Non-blanching rash = Meningococcal Septicaemia until proven otherwise. Do the glass test immediately. Do NOT wait for results — give ceftriaxone 2g IV NOW and call senior help.
Most dangerous form. Causes: Neisseria meningitidis (meningococcal — common in young adults), Streptococcus pneumoniae (pneumococcal — most common in adults overall, highest mortality), Listeria monocytogenes (elderly, immunocompromised, pregnancy), Haemophilus influenzae (now rare due to HiB vaccine).
Mortality 20–30% for pneumococcal; significant neurological sequelae in survivors.
Enteroviruses most common (Coxsackie, Echo). Also HSV-2, mumps, HIV. Usually self-limiting in immunocompetent patients. Milder presentation. Lymphocytic CSF. No antibiotics needed unless bacterial cannot be excluded.
Cryptococcus neoformans — mainly in HIV/AIDS patients (CD4 <100). Subacute onset. India ink positive in CSF. Liposomal amphotericin B + flucytosine induction, then fluconazole consolidation/maintenance.
Weeks of prodrome: headache, malaise, low-grade fever. Cranial nerve palsies (especially CN VI), hydrocephalus, and cerebral infarction. Treat with standard 4-drug RIPE regimen + dexamethasone. Duration 9–12 months. High risk in GCC migrant worker populations from endemic regions.
Classic triad present in only 44% of cases. Absence does not exclude meningitis. Have a low threshold to investigate.
Meningococcal septicaemia produces a characteristic rash progression:
Glass Test: Press a clear glass firmly over the rash.
Blanching (fades) = likely viral/benign
Non-blanching = MEDICAL EMERGENCY — meningococcal septicaemia until proven otherwise. Give antibiotics immediately. Do not delay for any investigation.
Inflammation of meninges (lining). Consciousness preserved (unless complicated). Headache, neck stiffness, fever. No focal neurology typically.
Inflammation of brain parenchyma. Altered consciousness, confusion, focal neurology, seizures. Think HSV encephalitis — temporal lobe involvement. Urgent aciclovir.
HSV Encephalitis: Fever + altered consciousness + temporal lobe signs (personality change, olfactory hallucinations, aphasia). Start aciclovir 10mg/kg TID IV immediately — do not wait for MRI/LP results.
Mass gatherings at Hajj (Mecca, Saudi Arabia) create high-density transmission risk for meningococcal disease. Meningococcal ACWY vaccine is mandatory for Hajj pilgrims — minimum 10 days before departure. GCC countries enforce this at point of entry.
Do NOT delay antibiotics for LP. If LP will be delayed >30 minutes for any reason (CT, consent, positioning), give ceftriaxone 2g IV immediately. Partial treatment does not significantly affect CSF results if LP within 4–6 hours.
Ceftriaxone 2g IV BD
Third-generation cephalosporin. Covers N. meningitidis and S. pneumoniae. Continue for 7 days (meningococcal) to 10–14 days (pneumococcal).
Amoxicillin 2g IV 4-hourly
Add if: age >60 years, immunocompromised (steroids, chemotherapy, HIV, organ transplant), or pregnancy. Listeria is resistant to cephalosporins.
Aciclovir 10mg/kg IV TID
If fever + altered consciousness + temporal lobe signs or seizures. Give for 14–21 days if HSV confirmed. Reduce dose in renal impairment. Ensure IV hydration.
Dexamethasone 0.15mg/kg QDS IV — give BEFORE or WITH the first antibiotic dose.
Reduces hearing loss and neurological sequelae in bacterial meningitis. NOT effective if given after antibiotics have started. Continue for 4 days.
CT head is required before LP only if:
If CT is needed, give antibiotics first — do not wait for CT before starting treatment. CT only delays LP, not antibiotics.
Maintain euvolaemia — neither aggressive fluid restriction nor aggressive fluid loading. Cerebral perfusion pressure must be maintained. Monitor urine output, BP, and signs of cerebral oedema (worsening GCS, Cushing's triad).
SIADH (syndrome of inappropriate ADH) is common — monitor sodium closely. If SIADH: fluid restrict to 1–1.5L/day, treat hyponatraemia cautiously.
LP is performed at L3–L4 or L4–L5 interspace — safely below the spinal cord (cord ends at L1–L2 in adults). Surface landmark: iliac crest = L4 spinous process level.
Fetal position — knees drawn to chest, chin tucked. Allows accurate opening pressure measurement.
Elbows on knees, chin tucked. Useful for obese patients or when lateral position difficult. Cannot measure opening pressure reliably.
