meningitis
and Martina Feichter, medical editor and biologistDr. med. Fabian Sinowatz is a freelancer in the medical editorial team.
More about the expertsMartina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.
More about the experts All content is checked by medical journalists.
Meningitis is inflammation of the meninges. Most often it is caused by viruses. Meningitis caused by bacteria is less common, but much more dangerous. It has to be treated as soon as possible! Bacterial meningitis can develop into a life-threatening emergency within a few hours. Read everything you need to know about meningitis: symptoms, causes, diagnosis, treatment and prognosis!
ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. G02A39A87G01G03
Brief overview
- What is meningitis? Inflammation of the skin that surrounds the brain - not to be confused with encephalitis. Both inflammations can occur at the same time (as meningoencephalitis).
- Causes: Mostly viruses (TBE viruses, Coxsackie viruses, herpes viruses etc.) or bacteria (pneumococci, meningococci etc.). More rarely, other pathogens (such as fungi, protozoa), cancer or inflammatory diseases (such as sarcoid) are the cause of meningitis.
- Signs & symptoms: flu-like symptoms (such as high fever, headache and body aches, nausea and vomiting), painful neck stiffness, sensitivity to noise and light, possibly clouded consciousness up to unconsciousness, possibly neurological deficits (such as speech and walking disorders) as well as epileptic Seizures.
- Diagnostics: taking the medical history (anamnesis), physical examination, blood sample, collection and analysis of nerve fluid (liquor puncture), computed tomography (CT), magnetic resonance imaging (MRT)
- Treatment: For bacterial meningitis antibiotics and possibly dexamethasone (a cortisone). For viral meningitis, symptomatic treatment (fever and painkillers) and possibly viral drugs (antivirals).
- Prognosis: If left untreated, meningitis can become life-threatening within hours, especially bacterial meningitis. However, it can often be cured with early treatment. However, some patients suffer permanent damage (such as hearing impairment).
Meningitis: symptoms
In general, at the onset of meningitis, symptoms similar to those of the flu appear. These include, for example, a high fever, headache and body aches, nausea and vomiting.
In the further course, a painful neck stiffness (meningism) joins. It is a very typical meningitis symptom: the meninges (in contrast to the brain) are equipped with pain receptors. They react to inflammation and irritation such as meningitis with pain. In addition, the neck stiffens. The pain is particularly noticeable when moving the head, because the membranes of the brain and spinal cord are slightly stretched. It hurts most when the chin is brought up to the rib cage. The pain also tenses the neck muscles. This increases the stiff neck.
Meninges and the brain itself can also be inflamed at the same time. This combination of meningitis and encephalitis is called meningoencephalitis.
The following is an overview of all the major meningitis symptoms in adults:
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Meningitis: symptoms in adults |
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painful stiff neck (meningism) |
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fever |
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headache |
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pronounced feeling of illness with pain in the limbs
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increased sensitivity of the eyes to light (photophobia) |
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increased sensitivity to noise (phonophobia) |
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Nausea and vomiting |
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Back pain |
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Confusion and drowsiness |
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possibly dizziness, hearing impairment, epileptic seizures |
Meningitis: Symptoms of Bacterial Meningitis
Meningitis symptoms are particularly strong in bacterial meningitis: within hours, the initially mild symptoms can worsen massively and even lead to death! It is therefore of vital importance to recognize the signs of a bacterial meningitis early and to alert the doctor.
The first symptoms of meningitis appear here two to five days (with meningococci about two to ten days) after you have become infected with the bacteria. As with other forms of meningitis, it begins with unspecific, flu-like symptoms. A highly acute clinical picture can develop in the course of hours or a few days. Those affected usually have severe headaches, extreme neck stiffness and a fever. Neurological deficits are also possible, for example a clouding of consciousness and slurred speech.
