Bacterial meningitis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

The differential diagnosis of bacterial meningitis includes two step approach. First is differentiating bacterial meningitis from other diseases which have similar clinical presentation as bacterial meningitis such as encephalitis, brain abscess, subarachnoid hemorrage, and brain tumour. Second step involves CSF examination and differentiating bacterial meningitis from viral, fungal and other causes of meningitis.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]

Differential diagnosis

Bacterial meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]

Differentiating bacterial meningitis from other diseases

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
Na+, K+, Ca2+ CT /MRI CSF Findings Gold standard test Neck stiffness Motor or Sensory deficit Papilledema Bulging fontanelle Cranial nerves Headache Fever Altered mental status
Brain tumour[2][3] ✔ Cancer cells[4] MRI ✔ ✔ ✔ ✔ ✔ ✔ Cachexia, gradual progression of symptoms
Delerium Tremens ✔ Clinical diagnosis ✔ ✔ ✔ ✔ ✔ ✔ Alcohal intake, sudden witdrawl or reduction in consumption Tachycardia, diaphoresis, hypertension, tremors, mydriasis, positional nystagmus, tachypnea
Subarachnoid hemorrhage[17] ✔ Xanthochromia[5] CT scan without contrast[7][8] ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Trauma/fall Confusion, dizziness, nausea, vomiting
Stroke ✔ Normal CT scan without contrast ✔ ✔ ✔ ✔ ✔ TIAs, hypertension, diabetes mellitus Speech difficulty, gait abnormality
Neurosyphilis[18][19] ✔ ↑ Leukocytes and protein CSF VDRL-specifc

CSF FTA-Ab -sensitive[20]

✔ ✔ ✔ ✔ ✔ ✔ Unprotected sexual intercourse, STIs Blindness, confusion, depression,

Abnormal gait

Viral encephalitis ✔ Increased RBCS or xanthochromia, mononuclear lymphocytosis, high protein content, normal glucose Clinical assesment ✔ ✔ ✔ ✔ ✔ ✔ ✔ Tick bite/mosquito bite/ viral prodome for several days Extreme lethargy, rash hepatosplenomegaly, lymphadenopathy, behavioural changes
Herpes simplex encephalitis ✔ Clinical assesment ✔ ✔ ✔ ✔ ✔ History of hypertension Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy Normal ✔ ✔ ✔ History of alcohal abuse Ophthalmoplegia, confusion
CNS abscess ✔ ↑ leukocytes >100,000/ul, ↓ glucose and ↑ protien, ↑ red blood cells, lactic acid >500mg Contrast enhanced MRI is more sensitive and specific,

Histopathological examination of brain tissue

✔ ✔ ✔ ✔ ✔ ✔ ✔ History of drug abuse, endocarditis, ↓ immune status High grade fever, fatigue,nausea, vomiting
Drug toxicity ✔ ✔ Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder Diagnosis of exclusion ✔ ✔ ✔ ✔ ✔ Tremors, blindness, difficulty swallowing
Electrolyte disturbance ↓ or ↑ Depends on the cause ✔ ✔ Confusion, seizures
Febrile seizures Not performed in first simple febrile seizures Clinical diagnosis and EEG ✔ ✔ ✔ ✔ Family history of febrile seizures, viral illness or gastroenteritis Age > 1 month,
Subdural empyema ✔ Clinical assesment and MRI ✔ ✔ ✔ ✔ ✔ ✔ History of relapses and remissions Blurry vision, urinary incontinence, fatigue
Hypoglycemia ↓ or ↑ Serum blood glucose

HbA1c

✔ ✔ ✔ History of diabetes Palpitations, sweating, dizziness, low serum, glucose

Differentiating bacterial meningitis from other causes of meningitis

Cerebrospinal fluid level Normal level Bacterial meningitis Viral meningitis Fungal meningitis Tuberculous meningitis Malignant meningitis
Cells/ul
Cells
Total protein (mg/dl)
Glucose ratio (CSF/plasma)
Lactate (mmols/l)
Others
Cerebrospinal Fluid
Normal Levels Acute Bacterial M. Acute Viral M. TB M. Neuroborreliosis
Cells/ul < 5 In the 1000s In the 100s In the 100s Some 100
Cells Lymph:Monos 7:3 Gran. > Lymph. Lymph. > Gran. Various leukos Lymph. monocytic
Total Protein (mg/dl) 45-60 Typically 100-500 Typically normal Typically 100-200 Typically up to 350
Glucose Ratio (CSF/plasma) Typically > 0.5 < 0.3 > 0.6 < 0.5 Normal
Lactate (mmol/l) < 2.1 > 2.1 < 2.1 > 2.1 -
Others ICP: 6-22 (cm H2O) PCR of HSV-DNA PCR of TBC-DNA IgG/IgM
CSF/Serum Ratio
CSF finding in different conditions[21]
Condition Glucose Protein Cells
Acute bacterial meningitis Low high high, often > 300/mm³
Acute viral meningitis Normal normal or high mononuclear, < 300/mm³
Tuberculous meningitis Low high pleocytosis, mixed < 300/mm³
Fungal meningitis Low high < 300/mm³
Malignant meningitis Low high usually mononuclear
Subarachnoid haemorrhage Normal normal, or high Erythrocytes