Microscopy, culture and sensitivity. Gram stain for bacteria. Fungal culture if immunocompromised. Store at body temperature (not fridge) if possible — meningococcus is fastidious.
CSF protein and glucose. Always send paired blood glucose sample at same time. CSF glucose must be compared to simultaneous blood glucose for meaningful interpretation.
Total WBC count and differential (neutrophils vs lymphocytes). Also RBC count — helps distinguish traumatic tap from true haemorrhage (xanthochromia).
HSV PCR, enterovirus PCR, cryptococcal antigen (CrAg), TB NAAT/culture, cytology if malignancy suspected. Keep as spare if unsure — can send later.
Normal: 7–18 cmH2O (lateral decubent position)
Raised (>20 cmH2O) — bacterial meningitis, cryptococcal, TB, raised ICP
Very high (>40 cmH2O) — cryptococcal meningitis (requires pressure drainage)
Orthostatic headache — worse when upright, relieved by lying flat. Caused by CSF leak at puncture site reducing CSF volume. Occurs in up to 30% of patients.
Management: flat rest, oral fluids, simple analgesia. If severe/persistent (>24–48h): epidural blood patch (99% effective).
Differentiate post-LP headache (positional, suboccipital) from worsening meningitis headache (generalised, with fever/neck stiffness).
Groups A, B, C, W135, Y. Transmission: droplet from nasopharyngeal carriers. Rapid deterioration — can be fatal within hours. Petechial/purpuric non-blanching rash = septicaemia. Complications: DIC, Waterhouse-Friderichsen syndrome (bilateral adrenal haemorrhage → adrenal crisis), skin necrosis requiring amputation.
Waterhouse-Friderichsen Syndrome: Massive adrenal haemorrhage due to meningococcal septicaemia/DIC. Presents as refractory shock despite fluids/vasopressors. Treat with IV hydrocortisone.
Most common bacterial meningitis in adults. Highest mortality (20–30%). Risk factors: asplenia, CSF leak (basal skull fracture), cochlear implant, sickle cell disease, elderly. Treatment: ceftriaxone ± vancomycin (if penicillin-resistant strain concern). Continue dexamethasone. Key complication: sensorineural hearing loss — most common neurological sequela. Pneumococcal vaccination (PCV13/PPSV23) recommended for high-risk groups.
Now rare in GCC and developed world due to HiB vaccine. Still seen in unvaccinated or immunocompromised. Close contacts: rifampicin prophylaxis (similar to meningococcal contacts). Treat with ceftriaxone.
Subacute onset over weeks. Prodrome of headache, fever, malaise, weight loss. Cranial nerve palsies (especially VI — lateral rectus palsy), hydrocephalus (obstructive), cerebral infarction (vasculitis). CSF: lymphocytic, high protein, very low glucose (typically <45%), AFB smear low sensitivity. Treatment: RIPE (Rifampicin + Isoniazid + Pyrazinamide + Ethambutol) for 2 months then RI for 10 months. Add dexamethasone to reduce vasculitis and mortality. High risk in South Asian and Sub-Saharan African migrant nurses in GCC.
HSV-1 most common cause of sporadic viral encephalitis in adults. Temporal lobe involvement: personality change, olfactory hallucinations, aphasia, memory disturbance, temporal lobe seizures. MRI: T2/FLAIR hyperintensity in temporal lobes. EEG: periodic lateralised epileptiform discharges (PLEDs). Treatment: Aciclovir 10mg/kg IV TID for 14–21 days. Ensure good hydration, monitor renal function. Without treatment: >70% mortality.
Mainly HIV/AIDS patients with CD4 <100. Also: organ transplant, other immunosuppression. Insidious onset, raised ICP prominent feature. CSF: India ink positive (budding yeast), cryptococcal antigen positive. Treatment: Liposomal amphotericin B 3–4mg/kg IV daily + flucytosine 25mg/kg QDS for 2 weeks (induction), then fluconazole 400mg/day for 8 weeks (consolidation), then fluconazole 200mg/day (maintenance until immune reconstitution). Serial LP for ICP management — aim to reduce opening pressure by 50% or to normal.
Droplet precautions for all suspected bacterial meningitis, especially meningococcal disease. Place patient in single room immediately on admission.
Patient is no longer infectious for meningococcal disease after 24 hours of appropriate antibiotics. Standard precautions apply. Isolation room can be discontinued.
Person living in same household OR within 1 metre for 8 or more hours in the 7 days before symptom onset. Includes: household members, sleeping partners, healthcare workers with unprotected exposure to respiratory secretions (e.g. mouth-to-mouth resuscitation, intubation without PPE).
