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CMN Infectious Meningitis

Vol. 37, No. 6 AbdelRahman M. Zueter, M.L.S., M.Sc., Ph.D.,1 and Amani Zaiter, M.Sc.,2 1Department of Medical
March 15, 2015 Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia,
www.cmnewsletter.com 2
Biological Sciences Department, Faculty of Science, Hashemite University, Zarqa, Jordan

Abstract
I n Th is Issu e
Infectious meningitis is a large public health concern, especially in children and immunocompromised
43 Infectious Meningitis patients. Although the epidemiology of meningitis has shown significant decline in past decades, partly
due to the introduction of vaccines, outbreaks are still reported worldwide. Diagnosis of meningitis is
of critical importance, and it is considered to be one of the most urgent of the microbiological medi-
cal emergencies. In order to improve the treatment strategy, various diagnostic methods have been
developed to detect the presence of infectious agents that cause meningitis, as well as their antibiotic
resistance patterns. This article aims to enhance the understanding of meningitis and to highlight the
most current updates that describe outbreaks of meningitis and the subsequent investigations. We also
describe the current diagnosis and treatment options.

Introduction noninfectious meningitis (2). Noninfectious

Corresponding author:
AbdelRahman M. Zueter,
M.L.S., M.Sc., Ph.D., Depart-
ment of Medical Microbiology
and Parasitology, School of
Medical Sciences, Universiti
Sains Malaysia, 16150 Kubang
Kerian, Kelantan, Malaysia.
Tel.: 0060136709343. Fax:
0060197676289. E-mail:
­zueterabdelrahman@gmail.com
Meningitis is an inflammation of the meningeal
layers of the brain and spinal cord. The infec-
tion involves the arachnoid, the pia mater, and
the intervening cerebrospinal fluid (CSF). The
inflammatory process extends throughout the
subarachnoid space of the brain and spinal cord
and involves the ventricles. Meningitis can cause
necrosis, decreased blood and CSF flow, and
impaired central nervous system (CNS) func-
tions. The early symptoms are headache, fever,
and chills; however, a combination of 2 to 4
symptoms (headache, fever, stiff neck, and altered
mental status) is found in 95% of patients. Death
occurs from shock and other serious complica-
tions within hours of the appearance of symp-
toms (1,2).
Meningitis is usually caused by an infection but
may also occur in response to noninfectious irri-
tants introduced into the subarachnoid space
(1). Noninfectious cases are uncommon or rare
compared with the infectious type, particularly
with their inability to spread from one person
to another (3). Therefore, meningitis could be
divided into two categories according to the
nature of the causative agents: infectious and
meningitis can be induced by certain drugs, auto-
immune hypersensitivity disorders, neoplasms,
and chemical agents (Table 1). When present in
the CSF, noninfectious agents or their products,
such as tumor cell products, act as inflammatory
irritants that induce inflammatory processes that
can progress to meningitis.
Infectious Meningitis
Infectious meningitis is a serious disease of the
CNS that involves inflammation of the meninges
as a result of microbial infection, and it occurs in
all age groups. It is caused most commonly by
viruses and bacteria, rarely by fungi and para-
sites (9). The clinical presentation of meningitis
depends on the virulence of the causative agent,
the pathogenesis of spread to the CNS, and the
area of CNS involvement (3). Headache, fever,
stiff neck, confusion, vomiting, and pleocytosis
are features of meningeal inflammation and are
common to many types of meningitis (e.g., bacte-
rial, fungal, viral, and chemical) and also to some
parameningeal processes. The CSF laboratory
findings are most helpful in distinguishing among
these processes (2).

