Bacterial meningitis differential diagnosis: Difference between revisions

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Revision as of 15:19, 11 January 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2]

Overview

Differential diagnosis

Bacterial meningitis may mimick other diseases in terms of clinical signs and symptoms. It is important to differentiate meningitis from other diseases with similar presentation. Once the diagnsis of meningitis is confirmed, the next step may be to differentiate different types of meningitis on the basis of CSF examnination:

Differentiating bacterial meningite is from other diseases

Diseases	Diagnostic tests				Physical Examination					Symptoms			Past medical history	Other Findings
Diseases	Na+, K+, Ca2+	CT /MRI	CSF Findings	Gold standard test	Neck stiffness	motor or Sensory deficit	Papilledema	Bulging fontanelle	Cranial nerves	Headache	Fever	Altered mental status		Other Findings
Brain tumour^[1]		✔	Cancer cells^[2]	MRI	✔	✔	✔	✔	✔	✔				Cachexia, gradual progression of symptoms
Delerium Tremens		✔			✔	✔	✔	✔	✔	✔	✔	✔	Hypertension	Neck stiffness
Subarachnoid hemorrhage		✔	Xanthochromia^[3]	CT scan without contrast^[4]^[5]	✔	✔	✔	✔	✔	✔	✔	✔	Trauma/fall	Confusion, dizziness, nausea, vomiting
Neurosyphilis^[6]^[7]		✔	↑ Leukocytes and protein	CSF VDRL-specifc CSF FTA-Ab -sensitive^[8]	✔	✔	✔	✔		✔		✔	STIs	Blindness, confusion, depression, Abnormal gait
Encephalitis				Clinical assesment			✔			✔			Family history of migraine	Presence of aura, nausea, vomiting
Herpes simplex encephalitis		✔		Clinical assesment			✔	✔	✔	✔	✔		History of hypertension	Delirium, cortical blindness, cerebral edema, seizure
Wernicke’s encephalopathy							✔	✔			✔		History of alcohal abuse	Ophthalmoplegia, confusion
CNS abscess		✔	↑ leukocytes, ↓ glucose and ↑ protien	MRI is more sensitive and specific	✔	✔	✔			✔	✔		History of drug abuse, endocarditis, ↓ immune status	High grade fever, fatigue,nausea, vomiting
Drug toxicity							✔	✔			✔			Lithium, Sedatives, phenytoin, carbamazepine
Conversion disorder				Diagnosis of exclusion	✔	✔	✔	✔		✔	✔	✔		Tremors, blindness, difficulty swallowing
Electrolyte disturbance	↓ or ↑			Depends on the cause										Confusion, seizures
Febrile seizures			↑ Leukocytes, ↑ Protein ↓ Glucose	CSF analysis^[9]					✔	✔				Fever, neck rigidity
Subdural empyema		✔	↑ CSF IgG levels (monoclonal bands)	Clinical assesment and MRI ^[10]	✔	✔	✔	✔	✔			✔	History of relapses and remissions	Blurry vision, urinary incontinence, fatigue
Seizure	↓ or ↑			Clinical assesment and EEG ^[11]	✔					✔	✔		Previous history of seizures	Confusion, apathy, irritability,
Hypoglycemia	↓ or ↑			Serum blood glucose HbA1c			✔	✔		✔	✔		History of diabetes	Palpitations, sweating, dizziness, low serum, glucose

Differentiating bacterial meningitis from other causes of meningitis

Cerebrospinal Fluid
	Normal Levels	Acute Bacterial M.	Acute Viral M.	TB M.	Neuroborreliosis
Cells/ul	< 5	In the 1000s	In the 100s	In the 100s	Some 100
Cells	Lymph:Monos 7:3	Gran. > Lymph.	Lymph. > Gran.	Various leukos	Lymph. monocytic
Total Protein (mg/dl)	45-60	Typically 100-500	Typically normal	Typically 100-200	Typically up to 350
Glucose Ratio (CSF/plasma)	Typically > 0.5	< 0.3	> 0.6	< 0.5	Normal
Lactate (mmol/l)	< 2.1	> 2.1	< 2.1	> 2.1	-
Others	ICP: 6-22 (cm H2O)		PCR of HSV-DNA	PCR of TBC-DNA	IgG/IgM CSF/Serum Ratio

References

↑ Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.
↑ Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.
↑ Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.
↑ Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.
↑ DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.
↑ Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.
↑ Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.
↑ Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.
↑ Carbonnelle E (2009). "[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]". Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.
↑ Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). "Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group". Arch Neurol. 51 (1): 61–6. PMID 8274111.
↑ Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.

Template:WikiDoc Sources

[pmid10582668-1] Morgenstern LB, Frankowski RF (1999). "Brain tumor masquerading as stroke". J Neurooncol. 44 (1): 47–52. PMID 10582668.

