The frequency of physical signs usually attributed to meningeal irritation in elderly patients

Acute Bacterial Meningitis

PURPOSE OF REVIEW

While acute bacterial meningitis is becoming less common in developed countries because of the widespread use of vaccines against Streptococcus pneumoniae, Neisseria meningitides, and Haemophilus influenzae, bacterial meningitis still occurs worldwide, with peak incidence in young children and the elderly. Bacterial meningitis is usually lethal unless appropriate antibiotics that cross the blood-brain barrier are given. Clinical suspicion of bacterial meningitis begins when patients present with the abrupt onset of fever, headache, and meningismus.

RECENT FINDINGS

New technologies are being developed for more rapid identification of the bacterial species causing meningitis. When appropriate, administration of adjunctive dexamethasone with the antibiotics often lessens neurologic sequelae in survivors, which may include aphasia, ataxia, paresis, hearing loss, and cognitive impairment.

SUMMARY

Confirmation of the diagnosis of bacterial meningitis comes mainly from examination and culture of CSF obtained from a lumbar puncture. Typically, the CSF shows an elevated neutrophil count, elevated protein, depressed glucose, positive Gram stain, and growth of the bacteria on appropriate culture media. Antibiotic sensitivities of the bacteria determine the appropriate antibiotics, although an educated guess of the best antibiotics to be given promptly must be made until the antibiotic sensitivities return, usually in a few days.

The History and Current Relevance of the Eponymous Signs of Meningitis

During the past several decades, researchers have shown that the eponymous signs of meningitis have reduced sensitivity and specificity compared with when they were originally described. This may be because of the changing epidemiology of meningitis and its treatment or it may be because of variations in performance of the maneuvers. For example, in the original descriptions, the Kernig sign (resistance of leg extension) is best elicited with the patient sitting and the Brudzinski nape of the neck sign involves holding down the patient's chest as the neck is flexed. These and other lesser-known signs of meningitis by Amoss, Bikeles and Edelmann all relate to the mechanics of stretching inflamed meninges, and this review will allow the clinician to understand how the history related to these maneuvers is still germane to clinical practice today.

The Optimal Management of Acute Febrile Encephalopathy in the Aged Patient: A Systematic Review

The elderly comprise less than 13 percent of world population. Nonetheless, they represent nearly half of all hospitalized adults. Acute change in mental status from baseline is commonly seen among the elderly even when the main process does not involve the central nervous system. The term "geriatric syndrome" is used to capture those clinical conditions in older people that do not fit into discrete disease categories, including delirium, falls, frailty, dizziness, syncope, and urinary incontinence. Despite the growing number of elderly population, especially those who require hospitalization and the high burden of common infections accompanied by encephalopathy among them, there are several unresolved questions regarding the optimal management they deserve. The questions posed in this systematic review concern the need to rule out CNS infection in all elderly patients presented with fever and altered mental status in the routine management of febrile encephalopathy. In doing so, we sought to identify all potentially relevant articles using searches of web-based databases with no language restriction. Finally, we reviewed 93 research articles that were relevant to each part of our study. No prospective study was found to address how should AFE in the aged be optimally managed.

Clinical picture of meningitis in the adult patient and its relationship with age

To analyze the clinical characteristics of acute meningitis and their relationship with age in adult patients presenting to the emergency department. We retrospectively investigated consecutive adult patients admitted with a diagnosis of bacterial or viral meningitis from 2002 to 2006. Data about patient's history, symptoms and signs at presentation, etiology and clinical course were collected. To investigate the relationship of clinical presentation with age, we divided patients in four age quartiles (<30 years, between 30 and 36 years, between 37 and 56 years, >56 years). Among the 202 patients considered in the study (mean age 42.8 ± 18.7 years, range 14-90), 162 (80.2%) patients had viral and 40 (19.8%) bacterial meningitis. Specific signs, such as neck stiffness or Kernig or Brudzinski signs, were more common in the first than in the fourth quartile (73.1 vs. 45.7% P = 0.041). Conversely, altered consciousness expressed as Glasgow Coma Scale (GCS) <15 was more frequent in the fourth (80.4%) than in the first (9.6%) quartile (P < 0.001). The linear regression analysis confirmed a significant decrease of GCS with the increasing of patient's age (r = -0.69, P < 0.001). At multivariate analysis, aging was associated with altered level of consciousness (OR 16.7, P < 0.001) independent of viral or bacterial etiology of the presence of comorbidities and of clinical severity (presence of severe sepsis or septic shock). Meningitis presentation largely differs with aging in adult patients. Level of consciousness is frequently altered in the older patients, when other specific signs become more rare, independent of etiology, comorbidities and clinical severity.

Central nervous system infections as a cause of an altered mental status? What is the pathogen growing in your central nervous system?

There are several central nervous system (CNS) infections (meningitis, encephalitis, and brain abscess), any of which may present with an altered level of consciousness. Because CNS infections can have a devastating outcome, it is important to recognize the presence of a CNS infection and begin treatment as soon as possible because early appropriate therapy may, in some cases, limit morbidity and mortality.

Pseudomeningeal syndrome of Dupre associated with cervical discopathy--case report

BACKGROUND AND PURPOSE

The below publication presents a case of a 51-year-old patient with cervical discopathy of unusual clinical course.