Clinical Microbiology Newsletter 37:6,2015 | ©2015 Elsevier 43

The age of the host and other underlying host factors (head
trauma, neurosurgery, or presence of a CSF shunt) contribute to
the etiology and the routes of entry. Initially, infectious agents
colonize or establish localized infection in the skin, nasopharynx,
respiratory tract, gastrointestinal tract, or genitourinary tract of
the host. From these sites, the organisms invades by circumvent-
ing host defenses (e.g., physical barriers, local immunity, and
phagocytes/macrophages) and gains access to the CNS through
(i) hematogenous spread, the most common route of infection, in
which the organisms spread via the blood vessels of the brain to
enter the subarachanoid space; (ii) direct spread from an infected
neighboring site contiguous to the CNS; (iii) an anatomical defect
in the CNS structure that resulted from surgery, trauma, or con-
genital abnormalities, which can allow microorganisms to easily
access the CNS; or (iv) travel along nerves leading to the brain, as
occurs with some viruses. Of note, neonates have the highest risk
of infection because of their immature immune system and the
increased permeability of the blood brain barrier (10). Infectious
meningitis is grouped on the basis of pathogen type (bacterial,
viral, fungal, or parasitic), host age (neonate, pediatric, and adult),
health status (healthy or immunocompromised), and symptom
duration (acute, subacute, or chronic [recurrent]).
Meningitis is transmitted from person to person through respira-
tory secretions (saliva, sputum, or nasal mucus), through the fecal-
oral route, or vertically through the colonized vaginal canal. The
infection is considered to be acute during the period when signs
and symptoms of less than 24 hours duration are observed and
subacute when signs and symptoms have been present for 1 to 7
days. Most cases of meningitis are acute, but some are chronic due
to the invasion of pathogens from a neighboring infected site (10).
The common infectious agents of acute meningitis are viruses
(mainly enteroviruses and, to a lesser degree, HIV, herpes sim-
plex viruses (HSV), and mumps virus), bacteria (Streptococcus
pneumoniae, Neisseria meningitidis, Streptococcus agalactiae (group B
streptococci), Haemophilus influenzae, and Listeria monocytogenes).
Less common causes of acute meningitis include parasites (Naegle-
ria fowleri, Strongyloides stercoralis, and Acanthamoeba cantonensis).
Subacute or chronic meningitis is characterized by delayed symp-
toms over weeks to months or even years. These patients may
also have some acute meningitis symptoms, but the onset is more
gradual, with lower fever and possibly associated lethargy and
disability. This type of meningitis may be caused by Mycobacteria
spp., spirochetes, Cryptococcus neoformans, Candida spp., and Coc-
cidioides spp. (1,3).
Bacterial meningitis
Bacterial meningitis is a major cause of morbidity and mortal-
ity, especially among children less than 5 years of age. The rapid
progression of symptoms and potentially devastating effect of the
disease necessitate early recognition and immediate treatment.
Shock, coagulation disorders, endocarditis, pyogenic arthritis,
and prolonged fever are the most common bacterial meningitis
complications (2). Despite many new antibacterial agents, bacterial
meningitis fatality rates remain high, with reported rates between
44 Clinical Microbiology Newsletter 37:6,2015 | ©2015 Elsevier
Table 1. Noninfectious causes of meningitis
Noninfectious cause/agent Examplea Reference
Drug hypersensitivity NSAID 4,5
antimicrobials
Systemic diseases SLE 6
Neoplastic diseases Metastatic carcinoma 7
Chemical agents Anaesthetics 8
a
NSAID, nonsteroidal anti-inflammatory drug; SLE, Systemic lupus erythomatosis.
2% and 30%. Permanent sequelae, such as epilepsy, mental retar-
dation, or sensorineural deafness, are observed in 10% to 20% of
those who survive (11,12).
In general, all human microbes can cause meningitis, but only
a few species account for most cases of bacterial meningitis. S.
agalactiae and Escherichia coli commonly infect neonates up to 3
months of age and are acquired during the passage of the baby
through a colonized vaginal canal. H. influenzae infects unvac-
cinated children between the age of 3 to 6 months and 6 years.
N. meningitidis infects children and young adults and is the only
organism that causes meningitis epidemics. S. pneumoniae occa-
sionally infects children and increases in incidence with age. L.
monocytogenes appears to be foodborne (dairy products, processed
meat, and uncooked vegetables) and infects people with defective
immunity or those receiving certain therapies (1-3). Some studies
report a dramatic drop in developed countries as a result of the
introduction of vaccines against common bacterial agents, such
as S. pneumoniae, H. influenzae type b, and N. meningitidis (2,11).
Data for community-acquired acute bacterial meningitis suggest
that almost 50% of cases are due to S. pneumoniae, 25% to N. men-
ingitidis, 13% to group B streptococci, 8% to L. monocytogenes, and
7% to H. influenzae. In contrast, nosocomial meningitis is associ-
ated with enteric gram-negative bacilli in up to 33% of cases. The
most common gram-negative bacterial agents in adults are E. coli
and Klebsiella/Enterobacter spp. Mortality rates of bacterial menin-
gitis in adults remain at approximately 20% but rise to at least 40%
for those older than age 60 (13). In neonates, S. agalactiae and E.
coli are the most common agents of meningitis in North America
(11), Australasia (14), and Europe (15). The morbidity rate of
neonatal meningitis is up to 56%; if not treated, the mortality can
approach 100% (16). In rare situations, other bacterial pathogens
can cause acute meningitis, including coagulase-negative staphy-
lococci, Burkholderia pseudomallei, Pseudomonas aeruginosa, mis-
cellaneous gram-negative bacilli, Staphylococcus aureus, viridans
streptococci, and anaerobic bacteria. Mixed bacterial infections
might occur as complications of neurosurgical procedures (e.g.,
spinal puncture) and low immunity status. Meningitis caused by
group A streptococci is uncommon but occasionally occurs after
acute otitis media. In approximately 10% of patients with acute
bacterial meningitis, the bacterial cause cannot be defined but is
diagnosed on the basis of other differential laboratory findings (3).
Mycobacterium tuberculosis, Treponema pallidum and Borrelia burg­