Complications
One possible complication of a meningococcal infection is "blood poisoning" (sepsis): the bacteria flood the patient's blood in large numbers. The result is a high fever, weakness and a severe feeling of illness with circulatory problems. In severe cases, this meningococcal sepsis (meningitis sepsis) can develop into the so-called Waterhouse-Friderichsen syndrome (especially in children and people without a spleen):
The meningococci have harmful sugar chains (endotoxins) on their surface. When the bacteria break down, large quantities of these toxins are released into the blood. This triggers an uncontrolled blood clotting reaction in the body: numerous blood clots (thrombi) form, which can clog smaller vessels. In addition, due to the massive clot formation, the coagulation factors necessary for blood coagulation are used up (consumption coagulopathy). This can lead to profuse bleeding in the skin, mucous membranes and internal organs.
For example, small hemorrhages initially appear in the skin and mucous membrane, so-called petechiae. At first they only show up as pin-sized, red or brownish dots. These become larger and larger over time and look like "bruises". Bleeding also occurs in internal organs, such as the adrenal glands. They are severely damaged as a result, so that they fail as hormone producers. Doctors then speak of adrenal weakness (adrenal insufficiency). The heavy bleeding causes the blood pressure to drop; a state of shock or even a coma can develop. The mortality from Waterhouse-Friderichsen Syndrome is high!
Waterhouse-Friderichsen syndrome can occur in various bacterial diseases. Most often, however, it is the result of meningitis caused by meningococci.
Meningitis: Symptoms of Viral Meningitis
Virus-induced meningitis is generally milder than bacterial meningitis. Signs first appear about two to fourteen days after infection: flu-like symptoms, followed by a painful stiff neck. In contrast to bacterial meningitis, the symptoms usually do not worsen within hours, but rather over the course of several days.
In people with a healthy immune system, the symptoms usually subside on their own over the course of a few days. However, the recovery phase can take a long time. The disease can also be severe in smaller children. The same applies to people with a weakened immune system (for example from medication, cancer or infections such as HIV).
Meningitis: Symptoms in Infants and Young Children
Many infants and young children show very unspecific meningitis symptoms. Meningitis is then often difficult to diagnose, especially in the early stages of the disease.
The first signs of meningitis in infants and young children are fever, poor drinking and noticeable tiredness. The little patients are unusually irritable and listless. Later abdominal pain, seizures, and high-pitched screams can be added. The fontanelle (a gap in the bone in the child's skull that is covered with connective tissue and skin) can be bulging. The painful stiff neck (meningism), which is usually a typical sign of meningitis, is often absent in toddlers and babies.
Tip: Since meningitis symptoms can develop quickly and become dangerous, especially in small children, you should see a doctor if you suspect the disease is vague.
Meningitis: Symptoms of Special Forms of Meningitis
The special forms of meningitis include tuberculous meningitis (caused by tuberculosis bacteria) and meningitis in neuroborreliosis (caused by borreliosis bacteria). Both start slowly - fever can be the only symptom of meningitis for days. Later, other signs of meningitis such as stiff neck and headache may appear.
Overall, these two special forms are very rare. However, they should be considered if the disease progresses for a long time.
Meningitis: causes and risk factors
In meningitis, the meninges are inflamed. These are connective tissue sheaths that lie against the brain within the skull. There are three pieces of it (inner, middle, and outer meninges).
Where the meninges are
The causes of such meningitis can be very different: On the one hand, meningitis can be caused by a large number of pathogens (viruses, bacteria, fungi, etc.). Depending on the type, such pathogens can be transmitted to other people with different degrees of ease. Therefore, meningitis caused by pathogens is contagious.
On the other hand, meningitis can also develop in the context of various diseases, for example sarcoid or cancer. In these cases, meningitis is not contagious. Read more about the possible causes of meningitis below.
Meningitis that is not caused by bacteria is also known as aseptic meningitis (abacterial meningitis).