CASE REPORT

The symptoms of the disease suddenly became aggravated and took a form of meningeal syndrome without inflammation of cerebrospinal fluid. The authors emphasize the symptomatology and diagnostic difficulties connected to unusual clinical course of cervical discopathy at the level of VC3/VC4.

DISCUSSION

Both medical and neurosurgical approaches to clinical history of cervical discopathic patient were presented in details. The patient underwent anterior cervical interbody fusion and the operative procedure was very effective for a few years up till now.

The diagnosis and management of acute bacterial meningitis in resource-poor settings

Acute bacterial meningitis is more common in resource-poor than resource-rich settings. Survival is dependent on rapid diagnosis and early treatment, both of which are difficult to achieve when laboratory support and antibiotics are scarce. Diagnostic algorithms that use basic clinic and laboratory features to distinguish bacterial meningitis from other diseases can be useful. Analysis of the CSF is essential, and simple techniques can enhance the yield of diagnostic microbiology. Penicillin-resistant and chloramphenicol-resistant bacteria are a considerable threat in resource-poor settings that go undetected if CSF and blood can not be cultured. Generic formulations of ceftriaxone are becoming more affordable and available, and are effective against meningitis caused by penicillin-resistant or chloramphenicol-resistant bacteria. However, infection with Streptococcus pneumoniae with reduced susceptibility to ceftriaxone is reported increasingly, and alternatives are either too expensive (eg, vancomycin) or can not be widely recommended (eg, rifampicin, which is the key drug to treat tuberculosis) in resource-poor settings. Additionally, improved access to affordable antibiotics will not overcome the problems of poor access to hospitals and the fatal consequences of delayed treatment. The future rests with the provision of effective conjugate vaccines against S pneumoniae, Haemophilus influenzae, and Neisseria meningitides to children in the poorest regions of the world.

Acute bacterial meningitis

Despite advances in medical care including antibiotics and vaccines, meningitis still has a high morbidity and mortality rate, especially in certain high-risk patients. Early diagnosis with the administration of appropriate antibiotics remains the key element of management. This article highlights methods of diagnosis, differential diagnoses, treatment options, and complications of treating bacterial meningitis.

Headache in the elderly

Headache in an elderly patient can be a sign of serious, potentially life-threatening disorders. All patients require a full assessment, including a complete neurologic examination. Particular emphasis should be placed on excluding subarachnoid hemorrhage, subdural hematoma, giant cell arteritis, intracranial neoplasm, cerebrovascular accident, acute-angle-closure glaucoma, and infectious etiologies such as meningitis and encephalitis. Once life-threatening disorders are excluded, the geriatrician can focus on more benign etiologies such as migraine, tension headache, and medication withdrawal. Treatment depends on the underlying etiology. This article discusses headaches that require emergent treatment and then describes more benign etiologies of headaches.

Geriatric neurologic emergencies

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.

Delayed diagnosis of meningitis caused by beta-haemolytic group G. Streptococcus in an older woman

A case of meningitis caused by group G beta-hemolytic Streptococcus (dysgalactiae, subspecies equisimilis) is reported in an 83-year-old woman. Streptococci species other than Streptococcus pneumoniae are seldom found in patients with acute bacterial meningitis, therefore, our discussion is focused on this rare organism. The question of the diagnosis of meningitis in the elderly is also addressed.

Bacterial meningitis in aging adults

Bacterial meningitis remains a highly lethal disease in older adults, with mortality rates averaging >20% despite modern antibiotic therapy. In this population, more variable presentations are seen, with fewer patients manifesting fever, neck stiffness, and headache than among younger adults. In addition, many older adults (aged > or =60 years) may have other underlying diseases causing symptoms that may be confused with those of meningitis. The spectrum of etiologic bacterial organisms is more broad than that for a younger population, in part because of the increased frequency of severe underlying diseases and in part as a result of immunosenescence. Therapy is complicated by both the range of possible causative organisms and the increasing antibiotic resistance manifested by some. These difficulties, contrasted with the success of vaccination in the pediatric population, highlight the need for improved preventive strategies for older adults. This review outlines some key clinical points in the management of bacterial meningitis in the older adult.

The role of lumbar puncture in the evaluation of dementia: the Durham Veterans Administration/Duke University Study

The use of lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis in the routine, initial evaluation of patients with dementia continues to be questioned. This is especially true in the investigation of infectious causes of dementia. To explore this question further, the authors performed a retrospective analysis of 672 hospitalized patients specifically evaluated for dementia. LP and CSF analysis were performed on 402 patients (60 per cent); routine bacteriologic, acid-fast, and fungal cultures were also obtained for 333 of these patients. Most patients were white (64 per cent) and male (63 per cent), their mean age being 66 +/- 11 years. Four patients were diagnosed as having meningitis--two with Cryptococcus neoformans, one with apparent Mycobacterium tuberculosis, and one with coagulase-positive Staphylococcus aureus. These patients were characterized by a subacute change in mental status, fever or meningismus, and CSF pleocytosis with abnormal CSF chemistries. None of the patients were found to have newly diagnosed neurosyphilis. The authors conclude that LP and CSF analysis should not be part of the routine evaluation of patients with dementia and should be performed only in the presence of such indications as a subacute duration of dementia, fever, and signs of meningeal irritation.