dorferi are considered to be the most common causes of chronic
bacterial meningitis (13); 1% of patients suffering from tuber­
culosis progress to complicated CNS tuberculosis (17).
Viral meningitis
Viral meningitis is more common than bacterial meningitis but is
much less severe. The clinical course of viral meningitis is usually
self-limited, with complete recovery in 7 to 10 days. Most cases of
community-acquired aseptic meningitis are the result of viruses.
Aseptic meningitis is suspected when CSF cultures for routine
bacteria are negative and there were no antibiotics given before
the lumbar puncture (16).
Enteroviruses account for 85 to 95% of aseptic meningitis (3,18).
Enteroviruses are single-stranded RNA viruses and, along with
rhinoviruses, represent a major group in the genus Enterovirus
in the family Picornaviridae. Recent classification systems rely on
RNA homology, which classifies the enteroviruses into four spe-
cies designated human enteroviruses A through D, encompassing
many serotypes of group A and B coxsackieviruses and enterovi-
ruses, echoviruses, and polioviruses (3).
Mumps virus, HIV-1, and HSV-2 may cause chronic recurrent
meningitis (2), a recurrent infection that occurs after full recovery.
The exact incidence of viral meningitis is known to be underes-
timated, due to poor reporting practices. In temperate regions,
seasonal aseptic meningitis usually peaks in summer and early
autumn, reflected by the seasonal pattern of outbreaks. Some
enteroviral serotypes (e.g., echoviruses 6, 9, 13, 18, and 30 and
coxsackievirus B5) cause widespread outbreaks, while coxsacki-
eviruses A9, B3, and B4 are associated with endemic infection.
Echovirus 30 has been implicated in European outbreaks every
3 to 5 years. Its distribution covers large geographical areas, and
infections are more common in children. On the other hand, no
seasonal preference has been reported for HSV and HIV (18).
Table 2 describes the recently published surveys and outbreaks of
acute meningitis worldwide.
Fungal and parasitic meningitis
Fungal meningitis is rare but poses a significant challenge, span-
ning a wide array of hosts, including immunocompetent and
immunosuppressed individuals, patients undergoing neurosurgical
procedures, and those with implantable CNS devices. C. neofor-
mans and Aspergillus spp. are the most common fungal pathogens
(51). C. neoformans infection is acquired by the inhalation route
and can be asymptomatic and limited to the lungs in immuno-
competent hosts. Upon immunosuppression, hematogenous
dissemination to the meninges may occur, which can end with a
fatal outcome in the absence of prompt management. Lympho­
proliferative malignancies, steroid therapy, diabetes mellitus, and
AIDS are the most common predisposing factors for cryptococ-
cal meningitis (51). C. neoformans is the most common cause of
meningitis in immunosuppressed and AIDS patients; the mortal-
ity rate in that population ranges from 10 to 30% and from 13 to
44% in developed and developing countries, respectively (52,53).
In one retrospective study performed in India, the prevalence of
C. neoformans among HIV patients was 14.3% (53). Candida spp.
cause acute meningitis indistinguishable from bacterial meningitis
in patients with low immunity or after neurosurgery procedures.
Chronic cryptococcal and candidal meningitis may mimic chronic
meningitis that is caused by M. tuberculosis (52).
Parasites can infect the meninges and cause aseptic meningitis;
they can also infect brain tissue, causing acute meningoencepha-
litis. From warm freshwater, the free-living amoeba N. fowleri
(the most virulent) invades the brain via direct extension from the
nasal mucosa and causes meningoencephalitis that is lethal within
1 week in most cases, predominantly in children and young adults.
Acanthamoeba species are commonly found in soil and primarily
infect immunocompromised patients, usually through inhalation
or skin wounds, causing encephalitis, which can be acute or chronic
(3,10). A listing of uncommon pathogens is provided in Table 3.
Approaches for Laboratory Diagnosis
Diagnosis of an infection involving the CNS is considered to be
a medical emergency. Combining the physical examination with
confirmatory laboratory tests and a clinical history of the patient
provides the strongest evidence of meningitis. Over the last few
years, many approaches have been developed and used for the
diagnosis of meningitis. Currently, several diagnostic methods
were evaluated in order to achieve sensitive, rapid, and specific
detection of meningitis etiology (10), especially in the case of bac-
terial meningitis, which requires immediate diagnosis and rapid
institution of antimicrobial therapy (2). When meningitis occurs,
inflammatory immune cells flow into the CSF and are usually
detectable on examination of the fluid. Therefore, the collection
of CSF specimen via lumbar puncture is one of the first steps in
the workup of a patient with suspected meningitis (2,13).
CSF collection
Routinely, CSF is collected into three sterile tubes from the same
puncture after considering the proper intracranial pressure. The
first tube is used for chemical and immunological testing due to
the potential for cell contamination during collection. To avoid
surface flora contamination, the second tube is selected for micro-
biological and molecular testing. The last volume collected best
represents the actual cellular composition of the CSF and is ideal
for cytological testing. In cases where a low volume of CSF is
collected, the sample is triaged for microbiology, cytology, and
chemistry, respectively, to optimize findings. After collection, the
sample is assessed for normal color, clarity, and viscosity and then
sent for further laboratory examination (65).
Cytology
Direct microscopy provides a screening method of CSF samples.
Various cell types in CSF should be evaluated and studied, yet
few have established usefulness in diagnosing infectious menin-
gitis. A microscopic examination includes total and differential
white blood cell (WBC) counts, as well as counts of red blood
cells (RBCs) and other cell types that could be uncommon or
abnormal (13).
A total CSF cell count is usually performed manually using a
hemacytometer chamber. Automated electronic-impedance-based
CSF cell counters increase precision and reduce turnaround time.
Clinical Microbiology Newsletter 37:6,2015 | ©2015 Elsevier 45
Table 2. Recent surveys and outbreaks of acute meningitis in selected countries worldwide