[pmid21371327-2] Weston CL, Glantz MJ, Connor JR (2011). "Detection of cancer cells in the cerebrospinal fluid: current methods and future directions". Fluids Barriers CNS. 8 (1): 14. doi:10.1186/2045-8118-8-14. PMC 3059292. PMID 21371327.

[pmid1198628-3] Lee MC, Heaney LM, Jacobson RL, Klassen AC (1975). "Cerebrospinal fluid in cerebral hemorrhage and infarction". Stroke. 6 (6): 638–41. PMID 1198628.

[pmid21694755-4] Birenbaum D, Bancroft LW, Felsberg GJ (2011). "Imaging in acute stroke". West J Emerg Med. 12 (1): 67–76. PMC 3088377. PMID 21694755.

[pmid21807345-5] DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF; et al. (2011). "ACR Appropriateness Criteria® on cerebrovascular disease". J Am Coll Radiol. 8 (8): 532–8. doi:10.1016/j.jacr.2011.05.010. PMID 21807345.

[pmid22482824-6] Liu LL, Zheng WH, Tong ML, Liu GL, Zhang HL, Fu ZG; et al. (2012). "Ischemic stroke as a primary symptom of neurosyphilis among HIV-negative emergency patients". J Neurol Sci. 317 (1–2): 35–9. doi:10.1016/j.jns.2012.03.003. PMID 22482824.

[pmid24365430-7] Berger JR, Dean D (2014). "Neurosyphilis". Handb Clin Neurol. 121: 1461–72. doi:10.1016/B978-0-7020-4088-7.00098-5. PMID 24365430.

[pmid22421697-8] Ho EL, Marra CM (2012). "Treponemal tests for neurosyphilis--less accurate than what we thought?". Sex Transm Dis. 39 (4): 298–9. doi:10.1097/OLQ.0b013e31824ee574. PMC 3746559. PMID 22421697.

[pmid19398286-9] Carbonnelle E (2009). "[Laboratory diagnosis of bacterial meningitis: usefulness of various tests for the determination of the etiological agent]". Med Mal Infect. 39 (7–8): 581–605. doi:10.1016/j.medmal.2009.02.017. PMID 19398286.

[pmid8274111-10] Giang DW, Grow VM, Mooney C, Mushlin AI, Goodman AD, Mattson DH; et al. (1994). "Clinical diagnosis of multiple sclerosis. The impact of magnetic resonance imaging and ancillary testing. Rochester-Toronto Magnetic Resonance Study Group". Arch Neurol. 51 (1): 61–6. PMID 8274111.

[pmid11385043-11] Manford M (2001). "Assessment and investigation of possible epileptic seizures". J Neurol Neurosurg Psychiatry. 70 Suppl 2: II3–8. PMC 1765557. PMID 11385043.