Adults: 600mg BD for 2 days. Children: 10mg/kg BD for 2 days. Warn about orange discolouration of body fluids (urine, tears, sweat) and reduced OCP efficacy.
Adults: 500mg single oral dose. Preferred in pregnancy and when rifampicin not suitable. Single dose improves compliance.
250mg IM single dose. Preferred in pregnancy (rifampicin and ciprofloxacin relatively contraindicated).
Close contacts should monitor for symptoms for 10 days from last contact. Advise to present urgently if fever, headache, rash develop.
Meningococcal meningitis and septicaemia are urgent notifiable diseases in all GCC countries. Notify public health / MOH within 24 hours of diagnosis. In UAE: DHA (Dubai) / DOH (Abu Dhabi) notification systems. In Saudi Arabia: MOH NISS system. In Qatar: QCHP notification.
MOH will coordinate with schools and workplaces. Do not send letters or contact schools directly — this is a public health authority responsibility. Give families the local MOH public health number.
Mandatory ACWY vaccine: All Hajj pilgrims must have MenACWY vaccine at least 10 days before departure. Required for visa issuance. GCC countries enforce this at entry checkpoints.
GCC hospitals see increased meningococcal presentations in the 3–4 weeks post-Hajj season. Nurses must maintain high clinical suspicion for Hajj returnees presenting with fever and headache.
Group W135 emerged as a major cause during Hajj 2000 outbreak — reason ACWY (not just AC) vaccine became mandatory. Group W135 has higher mortality and systemic complications.
| Parameter | Bacterial | Viral | TB | Fungal (Crypto) | Normal |
|---|---|---|---|---|---|
| Appearance | Turbid / cloudy | Clear | Clear / slightly turbid | Clear / slightly turbid | Clear, colourless |
| WBC (cells/μL) | 100–10,000+ | 10–500 | 100–500 | 10–200 | <5 |
| Cell type | Neutrophils (>80%) | Lymphocytes (>80%) | Lymphocytes (>80%) | Lymphocytes | Mononuclear |
| Protein (g/L) | Very high (>1.0) | Normal / mildly raised (0.4–0.8) | High (0.5–3.0) | Raised (0.5–2.0) | 0.15–0.45 |
| Glucose (CSF:blood ratio) | Very low (<0.3 / <30%) | Normal (>0.6) | Low (<0.5) | Low (<0.5) | >0.6 (60%) |
| Opening pressure | Raised | Normal / slightly raised | Raised | Very raised | 7–18 cmH2O |
| Key test | Gram stain, Culture | Viral PCR (HSV, Enterovirus) | AFB smear, NAAT | India ink, CrAg | — |
Exam trap: Dexamethasone must be given BEFORE or WITH the first antibiotic dose — not after. If given after, benefit is lost.
First-line antibiotic: Ceftriaxone 2g IV BD. Add amoxicillin for Listeria risk (age >60, immunocompromised, pregnancy).
Do NOT delay antibiotics waiting for LP. Give within 30 minutes of admission to ED for suspected bacterial meningitis.
Kernig's Sign: Patient supine. Flex hip to 90°. Attempt to extend knee. Positive = inability to extend knee >135° due to pain — meningeal irritation.
Brudzinski's Sign: Patient supine. Passively flex the neck (chin to chest). Positive = involuntary flexion of hips and knees — meningeal irritation.
Both signs have low sensitivity (~50%) but high specificity. Jolt accentuation of headache is more sensitive — horizontal head rotation at 2–3 Hz worsens headache.
Press a clear drinking glass firmly against a petechial or purpuric rash. Apply enough pressure to blanch surrounding skin.
Blanching (disappears under glass) = likely viral exanthem or drug reaction — lower urgency.
Non-blanching (remains visible under glass) = meningococcal septicaemia until proven otherwise. This is a MEDICAL EMERGENCY. Administer ceftriaxone 2g IV immediately regardless of other findings.
CT before LP only if: GCS <13, focal neurology, papilloedema, new seizure, immunocompromised, coagulopathy.
If none of the above: LP can be done without prior CT.
NEVER delay antibiotics for CT or LP. Antibiotics first, investigations after.
ACWY meningococcal vaccine mandatory >10 days before Hajj departure. Group W135 strain emerged from Hajj 2000 outbreak. Post-Hajj period: heightened surveillance in GCC hospitals. Pilgrims presenting with fever, headache, neck stiffness within 14 days of return from Hajj = high-risk, investigate urgently.