Viral meningitis
Viral meningitis is the most common form of meningitis. The main triggering viruses are:
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virus |
Diseases primarily caused by the virus | |
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Coxsackie Virus A and B |
Hand, foot and mouth disease, herpangina, summer flu | |
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Herpes simplex virus types 1 and 2 (HSV-1, HSV-2) |
Cold sores, genital herpes | |
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TBE virus |
Early summer meningoencephalitis | |
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Varicella zoster virus (VZV) |
Chickenpox and Shingles | |
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Epstein Barr Virus (EBV) |
Pfeiffer glandular fever (infectious mononucleosis) | |
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Mumps virus |
Mumps | |
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Measles virus |
measles | |
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Many other viruses: HI virus (HIV), polio virus, rubella virus, Parvo-B19 virus, etc. | ||
The type of infection depends on the type of virus. Coxsackie viruses, for example, can be transmitted by droplet infection: Patients can distribute tiny droplets of saliva into the surrounding air when they cough, sneeze and speak. The droplets contain Coxsackie virus. If they are inhaled by a healthy person, they can also become infected. Coxsackie viruses primarily trigger other diseases, such as summer flu or herpangina. As part of this primary disease, the viruses can spread to the meninges and cause meningitis.
Meningitis is infected in a different way, for example with TBE viruses: The pathogens are transmitted through the bite of blood-sucking ticks.
How much time elapses between infection and the appearance of the first symptoms of the disease (incubation period) also depends on the type of virus. In general, the meningitis incubation period is usually around two to fourteen days.
Bacterial meningitis
Bacterial meningitis is less common than viral meningitis, but it is often much more severe. The most common cause of bacterial meningitis are the so-called pneumococci (Streptococcus pneumoniae). The meningitis is then also known as pneumococcal meningitis. However, pneumococci can also cause other diseases, for example pneumonia, otitis media or sinusitis.
Another common cause of bacterial meningitis is meningococci (Neisseria meningitidis). They are transmitted through body fluids (secretions). However, only close contact with it usually causes infection, which is why an infection in normal everyday life is unlikely. Meningococcal meningitis is very dangerous. The infection can develop into "blood poisoning" (meningococcal sepsis) within a few hours. A dreaded complication is the Waterhouse-Friderichsen syndrome with septic shock. There is an acute danger to life!
Frequency of meningococcal disease
There are different subgroups of meningococci, so-called serogroups. Most meningococcal diseases are caused by serogroups A, B, C, W135 and Y. These serogroups are not equally common all over the world. For example, serogroup A meningococci in particular cause major epidemics in Africa. In Europe, on the other hand, people are mainly infected with serogroups B and C.
In Germany, around four out of a million people develop meningococci every year. In 65 to 70 percent of cases in this country, serogroup B is responsible for the disease, in 20 to 25 percent of cases, serogroup C. The few remaining cases are attributable to other serogroups.
Meningococcal disease is most common in children under five years of age (especially in the first two years of life). A second, smaller peak of illness is seen in the 15 to 19 age group. In principle, however, you can get a meningococcal infection at any age. People with weakened immune systems are particularly at risk.
Pathogen causing bacterial meningitis and other diseases
Pneumococci and meningococci are the main triggers of bacterial meningitis. But there are also many other bacteria that can be causative:
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bacterium |
caused diseases | |
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Pneumococci |
especially meningitis, pneumonia, inflammation of the middle ear and sinuses etc. | |
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Meningococci |
especially meningitis and blood poisoning (sepsis) | |
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Staphylococci |
Meningitis, food poisoning, wound infections, blood poisoning (sepsis), etc. | |
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Enterobacteria including Pseudomonas aeruginosa |
Diarrhea, intestinal inflammation, pneumonia, meningitis, etc. | |
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Haemophilus influenzae type B |
Meningitis, pneumonia, blood poisoning (sepsis), inflammation of the heart muscles (myocarditis) | |
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Streptococcus agalactiae (B streptococci) |
Meningitis, blood poisoning (sepsis), urinary tract infections, wound infections | |
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Listeria monocytogenes |
"Listeriosis" (diarrhea and vomiting, blood poisoning, meningitis, encephalitis etc.) | |
The different bacteria are often the trigger of meningitis, depending on their age. For example, meningitis in infants is often caused by Strepotcoccus agalactiae, Listeria monocytogenes or E. coli (one of the enterobacteria). In young children, meningococci, pneumococci and Haemophilus influenzae type B are usually the triggers. Meningitis in adults is also mostly caused by pneumococci or meningococci.