Country Age group Predominant pathogensa Study interval Diagnostic methodc Reference

Asia
India Allb S. aureus, Klebsiella spp., E. coli, Acinetobacter spp., 2009-2010 Culture 19
N. meningitidis, S. pneumoniae
Japan Neonates H. influenzae, S. pneumoniae, S. agalactiae, E. coli 2008-2010 Culture 20
Japan Adult Enteroviruses, mumps virus, VZV, HSV 2004-2014 PCR, culture 21
China All S. pneumoniae, N. meningitidis, H. influenzae 2006-2009 Agglutination, culture 22
China Pediatric Enteroviruses, adenoviruses 2006-2012 PCR, culture 23
China Pediatric Enteroviruses (echovirus 30, coxsackievirus B5) Outbreak PCR, culture, 24
2008, 2012 genotyping
Australia All Enteroviruses (echoviruses 6, 4, 30, 25, and 2007-2013 PCR, culture, 25
coxsackievirus A9) genotyping
Middle East
Jordan Pediatric Enteroviruses 1999 Culture, IFA 26
Palestine Adults Enteroviruses (echovirus 27) 1978-2012 Culture, serology 27
Kuwait Pediatric Enteroviruses (echoviruses 9, 11, 30) 2006-2009 PCR, hybridization 28

