Meningitis and Encephalitis

  • Vasudha Singhal
  • Prasanna Udupi Bidkar


A 26-year-old male presented to the emergency department (ED) with a history of headache and fever since the past 1 day, and altered sensorium for the past 6 h. His past medical history revealed a history of sinusitis. On physical examination, the patient was confused, with a stiff neck, but no focal neurological deficits. His vitals revealed a heart rate of 102 beats/min, blood pressure 106/64 mmHg, respiratory rate 26/min, SpO2 99%, and temperature 38.8 °C. On arrival in the ED, the patient was resuscitated with iv fluids, antipyretics were administered for temperature control, and blood samples were sent for routine laboratory investigations, along with blood cultures. A shot of dexamethasone 10 mg iv was administered, and parenteral antibiotics—Inj Ceftriaxone 2 g iv and Inj Vancomycin 1 g iv were begun prophylactically. The patient was shifted to the ICU for close neuromonitoring. A diagnostic lumbar puncture was performed, which revealed a cell count of 5600 cells/cu mm with 98% neutrophils, glucose 20 mg/dL, and proteins 1244. The gram’s stain showed gram positive cocci, and the CSF PCR revealed Streptococcus pneumoniae. Ceftriaxone 2 g iv BD/Vancomycin 1 g iv BD were continued, along with dexamethasone 10 mg iv QID. The patient improved neurologically over the next 2 days, and was shifted to the ward. The CSF culture & sensitivity also revealed Streptococcus pneumoniae, which was sensitive to both ceftriaxone and vancomycin. Steroids were administered for 3 days and then stopped. Antibiotics were continued for 14 days, and the patient was discharged with no residual deficits.


  1. 1.
    Tintinalli JE, Stapczynski JS. Tintinalli’s emergency medicine: a comprehensive study guide. 7th ed. New York: McGraw-Hill; 2011.Google Scholar
  2. 2.
    Pruitt AA. Neurologic infectious disease emergency. Neurol Clin. 2012;30:129–59.CrossRefGoogle Scholar
  3. 3.
    Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. 1993;328:21–8.CrossRefGoogle Scholar
  4. 4.
    Kourbeti IS, Jacobs AV, Koslow M, et al. Risk factors associated with postcraniotomy meningitis. Neurosurgery. 2007;60:317–25.CrossRefGoogle Scholar
  5. 5.
    Fitch MT, Abrahamian FM, Moran GJ, Talan DA. Emergency department management of meningitis and encephalitis. Infect Dis Clin N Am. 2008;22(1):33–52.CrossRefGoogle Scholar
  6. 6.
    Attia J, Hatala R, Cook DJ, et al. The rational clinical examination. Does this adult patient have acute meningitis? JAMA. 1999;282(2):175–81.CrossRefGoogle Scholar
  7. 7.
    Saex-Llorens X, McCracken GH Jr. Bacterial meningitis in children. Lancet. 2013;361:2139–48.CrossRefGoogle Scholar
  8. 8.
    Thomas KE, Hasbun R, Jekel J, et al. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clin Infect Dis. 2002;35(1):46–52.CrossRefGoogle Scholar
  9. 9.
    Nakao JH, Jafri FN, Shah K, et al. Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014;32(1):24–8.CrossRefGoogle Scholar
  10. 10.
    Proulx N, Fréchette D, Toye B, et al. Delays in the administration of antibiotics are associated with mortality from adult acute bacterial meningitis. QJM. 2005;98(4):291–8.CrossRefGoogle Scholar
  11. 11.
    Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267–84.CrossRefGoogle Scholar
  12. 12.
    van de Beek D, de Gans J. Dexamethasone in adults with community-acquired bacterial meningitis. Drugs. 2006;66(4):415–27.CrossRefGoogle Scholar
  13. 13.
    Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015;9:CD004405.Google Scholar
  14. 14.
    Donald PR, Toorn RV. Use of corticosteroids in tuberculous meningitis. Lancet. 2016;387:2585–7.CrossRefGoogle Scholar
  15. 15.
    Estebanez CR, Lizarraga KJ, Merenda A. A systematic review on the role of adjunctive corticosteroids in herpes simplex virus encephalitis: is timing critical for safety and efficacy? Antivir Ther. 2014;19:133–9.CrossRefGoogle Scholar
  16. 16.
    Glimaker M, Johansson B, Grindborg O, et al. Adult bacterial meningitis: earlier treatment and improved outcome following guideline revision promoting prompt lumbar puncture. Clin Infect Dis. 2015;60(8):1162–9.CrossRefGoogle Scholar
  17. 17.
    Sakushima K, Hayashino Y, Kawaguchi T, et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infect. 2011;62(4):255–62.CrossRefGoogle Scholar
  18. 18.
    Kennedy PG. Viral encephalitis: causes, differential diagnosis, and management. J Neurol Neurosurg Psychiatry. 2004;75(Suppl 1):i10–5.CrossRefGoogle Scholar

Copyright information

© The Editor(s) (if applicable) and The Author(s)  2020

Authors and Affiliations

  • Vasudha Singhal
    • 1
  • Prasanna Udupi Bidkar
    • 2
  1. 1.Medanta-the MedicityGurugramIndia
  2. 2.Jawaharlal Institute of Postgraduate Medical Education and ResearchPondicherryIndia

Personalised recommendations