medication regularly?
• Do you or your child have an allergy to medication (for example, antibiotics)?
• Have you or your child had contact with other people with headaches, fever and neck stiffness?
• Have you or your child recently been abroad (for example, to an African country)?

Physical examination

During the physical examination the doctor will first check the classic signs of meningitis. To do this, he tries to guide the head of the patient lying on his back with his chin towards the chest. Painful neck stiffness (meningism) can be diagnosed. In addition, patients with this head tilt typically reflexively tighten their legs (Brudzinski’s sign) – an involuntary reaction to the pain caused by the slight stretching of the meninges and spinal cords when tilting the head. The Brudzinski sign is a good indication of meningitis).

Another sign of meningitis is when the sufferer cannot stretch the leg straight while sitting because it is too painful (Kernig sign).

The so-called Lasègue sign can also be conspicuous in meningitis: The doctor moves one stretched leg slowly upwards for each lying patient – he thus performs a hip joint flexion with the knee extended. If the patient feels pain shooting from the back into the leg (positive Lasègue sign), this indicates an irritation of the meninges.

The Lasègue sign is also positive in the case of a slipped disc.

Very important is also the exact examination of the patient’s entire skin. In severe bacterial meningitis, small bleedings on the skin (petechiae) may occur. They are an alarm signal for the doctor! He will immediately initiate further investigations and treatment. The bleedings initially look like small blue or brownish spots. In the course of time, these become larger stains and typically cannot be pushed away with a transparent object (glass) (glass test).

Further investigations

Through the anamnesis interview and the physical examination, the doctor can already assess whether meningitis is present that requires treatment. If there is even the slightest indication that it is indeed meningitis, the physician will arrange for further examinations. For example, if you have been to your family doctor or paediatrician first, you will usually be referred directly to a clinic. Because of the possible serious complications of meningitis, further examinations and treatment should be better carried out in hospital.

The first steps of further examinations in case of suspected meningitis are

1. Taking blood for blood cultures: So-called blood cultures can be used to try to detect and identify a pathogen – especially bacteria. The doctor can then select a suitable antibiotic for bacterial meningitis therapy that is effective against the type of bacteria in question.

2. Withdrawal of cerebrospinal fluid (cerebrospinal fluid puncture): During a cerebrospinal fluid puncture, a fine hollow needle is used to withdraw some cerebrospinal fluid (liquor) from the spinal canal at the level of the lumbar vertebrae. The whole procedure only takes a few minutes and is usually not felt to be particularly painful. The cerebrospinal fluid sample taken is examined in the laboratory for possible pathogens causing meningitis. If necessary, a computer tomography (CT) is carried out before the cerebrospinal fluid puncture in order to rule out an increased cerebral pressure. In the case of increased cerebral pressure, cerebrospinal fluid puncture should not be performed.

3. Computer tomography (CT) or magnetic resonance imaging (MRI): These imaging techniques provide further information about the state of the brain. Sometimes they can also provide clues as to where the pathogen originally came from (for example, from suppurated sinuses).

Meningitis: treatment

If meningitis is suspected, a rapid start of treatment can be decisive for the prognosis. Since it is difficult to predict how the disease will develop, it should always be treated in hospital. The most suitable hospital is one with a neurological department.

As soon as blood and spinal fluid have been drawn, the doctor starts antibiotic therapy – even if it is not yet known whether a bacterial meningitis is actually present. Playing it safe by administering antibiotics at an early stage, because bacterial meningitis can quickly become very dangerous.

The doctor uses broad-spectrum antibiotics (ceftriaxone, ampicillin, etc.) for treatment. These antibiotics are effective against many bacteria at the same time, including those most commonly responsible for bacterial meningitis. The antibiotics are usually administered as an infusion directly into a vein. This allows them to take effect quickly.

As soon as the actual pathogen has been determined on the basis of the blood and spinal fluid sample, the doctor will adjust the meningitis treatment accordingly: If it really is bacterial meningitis, the patient may be switched to other antibiotics that fight the causative bacteria better and more specifically. However, if it turns out that a virus is responsible for the meningitis, usually only the symptoms are treated.

Bacterial meningitis: Therapy

The antibiotic therapy described above can combat the cause of bacterial meningitis. In addition, the glucocorticoid (“cortisone”) dexamethasone is sometimes given. It has an anti-inflammatory effect. This can reduce mortality from pneumococcal meningitis, for example. In addition, combined treatment with antibiotics and dexamethasone may reduce the incidence of severe hearing loss in Haemophilus influenzae meningitis.

Should the dreaded Waterhouse-Friderichsen syndrome develop, treatment in the intensive care unit is necessary.

Specific measures for meningococcal meningitis

To reduce the risk of infection for others, the patient is placed in a single room and isolated from other patients. If necessary, the patient’s contact persons are given an antibiotic, for example rifampicin in tablet form, as a preventive measure: this is necessary for all people who had close contact with the patient about seven days before to ten days after the onset of the illness (family members, work colleagues, schoolmates, etc.). Meningococcal vaccination may also be useful for the contact persons if they have not been vaccinated as children.