Europe
France, Italy, Greece, All Enteroviruses (echovirus 30) Outbreak, PCR, culture, 29,30-32
Finland, Bulgaria, 2009-2013 genotyping
Serbia, Latvia, Spain,
Turkey Children S. pneumoniae, N. meningitidis, H. influenzae 2005-2006 PCR, culture 38
Denmark All S. pneumoniae, N. meningitidis, 1998-2010 Agglutination, 39
streptococcus groups A, B, G culture
UK Neonates S. agalactiae, E. coli, S. pneumoniae, N. meningitidis 2010-2011 Gram stain, culture 40
Iceland Children N. meningitidis, H. influenzae 1975-2010 Gram stain, culture 41
S. pneumoniae, S. agalactiae
Spain Adults, N. meningitidis, S. pneumoniae, L. monocytogenes 1982-2010 Gram stain, culture, 42
Elderly S. pneumoniae, L. monocytogenes, agglutination
Gram-negative bacilli
Americas
Brazil, Panama All Enteroviruses (echovirus 30) 2005, 2008 PCR, culture, 43,44
genotyping
Brazil All N. meningitidis, S. pneumoniae 2004-2006 Gram stain 45,46
H. influenzae 2000-2010 PCR, agglutination
USA All S. pneumoniae, N. meningitidis 1998-2007 Culture 11
USA All Enteroviruses (echoviruses 30, 6) 5 yr PCR, culture, 47
genotyping

Africa
Malawi Neonates S. agalactiae, S. pneumoniae, S. enterica 2002-2008 Gram stain, culture 12
Burkina Faso Children H. influenzae, S. pneumoniae, N. meningitidis 2004-2012 Gram stain, 48
PCR, culture
Niger All N. meningitidis, S. pneumoniae, H. influenzae 2002-2010 PCR, culture, 49
agglutination
South Africa Pediatric Enteroviruses (echoviruses 4, 9, and 2010-2011 PCR, culture, 18
coxsackievirus B5 genotyping
Kenya Pediatric S. pneumoniae, N. meningitidis, H. influenzae 2014 Culture, Gram stain 50
a
Pathogens are listed in the order of highest frequency to lowest frequency. VZV, varicella-zoster virus.
b
All includes pediatric patients, adults, and the elderly.
c
IFA, immunofluorescence assay.

46 Clinical Microbiology Newsletter 37:6,2015 | ©2015 Elsevier

Moreover, the nature of normal CSF cell constituents represent
cells in low density, which interferes with the working principle
of the automated counter, thus resulting in values higher than
“normal” cell counts. Therefore, the impedance-based technology
may not be routinely applicable, since most CSF samples tested in
the laboratory are in the normal/low cell count range (65). Some
studies have reported agreement of cell counts performed on
automated analyzers that use flow cytometry and flow cell digital-
imaging principles with those from the manual hemacytometer
method (66). Unfortunately, automated systems cannot identify
pathologic cell types, such as neoplastic cells, lipophages, and sid-
erophages. A differential cell count is best performed by Wright’s
stain of CSF sediment smear prepared by cytocentrifugation. The
normal CSF does not contain RBCs; however, normal adult CSF
contains a total of 0 to 5 WBCs/µl, specifically, lymphocytes and
monocytes. In children, the total WBC count is 0 to 10 WBCs/
µl; in healthy neonates, counts as high as 30 WBCs/µl, with a pre-
dominance of monocytes, can be normal (2,65).
Chemical examination
Numerous chemical constituents in the CSF sample are evalu-
ated, but few give useful diagnostic data for meningitis etiol-
ogy. Since result values differ in response to the different types
of microorganisms involved, assays such as glucose, lactate, and
various proteins assays can provide diagnostic information (Table
4) and help classify the type of meningitis, but results from cytol-
ogy and chemistry laboratories cannot conclusively determine
whether the infection is bacterial, viral, fungal, or parasitic due to
similarity of results that may be obtained in response to infections
by different microorganism types. Confirmatory tests should be
performed (2,18).
Normal CSF glucose levels range from 50 to 80 mg/dl, which is
approximately 60% to 70% of the plasma concentration. In con-
trast, CSF lactate is unrelated to plasma and is present in normal
concentrations of 10 to 22 mg/dl. More than 50% of infectious
meningitis cases cause decreases in the CSF glucose level due
to defects in glucose transport across the blood brain barrier or
increased glucose consumption within the CNS. Increased lactate
is an indicator of anaerobic metabolism within the CNS due to
decreased oxygenation and blood supply.
The CSF total protein assay assesses the integrity of the blood
brain barrier. The total CSF protein level varies with the age and
the site from which the CSF is obtained and is higher when col-
lected from the lumbar region. A CSF total protein level of 15 to
45 mg/dl is considered normal. Protein screens include assessment
of CSF proteins and immunoglobulins by electrophoresis, and the
definitive concentrations are measured by nephelometry (2,65).
Microbiological examination
Microbiological staining is used for visual detection of causative
agents in the CSF sediments. The sediment could be concen-
trated or smeared, dried, and stained with Gram stain, India ink,
and Ziehl-Neelsen stain for bacteria and yeast, Cryptococcus spp.,
and Mycobacteria spp., respectively. Wet-mount preparation can
be used for parasite detection (10). Direct microscopy and stain-
ing of concentrated CSF sediment provide rapid presumptive
diagnosis of meningitis in 60% to 80% of untreated patients and