How the meningitis is transmitted also depends on the causative bacterium (usually droplet infection).
Other causes of meningitis
Viruses and bacteria are responsible for the majority of all meningitis. Meningitis rarely has any other cause. This is often the case with people whose immune system is weakened by another disease (such as HIV or cancer) or medication (immunosuppressants). In the following you will find an overview of other triggers of meningitis (in addition to viruses and bacteria):
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Other causes of meningitis |
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Special bacteria: tuberculosis (tuberculous meningitis), neuroborreliosis |
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Fungal infection: candidiasis, cryptococcosis, aspergillosis |
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Parasites: Echinococcosis (tapeworm) |
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Protozoa (single cell): toxoplasmosis |
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Cancer diseases: meningeosis carcinomatosa, meningeosis leucaemica |
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Inflammatory diseases: sarcoid, lupus erythematosus, Behçet's disease |
Meningitis: examinations and diagnosis
If you suspect meningitis, don't waste any time. You need to see a doctor without delay! Contact your general practitioner, pediatrician (for small patients), neurologist, or a hospital emergency room. Diagnosing and treating meningitis quickly can save lives!
An experienced doctor can diagnose meningitis based on the symptoms and physical examination. However, it is essential to clarify whether it is bacterial or viral meningitis. The treatment depends on it.
The most important steps in diagnosing meningitis are:
Medical history (anamnesis)
During the conversation, the doctor will first collect your medical history or that of your sick child (anamnesis). Possible questions from the doctor include:
- Do you currently have a cold (sore throat, cough, chronic runny nose)?
- Do you experience a headache, fever and / or painful neck stiffness?
- Are there any known underlying or previous illnesses (HIV, sarcoid, borreliosis, etc.)?
- Do you or does your child take medication regularly?
- Do you or does your child have an allergy to medication (for example to antibiotics)?
- Did you or your child have contact with anyone with a headache, fever and stiff neck?
- Have you or your child recently been abroad (for example in an African country)?
Physical examination
During the physical exam, the doctor will first check the classic signs of meningitis. To do this, he tries to bring the head of the patient lying on his back to the chest with his chin. This is how painful neck stiffness (meningism) can be determined. In addition, when the head tilts, patients typically tend to draw their legs reflexively (Brudzinski's sign) - an involuntary reaction to the pain caused by the slight stretching of the meninges and spinal cords when the head is tilted. The Brudzinski sign is a good indicator of meningitis).
Another sign of meningitis is when the patient cannot straighten his leg while sitting because it is too painful (Kernig's sign).
The so-called Lasègue sign can also be conspicuous in meningitis: the doctor slowly moves one straight leg upwards when the patient is lying down - so he flexes the hip with the knee extended. If the patient experiences pain shooting from the back into the leg (positive Lasègue sign), this indicates irritation of the meninges.
The Lasègue sign is also positive in the case of a herniated disc.
It is also very important to examine the patient's entire skin carefully. With severe bacterial meningitis, small bleeding marks on the skin (petechiae) may occur. You are an alarm signal for the doctor! He will immediately initiate further examinations and treatment. The bleeding initially looks like small blue or brownish dots. Over time, these become larger stains and typically cannot be pushed away with a transparent object (glass) (glass test).
Further investigations
Through the anamnesis discussion and the physical examination, the doctor can already assess whether there is a meningitis that requires treatment. If there is even the slightest indication that meningitis is actually involved, the doctor will arrange for further investigations. For example, if you first went to the family doctor or pediatrician, you will usually be forwarded directly to a clinic. Because of the possible serious complications of meningitis, further examinations and treatment should better be done in hospital.
The first steps in further examinations if meningitis are suspected are:
1. Taking blood for blood cultures: With so-called blood cultures one can try to detect and identify a pathogen - especially bacteria. The doctor can then select a suitable antibiotic for bacterial meningitis therapy that is effective against the type of bacteria in question.
