Infecto

Management of
A c u t e , R e c u r re n t , a n d
C h ro n i c M e n i n g i t i d e s
in Adults
Tracey A. Cho,

MD*,

Nagagopal Venna,

MD, MRCP

KEYWORDS
 Meningitis  Bacterial  Viral  Aseptic
 Chronic  Management

By common usage, the term meningitis implies inflammation of the leptomeninges (the
arachnoid and pia) and, by extension, involvement of the cerebrospinalfluid (CSF) in
the subarachnoid space. In the rare pachymeningitis, inflammation predominantly
affects the dura, and its causes and course are distinct from those of leptomeningitis.
This review focuses on leptomeningitis, with the understanding that many processes
may affect all 3 layers of the meninges simultaneously.
Meningitis may be further classified based on the time course. Mostinvestigators
distinguish between acute meningitis (with onset over hours to days) and chronic
meningitis (syndrome persisting more than 4 weeks). Those meningitis syndromes
evolving over several days but less than 4 weeks may be termed subacute, although
the distinction between these and the other 2 categories is arbitrary. Recurrent meningitis is distinguished by symptoms that appear and thenresolve completely between
distinct episodes. Although there may be some etiologic overlap, the clinical distinction between acute, chronic, and recurrent meningitis is relevant because the causes
and approaches to management are often different.
Meningitis typically manifests as headache, neck stiffness, light sensitivity, and
varying degrees of neurologic symptoms and signs. Acute meningitis ismore often
accompanied by fever and mental status changes, whereas symptoms are more indolent in chronic meningitis. Furthermore, inflammation of the meninges sometimes
extends into the parenchyma with resultant symptoms and signs of cerebral or spinal
cord involvement, often termed meningoencephalitis or meningoencephalomyelitis.
Viral syndromes in particular often cause a broad spectrum ofneurologic disorders,

Neurology-Infectious Diseases Section, Department of Neurology, Massachusetts General
Hospital, WACC 835, 55 Fruit Street, Boston, MA 02114, USA
* Corresponding author.
E-mail address: tcho@partners.org
Neurol Clin 28 (2010) 1061–1088
doi:10.1016/j.ncl.2010.03.023
neurologic.theclinics.com
0733-8619/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.1062

Cho & Venna

but this article concentrates on those syndromes predominantly affecting the
meninges.
The most common and often most severe forms of meningitis are due to infections,
including bacteria, viruses, fungi, and parasites. Noninfectious causes of meningitis
include primary inflammatory syndromes such as vasculitis and connective tissue
disease, neoplasms of solid tumor andhematologic forms, and chemical irritants
including certain medications, subarachnoid blood, and biologic matter spilling into
the CSF from tumors. Although a patient may present with symptoms of meningitis
within days of onset, distinguishing acute from subacute or chronic meningitis may
not always be possible early in the course. Nevertheless, the distinction is important
because of thevarying urgency, causes, and treatment strategy involved in each
syndrome. Although the list of possible causes of acute, chronic, and recurrent meningitis is extensive, this article focuses on the most important and treatable causes.

ACUTE MENINGITIS

The most common causes of acute meningitis are bacteria and viruses. Acute meningitis begins with the abrupt onset of headache, fever, and neckstiffness, with varying
degrees of mental status change. Neck stiffness may be elicited on physical examination as pain and resistance to passive neck flexion, knee and hip flexion in response to
passive neck flexion (Brudzinski sign), or resistance and pain to passive extension of the
knee with the hip flexed (Kernig sign). However, these signs are not sensitive. Although
patients may not...