Table 3. Recent cases of meningitis of chronic and uncommon etiologies

Age/gender Meningitis etiology Risk factora Complication Diagnostic methodb Outcome Reference
50 yr/male Rhodotorula glutinis AIDS Gram stain, culture Cured 54
34 yr/male C. neoformans AIDS Reversible blindness Culture Cured 55
42 yr/male C. neoformans HIV-induced IRIS Agglutination Relapsed 56
19 mo/male A. cantonensis Poor hygiene Permanent Microscopy Cured 68
neurological sequelae
64 yr/male Abiotrophia defectiva Neurosurgical Culture, genotyping Cured 57
procedures
17 mo/male M. tuberculosis Disseminated PCR Cured 59
tuberculosis
18 mo/male M. tuberculosis Disseminated Communicating CT scan Cured
tuberculosis hydrocephalus
52 yr/female Pantoea calida Post surgery Culture, genotyping Cured 60

36 yr/male Salmonella enterica Salmonella Virchow Culture Cured 61

serovar Virchow carrier
21 yr/female Mycobacterium chelonae Culture, RFLP Cured 62
6 yr/male N. fowleri Contaminated water Microscopy Cured 63
reservoir
8 mo/male Methicillin-resistant MRSA sepsis Culture Cured 64
S. aureus (MRSA)
a
IRIS, immune reconstitution inflammatory syndrome.
b
CT, computed tomography; RFLP, restriction fragment length polymorphism.