References

  1. ↑ 1.0 1.1 Stern TA, Celano CM, Gross AF, Huffman JC, Freudenreich O, Kontos N; et al. (2010). "The assessment and management of agitation and delirium in the general hospital". Prim Care Companion J Clin Psychiatry. 12 (1): PCC.09r00938. doi:10.4088/PCC.09r00938yel. PMC 2882819. PMID 20582303.
  2. ↑ 2.0 2.1 2.2 Soffer D (1976) Brain tumors simulating purulent meningitis. Eur Neurol 14 (3):192-7. PMID: 1278192
  3. ↑ 3.0 3.1 3.2 Terheggen HG (1985) [CNS tumors with the clinical picture of meningitis.] Monatsschr Kinderheilkd 133 (1):13-9. PMID: 3883130
  4. ↑ 4.0 4.1 4.2 Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
  5. ↑ 5.0 5.1 5.2 Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
  6. ↑ 6.0 6.1 Han JH, Wilber ST (2013). "Altered mental status in older patients in the emergency department". Clin Geriatr Med. 29 (1): 101–36. doi:10.1016/j.cger.2012.09.005. PMC 3614410. PMID 23177603.
  7. ↑ 7.0 7.1 7.2 Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
  8. ↑ 8.0 8.1 8.2 DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
  9. ↑ 9.0 9.1 Stein MT, Trauner D (1982). "The child with a stiff neck". Clin Pediatr (Phila). 21 (9): 559–63. PMID 7105615.
  10. ↑ 10.0 10.1 De Cauwer HG, Eykens L, Hellinckx J, Mortelmans LJ (2007). "Differential diagnosis between viral and bacterial meningitis in children". Eur J Emerg Med. 14 (6): 343–7. doi:10.1097/MEJ.0b013e328270366b. PMID 17968200.
  11. ↑ 11.0 11.1 Spanos A, Harrell FE, Durack DT (1989). "Differential diagnosis of acute meningitis. An analysis of the predictive value of initial observations". JAMA. 262 (19): 2700–7. PMID 2810603.
  12. ↑ 12.0 12.1 Lindquist L, Linné T, Hansson LO, Kalin M, Axelsson G (1988). "Value of cerebrospinal fluid analysis in the differential diagnosis of meningitis: a study in 710 patients with suspected central nervous system infection". Eur J Clin Microbiol Infect Dis. 7 (3): 374–80. PMID 3137038.
  13. ↑ 13.0 13.1 Naganuma M, Fujioka S, Inatomi Y, Yonehara T, Hashimoto Y, Hirano T; et al. (2008). "Clinical characteristics of subarachnoid hemorrhage with or without headache". J Stroke Cerebrovasc Dis. 17 (6): 334–9. doi:10.1016/j.jstrokecerebrovasdis.2008.04.009. PMID 18984423.
  14. ↑ 14.0 14.1 Rajnik M, Ottolini MG (2000). "Serious infections of the central nervous system: encephalitis, meningitis, and brain abscess". Adolesc Med. 11 (2): 401–25. PMID 10916131.
  15. ↑ 15.0 15.1 Tyler KL (2004). "Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret's". Herpes. 11 Suppl 2: 57A–64A. PMID 15319091.
  16. ↑ 16.0 16.1 Kennedy PG (2004). "Viral encephalitis: causes, differential diagnosis, and management". J Neurol Neurosurg Psychiatry. 75 Suppl 1: i10–5. PMC 1765650. PMID 14978145.
  17. ↑ Yeh ST, Lee WJ, Lin HJ, Chen CY, Te AL, Lin HJ (2003) Nonaneurysmal subarachnoid hemorrhage secondary to tuberculous meningitis: report of two cases. J Emerg Med 25 (3):265-70. PMID: 14585453
  18. ↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
  19. ↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
  20. ↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
  21. ↑ Provan, Drew (2005). Oxford Handbook of clinical and laboratory investigation. Oxford: Oxford university press. ISBN 0198566638. Unknown parameter |coauthors= ignored (help)


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