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@@ Line 12: / Line 12: @@
 ! colspan="4" |<small>Diagnostic tests</small>
 ! colspan="5" |<small>Physical Examination</small>
-! colspan="4" |<small>Symptoms
+! colspan="3" |<small>Symptoms
 ! colspan="1" |<small>Past medical history</small>
 ! rowspan="2" |<small>Other Findings</small>
@@ Line 20: / Line 20: @@
 !<small>CSF Findings</small>
 !<small>Gold standard test</small>
-!<small>Motor Deficit</small>
+!Neck stiffness
-!<small>Sensory deficit</small>
+!<small>motor or Sensory deficit</small>
-!<small>Speech difficulty</small>
+!Papilledema
-!<small>Gait abnormality</small>
+!Bulging fontanelle
 !<small>Cranial nerves</small>
 !<small>Headache</small>
-!<small>LOC</small>
+!Fever
-!<small>Motor weakness</small>
+!Altered mental status
-!<small>Abnormal sensations</small>
 !
 |-
@@ Line 42: / Line 41: @@
 | style="background: #F5F5F5; padding: 5px; text-align:center" |      ✔
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-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
@@ Line 48: / Line 46: @@
 |style="background: #F5F5F5; padding: 5px;" |[[Cachexia]], gradual progression of symptoms
 |-
-|style="background: #DCDCDC; padding: 5px; text-align: center;" |Hemorrhagic stroke
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |Delerium Tremens
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
-|style="background: #F5F5F5; padding: 5px;" |Xanthochromia<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628  }}</ref>
+| style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px;" |CT scan  without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755  }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345  }}</ref>
+| style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
@@ Line 61: / Line 59: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |[[Hypertension]]
 |style="background: #F5F5F5; padding: 5px;" |Neck stiffness
 |-
-|style="background: #DCDCDC; padding: 5px; text-align: center;" | Subdural hemorrhage
+|style="background: #DCDCDC; padding: 5px; text-align: center;" | Subarachnoid  hemorrhage
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
-|style="background: #F5F5F5; padding: 5px;" |
+|style="background: #F5F5F5; padding: 5px;" |Xanthochromia<ref name="pmid1198628">{{cite journal| author=Lee MC, Heaney LM, Jacobson RL, Klassen AC| title=Cerebrospinal fluid in cerebral hemorrhage and infarction. | journal=Stroke | year= 1975 | volume= 6 | issue= 6 | pages= 638-41 | pmid=1198628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1198628  }}</ref>
 |style="background: #F5F5F5; padding: 5px;" |CT scan  without contrast<ref name="pmid21694755">{{cite journal| author=Birenbaum D, Bancroft LW, Felsberg GJ| title=Imaging in acute stroke. | journal=West J Emerg Med | year= 2011 | volume= 12 | issue= 1 | pages= 67-76 | pmid=21694755 | doi= | pmc=3088377 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694755  }}</ref><ref name="pmid21807345">{{cite journal| author=DeLaPaz RL, Wippold FJ, Cornelius RS, Amin-Hanjani S, Angtuaco EJ, Broderick DF et al.| title=ACR Appropriateness Criteria® on cerebrovascular disease. | journal=J Am Coll Radiol | year= 2011 | volume= 8 | issue= 8 | pages= 532-8 | pmid=21807345 | doi=10.1016/j.jacr.2011.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21807345  }}</ref>
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
@@ Line 78: / Line 75: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |Trauma/fall
 |style="background: #F5F5F5; padding: 5px;" |Confusion, dizziness, nausea, vomiting
@@ Line 95: / Line 91: @@
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px;" |STIs
@@ Line 102: / Line 97: @@
 Abnormal [[gait]]
 |-
-|style="background: #DCDCDC; padding: 5px; text-align: center;" |Complex or atypical migraine
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |Encephalitis
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
@@ Line 115: / Line 110: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px;" |Family history of [[migraine]]
 |style="background: #F5F5F5; padding: 5px;" |Presence of aura, [[nausea]], [[vomiting]]
 |-
-|style="background: #DCDCDC; padding: 5px; text-align: center;" |Hypertensive encephalopathy
+|style="background: #DCDCDC; padding: 5px; text-align: center;" |Herpes simplex encephalitis
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |✔
@@ Line 131: / Line 125: @@
 |style="background: #F5F5F5; padding: 5px;" |✔
 |style="background: #F5F5F5; padding: 5px;" |✔
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |History of hypertension
@@ Line 148: / Line 141: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |✔
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |History of alcohal abuse
@@ Line 165: / Line 157: @@
 |style="background: #F5F5F5; padding: 5px;" |✔
 |style="background: #F5F5F5; padding: 5px;" |✔
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |History of drug abuse, endocarditis, '''↓''' immune status
@@ Line 182: / Line 173: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |✔
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
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@@ Line 198: / Line 188: @@
 |style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px; text-align:center" | ✔
-|style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 |style="background: #F5F5F5; padding: 5px; text-align:center" |✔
@@ Line 209: / Line 198: @@
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |Depends on the cause
-|style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
 |style="background: #F5F5F5; padding: 5px;" |
@@ Line 221: / Line 209: @@
 |style="background: #F5F5F5; padding: 5px;" |Confusion, seizures
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Meningitis or encephalitis
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |Febrile seizures
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
@@ Line 236: / Line 224: @@
 | style="background: #F5F5F5; padding: 5px; text-align:center" |   ✔
 | style="background: #F5F5F5; padding: 5px; text-align:center" |✔
-| style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
@@ Line 243: / Line 230: @@
 rigidity
 |-
-| style="background: #DCDCDC; padding: 5px; text-align: center;" |Multiple sclerosis exacerbation
+| style="background: #DCDCDC; padding: 5px; text-align: center;" |Subdural empyema
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px; text-align:center" |✔
@@ Line 256: / Line 243: @@
 | style="background: #F5F5F5; padding: 5px;" |
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 | style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 | style="background: #F5F5F5; padding: 5px;" |History of relapses and remissions
@@ Line 274: / Line 260: @@
 | style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 | style="background: #F5F5F5; padding: 5px;" |Previous history of seizures
 | style="background: #F5F5F5; padding: 5px;" |Confusion, apathy, irritability,
@@ Line 292: / Line 277: @@
 | style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 | style="background: #F5F5F5; padding: 5px;" |
-| style="background: #F5F5F5; padding: 5px; text-align:center" |✔
 | style="background: #F5F5F5; padding: 5px;" |History of [[Diabetes mellitus|diabetes]]
 | style="background: #F5F5F5; padding: 5px;" |[[Palpitation|Palpitations]], sweating, [[dizziness]], low serum, glucose