Clinical Microbiology Newsletter 37:6,2015 | ©2015 Elsevier 47

in 40% to 60% of treated patients (65). Culture is considered the
gold standard for several protocols. The organism could be grown
on special nutritive medium that supports its growth after proper
incubation under suitable atmosphere and temperature. Culture is
routinely used for bacterial and fungal diagnosis. Traditional labo-
ratory diagnostic culture methods for the identification of bacte-
rial meningitis pathogens take up to 36 hours or more and enable
the isolation of common types of bacteria in 80% to 90% of cases
(65,67). Unfortunately, in many clinical settings, the administra-
tion of short-course antibiotic therapy prior to lumbar puncture
reduces the chance of isolation of bacteria in CSF culture, decreas-
ing the diagnostic accuracy for bacterial meningitis to only 30%.
Therefore, a growing discrepancy exists between the numbers of
clinically suspected and culture-confirmed cases of bacterial men-
ingitis. Thus, negative CSF cultures in patients suspected to have
meningitis can be confirmed by other methods that are not affected
by antibiotic administration (67), such as PCR (3).
Cell lines for viral culture are part of routine laboratory diagnosis
for viral meningitis in countries where viral meningitis outbreaks
are endemic. In some cases, the purpose of viral culture is more
often focused on molecular genotyping applications that require
isolation of the viral genome than on primary diagnosis (3,25).
Enteroviruses are isolated in cell line culture with sensitivities of 65
to 75% and takes 4 to 8 days. HSV-2 can be cultured from CSF in
approximately 75% of patients with aseptic meningitis (2). Devel-
opment of CSF PCR panels for diagnostic purposes is ongoing.
Immunodiagnostics
Immunoassays are based on the principle of antigen-antibody reac-
tion for identification of microbial agents. Microbial structures,
such as capsules, can be targeted as an antigen and then detected
by a reagent antibody. Rapid antigen detection from CSF has been
largely accomplished by the principles of latex agglutination, coag-
glutination, immunoassay, and counter-immunoelectrophoresis.
Immunoassays represent a screening tool for primary diagnosis,
along with other screens for microbial detection and cell counting.
Currently, immunologic tests are applicable for the detection of
several types of bacteria and fungi that cause meningitis, includ-
ing S. pneumoniae, S. agalactiae, H. influenzae, N. meningitidis, Coc-
cidioides immitis, M. tuberculosis, and C. neoformans. Additionally,
certain kits are used to detect either antibodies or antigens that
Table 4. Common laboratory results in meningitis in children and adultsa
Clinical status WBCs (cells/µl) Predominant cell type
Normal 0-5 None
Bacterial meningitis >1,000 Neutrophils; lymphocytes in early infection
Tuberculosis-meningitis 100-500 Lymphocytes, monocytes
Viral meningitis 5-500 Lymphocytes
Fungal meningitis 5-500 All differential cells
Parasitic meningitis 2-200 Eosinophils, neutrophils
a
Modified from references 2, 10, and 65.
48 Clinical Microbiology Newsletter 37:6,2015 | ©2015 Elsevier
are specific for some viruses (10,65). The latex slide agglutination
test for C. neoformans antigen shows moderate to high sensitiv-
ity (60% to 99%) and specificity (80% to 99%). In addition, the
antigen titer serves as a good prognostic indicator (65). However,
CSF serology for detection of bacterial antigens is not widely used
because it has lower sensitivity and specificity than Gram stain and
culture (3,10,65).
Molecular methods and applications
Molecular assays have become widely applied in the microbiol-
ogy field as diagnostic and research tools. Molecular techniques
are used for confirmatory diagnosis and have been gradually
introduced for routine primary diagnosis of viral meningitis (10).
Nucleic acid assays, mainly PCR and its variants, have been used
in diagnosis involving direct detection of microorganisms in CSF
specimens, confirmation of bacteria and viruses grown in culture
media and cell lines, genotyping of viruses beyond identification
for molecular epidemiology and phylogenetic purposes, and iden-
tification of antimicrobial resistance for certain bacteria.
Molecular methods shorten diagnosis time (up to 4 hours) and
have increased specificity and sensitivity of diagnosis. Addition-
ally, they solve the discrepancy problems in suspected patients who
show culture-negative results. These combined characteristics pro-
vide advantages for PCR over any other laboratory test (10,23).
Reverse transcription (RT)-PCR targeting the 5' non-translated
region (NTR) of the enteroviral genome, which is the most con-
served genomic region, is essential for enteroviral-meningitis diag-
nosis and delivers results in as little as 5 hours, thereby shortening
inpatient hospital stays and minimizing the unnecessary use of
empirical antimicrobial agents. In comparison with cell line cul-
ture, RT-PCR sensitivity and specificity in CSF are 85 to 100%
and 90 to 100%, respectively. PCR for HSV-2 DNA is usually
positive in the CSF of patients with initial episodes of meningi-
tis. PCR is also is positive in approximately 80% of patients with
benign recurrent meningitis caused by lymphocytic choriomen-
ingitis virus (2,18).
A systematic review and meta-analysis study was performed to