2. Removal of nerve fluid (liquor puncture): During the liquor puncture, some nerve fluid (liquor) is taken from the spinal canal at the level of the lumbar vertebrae with a fine hollow needle. The whole thing only takes a few minutes and is usually not perceived as particularly painful. The liquor sample taken is examined in the laboratory for possible pathogens causing meningitis. If necessary, computed tomography (CT) is performed before the CSF puncture in order to rule out increased intracranial pressure. Cerebrospinal fluid puncture should not be performed if the intracranial pressure is increased.
3. Computed tomography (CT) or magnetic resonance imaging (MRI): These imaging procedures provide further information about the condition of the brain. They can sometimes also provide clues as to where the pathogen originally came from (for example, from ulcerated sinuses).
Meningitis: treatment
If meningitis is suspected, starting treatment quickly can be decisive for the prognosis. Since it is difficult to predict how the disease will develop, it should definitely be treated in hospital. A hospital with a neurology department is best.
As soon as the blood and nerve fluid have been drawn, the doctor begins antibiotic therapy - even if you do not yet know whether there is actually a bacterial meningitis. With the early administration of antibiotics you play it safe, because bacterial meningitis can quickly become very dangerous.
The doctor uses broad-spectrum antibiotics (ceftriaxone, ampicillin, etc.) for treatment. These antibiotics are effective against a large number of bacteria at the same time, including those most commonly responsible for bacterial meningitis. Usually the antibiotics are given as an infusion directly into a vein. So they can quickly develop their effect.
As soon as the actual pathogen has been determined on the basis of the blood and nerve water sample, the doctor adjusts the meningitis treatment accordingly: If it is actually a bacterial meningitis, the patient may be switched to other antibiotics that fight the causative bacterium better and more specifically . However, if it turns out that a virus is responsible for the meningitis, usually only the symptoms are treated.
Bacterial meningitis: therapy
The antibiotic therapy described above can fight the cause of bacterial meningitis. In addition, the glucocorticoid ("cortisone") dexamethasone is sometimes given. It has an anti-inflammatory effect. This can, for example, reduce mortality from pneumococcal meningitis. In addition, the combined treatment with antibiotics and dexamethasone can reduce the incidence of severe hearing impairment in Haemophilus influenzae meningitis.
If the dreaded Waterhouse-Friderichsen syndrome develops, treatment in the intensive care unit is necessary.
Special measures for meningococcal meningitis
In order to reduce the risk of infection for others, the patient is housed in a single room and isolated from other patients. Contact persons of the patient may receive an antibiotic as a preventive measure, for example rifampicin in tablet form: This is necessary for all people who have had close contact with the patient about seven days before to ten days after the onset of the illness (family members, work colleagues, classmates, etc.). A meningococcal vaccination may also be useful for the contact persons if they were not vaccinated as a child.
Viral meningitis: therapy
In the case of viral meningitis, usually only the symptoms are treated. There are only a few viruses that have special drugs (antivirals) that can alleviate the course of the disease. This applies, for example, to the group of herpes viruses (herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus) and the HI virus (HIV).
In principle, viral meningitis is primarily about relieving symptoms. Bed rest as well as antipyretic and pain reliever medication help. It may also be necessary to use medication to prevent an epileptic seizure. If the disease goes well, the patient can usually soon be discharged and further treatment at home.
Other cause meningitis: therapy
If meningitis has causes other than bacteria or viruses, the trigger is treated accordingly if possible. For example, antifungal drugs are prescribed for meningitis caused by fungi. Anthelmintics (anthelmintics) are used against tapeworms. If the meningitis is caused by sarcoid, cancer or another underlying disease, this is treated in a targeted manner.
Meningitis: disease course and prognosis
Meningitis is a potentially life-threatening disease. The prognosis depends, among other things, on which pathogen is causing the meningitis and how quickly the patient is treated properly.