Viral Meningitis: Therapy

In the case of viral meningitis, usually only the symptoms are treated. There are only a few viruses for which there are special drugs (antivirals) that can reduce the course of the disease. This applies, for example, to the group of herpes viruses (herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus) and the HIV virus (HIV).

In principle, the main aim of viral meningitis is to relieve symptoms. Bed rest as well as antipyretic and pain-relieving medication can help here. It may also be necessary to prevent an epileptic seizure with medication. If the disease progresses favourably, the patient can usually be discharged soon and further treatment can be given at home.

Meningitis of other cause: Therapy

If meningitis has causes other than bacteria or viruses, the trigger is treated accordingly whenever possible. For example, fungicides (antimycotics) are prescribed for meningitis caused by fungi. Worming agents (antihelmintics) are used against tapeworms. If sarcoidosis, cancer or another underlying disease is behind the meningitis, it is treated specifically.

Meningitis: course of the disease and prognosis

Meningitis is a potentially life-threatening disease. The prognosis depends, among other things, on which pathogen causes the meningitis and how quickly the patient is professionally treated.

Bacterial meningitis in particular is an emergency that must be treated with antibiotics as soon as possible. Untreated, it practically always ends fatally. However, if the treatment is carried out in time, there is a good chance that the patient will recover completely. The chances of complete recovery depend on the exact type of pathogen and the patient’s general state of health. For example, the prognosis for infants and sometimes for seniors is less favorable because their immune system is often not as powerful as in a healthy adult.

A viral meningitis is usually much less life-threatening than a bacterial meningitis. However, here too, the prognosis depends on the respective virus and the general physical condition. The first few days are particularly critical. If the affected person has survived these well, the chances of recovery are usually good. A viral meningitis then generally heals within several weeks without consequential damage.

Meningitis: Follows

In some cases, meningitis can result in permanent neurological damage. These include hearing damage, paralysis or impairment of the psyche or behaviour. Complications and long-term damage occur more frequently when the inflammation also spreads to the brain (meningoencephalitis).

Meningitis: Prevention

If you want to prevent meningitis, you should, if possible, protect yourself against infections with the most common pathogens (viruses and bacteria).

Bacterial meningitis: prevention through vaccination

The Permanent Vaccination Commission at the Robert Koch Institute (RKI) recommends various vaccinations for all children. This includes three vaccinations against common pathogens of bacterial meningitis: meningococcal vaccination, pneumococcal vaccination and Haemophilus influenzae type B vaccination. The immune system of small children is not yet fully developed and therefore cannot fend off pathogens so well. Therefore, these three vaccinations can significantly reduce the risk of bacterial meningitis:

Meningococcal vaccination

There are different subgroups (serogroups) of meningococcae. In Europe, meningococcal meningitis is usually caused by the serogroups B and C.

Meningococcal meningitis C is less common, but often severe and with complications (such as Waterhouse-Friderichsen syndrome). All children aged 2 years should therefore be vaccinated against meningococcal C. If this vaccination date is missed, the vaccination should be made up until the age of 18.

A completely new vaccine against the much more common meningococcal B meningitis has been available since the end of 2013. In infants it is administered in four vaccine doses. For older children two doses of vaccine are sufficient. To date, the STIKO does not have sufficient data to recommend this vaccination for all children. Currently, meningococcal B vaccination is therefore only advised for people with certain underlying diseases – in addition to the combined vaccination against meningococcae A, C, W and Y. These include, for example, people with a congenital or acquired immunodeficiency (for example, in the absence of a spleen) and laboratory staff at risk. The same applies to unvaccinated persons who live in the same household as patients who are experiencing a severe infection with one of the meningococcal serogroups concerned (A, B, C, W or Y).

Pneumococcus vaccination

Pneumococcus vaccination is recommended for all children. Three doses of vaccine are planned: the first dose should be given at the age of two months, the second dose at the age of four months. The third dose of vaccine should be administered six months later at the age of 11 to 14 months.

Haemophilus influenzae type B vaccination

Hib vaccination is also recommended for all children. It is administered in four vaccine doses – one dose each from the completed 2nd month of life, in the completed 3rd month of life, from the completed 4th month of life and at the end of the first year of life (11th to 14th month of life).

Viral meningitis: prevention through vaccination

Some forms of viral meningitis can also be prevented with a vaccination. The standard recommended vaccinations for all children are mumps vaccination, measles vaccination and rubella vaccination (usually administered in combination as MMR vaccination).

There is also a vaccine against early summer meningoencephalitis (TBE). This is a tick-borne viral inflammation of the meninges and brain. The STIKO recommends TBE vaccination to all people living or staying in TBE risk areas (e.g. on holiday) who could be bitten by ticks (through frequent or long stays in nature).

For a longer period of protection, a basic immunisation with three doses of vaccine is recommended. After three years, the TBE vaccination can be refreshed with a further dose. Thereafter, booster vaccinations at five-year intervals are recommended if combined meningitis and encephalitis caused by TBE viruses are to be prevented.