evaluate the accuracy of broad-range 16S rRNA PCR in the diag-
nosis of bacterial meningitis. The study judged the benefit of PCR
for diagnosis in emergency departments (68). Fourteen articles
were analyzed, in which 488/2,780 CSF samples were proven to
Glucose (mg/dl) Protein (mg/dl)
45-100 15-50
<40 >100
≤40 >50
Normal 50-150
≤40 >100
≤40 >50
be culture positive. Pooled analysis showed a sensitivity of 92%
(95% confidence interval [CI], 75 to 98%), a specificity of 94%
(95% CI, 90 to 97%), a positive likelihood ratio of 16.26 (95% CI,
9.07 to 29.14), and a negative likelihood ratio of 0.09 (95% CI,
0.03 to 0.28). PCR also amplified 30% of culture-negative cases
(68). Many recent studies applied and evaluated various PCR-
based methods, showed their utility, and compared them with
other detection methods to investigate for common meningitis
infectious agents, but they are beyond the scope of this review.
Recently, molecular typing approaches to enteroviruses targeting
the VP1 region of the enteroviral genome that encodes serotype-
specific neutralization epitopes have been successfully applied
during enteroviral-meningitis outbreak investigations in many
countries worldwide (18,23,24,25,27,33,34,44,47). They have
provided details of enteroviral molecular phylogeny that help us
to understand its association with specific disease manifestations
and possible clonal geographical clustering (34) (Table 2).
Therapeutic Management
The ideal antibiotic for CNS infection would be inexpensive and
would cover a broad range of gram-positive and -negative bacteria
(13). If the infecting organism is observed on examination of the
Gram-stained smear of the CSF sediment collected from a patient
with suspected bacterial meningitis, specific therapy is initiated;
otherwise, empirical antimicrobial therapy should be initiated.
Prompt treatment of bacterial meningitis usually results in rapid
recovery of neurologic function.
Bacterial meningitis is treated using various antibacterial families
such as beta-lactams, cephalosporins, aminoglycosides, fluoro-
quinolones, and other drugs, like trimethoprim-sulfamethoxazole
and vancomycin; the type of antibiotic, its dose and duration, and
whether to combine it with other antibiotics are all decided by
the physician according to the causative agent, patient’s age, and
other clinical considerations.
Effective vaccines are now available for many subtypes of H. influ-
enzae type b, meningococcal serogroups (A, C, Y, and W-135),
S. pneumoniae, M. tuberculosis, and S. agalactiae (2). Adherence to
recommended vaccination schedules substantially reduces menin-
gitis from each of those organisms. Previous studies indicated that
five bacteria, namely, H. influenzae, N. meningitidis, S. pneumoniae,
L. monocytogenes, and S. agalactiae, accounted for almost 80% of
cases of meningitis. However, upon the introduction of conjugate
vaccines, substantial reduction in the prevalence of cases due to
these five pathogens was achieved (59,69). Another study reported
a 31% decline in the incidence of bacterial meningitis during the
surveillance periods 1998-1999 and 2006-2007 (11).
Most viral-meningitis cases are self-limited, but some cause
chronic or recurrent illness. Treatment of acute viral meningitis
is directed at relief of symptoms, supportive care, and preven-
tion and management of complications. Full recovery from viral
meningitis usually occurs within 1 to 2 weeks of onset, although
some patients describe persistence of fatigue, lightheadedness,
and asthenia for months. Introduction of mumps vaccine reduces
aseptic meningitis due to mumps virus.
No approved antiviral chemotherapy is available for enterovi-
ral meningitis. Intravenous acyclovir is used to treat hospital-
ized, symptomatic patients with HSV-2 meningitis. In patients
with frequent recurrences of HSV meningitis, it is reasonable to
attempt prophylaxis with oral antivirals: valacyclovir, famciclovir,
or acyclovir (2). For patients with cryptococcal CNS infection,
amphotericin B plus flucytosine, followed by fluconazole, is the
ideal treatment. Most experiences with therapy of Candida men-
ingitis have been with amphotericin B, often in combination with
flucytosine because of the latter agent’s ability to penetrate the
blood brain barrier (70).
For patients with cryptococcal CNS infection, amphotericin B plus
flucytosine, followed by fluconazole, is the ideal treatment. Most
experiences with therapy of Candida meningitis have been with
amphotericin B, often in combination with flucytosine because of
the latter agent’s ability to penetrate the blood brain barrier (70).
Many cases of fungal meningitis and meningioencephalitis are fatal
because of the course of the disease, the considerable toxic effects
of amphotericin B, and other anti-fungals, such as miconazole,
ketoconazole, and flucytosine (2,18).
Conclusion
Infectious meningitis is a large public health concern. Continu-
ous diagnosis improvement is necessary to minimize disease mor-
tality and life-threatening complications. Continued updates to
describe prevalence and expanded reporting of outbreaks will help
to evaluate vaccination outcomes and impact. Viral genotyping in
outbreaks provides a clearer picture for virus epidemiology and
geographical distribution and helps predict the emergence of new
strains by phylogenetic studies.
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