Bacterial meningitis in particular is an emergency that must be treated with antibiotics as quickly as possible. If left untreated, it is practically always fatal. With timely treatment, however, there is a good chance that the patient will be completely healthy again. The chances of full recovery depend on the exact type of pathogen and the general health of the patient. For example, the prognosis for infants and sometimes for seniors is less favorable because their immune systems are often not as efficient as those of a healthy adult.
Viral meningitis is usually much less life threatening than bacterial meningitis. But here, too, the prognosis depends on the virus in question and the general physical condition. The first few days are particularly critical. If the person concerned has survived this well, the chances of recovery are usually good.Viral meningitis then generally heals within several weeks without any consequential damage.
Meningitis: Consequences
In some cases, meningitis can cause permanent neurological damage. These include hearing damage, paralysis or impairment of the psyche or behavior. Complications and long-term damage occur more frequently when the inflammation also spreads to the brain (meningoencephalitis).
Meningitis: prevention
If you want to prevent meningitis, you should, if possible, protect yourself against infections with the most common pathogens (viruses and bacteria).
Bacterial meningitis: Prevent with vaccination
The Standing Vaccination Commission at the Robert Koch Institute (RKI) recommends various vaccinations for all children. This also includes three vaccinations against common pathogens of bacterial meningitis: meningococcal vaccination, pneumococcal vaccination and Haemophilus influenzae type B vaccination. The immune system of young children is not yet fully developed and can therefore not fight off pathogens as well. That is why these three vaccinations can significantly reduce the risk of bacterial meningitis:
Meningococcal vaccination
There are different subgroups (serogroups) of meningococci. In Europe, meningococcal meningitis is mostly caused by serogroups B and C.
Meningitis caused by meningococcal C is less common, but is often difficult and with complications (such as Waterhouse-Friderichsen syndrome). All children in the 2nd year of life should therefore be vaccinated against meningococcal C. If this vaccination date is missed, the vaccination should be made up until the age of 18.
Since the end of 2013, there has been a separate vaccine against the much more common meningococcal B meningitis. In young children, it is given in four doses. Two doses are sufficient for older children. The STIKO does not yet have sufficient data to recommend this vaccination for all children. The meningococcal B vaccination is currently only recommended for people with certain underlying diseases - usually in addition to the combined vaccination against meningococcal A, C, W and Y. These include, for example, people with a congenital or acquired immune deficiency (e.g. if there is a missing spleen) and people at risk Laboratory staff. The same applies to people who have not been vaccinated and who live in the same household as patients who are severely infected with one of the meningococcal serogroups concerned (A, B, C, W or Y).
Pneumococcal vaccination
Pneumococcal vaccination is recommended for all children. There are three doses of the vaccine: the first dose should be given at two months of age and the second dose at four months of age. The third dose of vaccine should be given six months later between the ages of 11 and 14 months.
Haemophilus influenzae type B vaccination
The Hib vaccination is also recommended for all children. It is administered in four vaccine doses - one dose each from the completed 2nd month of life, in the completed 3rd month of life, from the completed 4th month of life and at the end of the first year of life (11th to 14th month of life).
Viral meningitis: Prevention with vaccination
Some forms of viral meningitis can also be prevented with a vaccination. The mumps vaccination, measles vaccination and rubella vaccination (usually given in combination as an MMR vaccination) are recommended as standard for all children.
There is also a vaccine for early summer meningoencephalitis (TBE). This is a tick-borne viral inflammation of the meninges and brain. The STIKO recommends the TBE vaccination to all people who live or stay in TBE risk areas (e.g. on vacation) and who could be bitten by ticks (through frequent or long stays in nature).
For a longer vaccination protection, a basic immunization with three vaccine doses is recommended. After three years, the TBE vaccination can be boosted with another dose. Afterwards, booster vaccinations are recommended every five years if you want to continue to prevent combined meningitis and encephalitis caused by TBE viruses.
Additional information
Guidelines:
- Guideline "Viral Meningoencephalitis" of the German Society for Neurology
- Guideline "Community-acquired bacterial (purulent) meningoencephalitis in adulthood" of the German Society for Neurology
