Meningitis

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Management of suspected meningitis (fever + headache + neck stiffness) at District level (or higher):

• Urgent lumbar puncture (18G cannula adequate in adults if spinal needle unavailable).
• Blood slide for malaria parasites.

If diagnosis is in doubt DO NOT perform a lumbar puncture. Refer to a higher level.

Contraindications to lumbar puncture:

• deeply unconscious + focal signs;
• one pupil large and unresponsive;
• papilloedema (if fundoscopy available);
• rapidly falling level of consciousness.

These are indications for referral to a tertiary care centre.

• Lumbar puncture should be considered mandatory, and, preferably, when the condition is first suspected since Cryptococcal meningitis must always be excluded.
• Tuberculous meningitis should always be suspected. It may have no special distinguishing features, and can present acutely.

If symptoms suggestive of a meningitis:

Medicine	Adult dose	Frequency	Duration
benzylpenicillin iv	3g (5MU)	6 hourly
chloramphenicol iv	500mg	6 hourly	until CSF results out

Note: for dose in children see chapter on Paediatric conditions

Spinal fluid microscopy, (protein, glucose; Gram stain India ink stain, Ziehl-Neelsen stain and cultures if possible) and blood glucose.

Treatment for Bacterial Meningitis:

	Medicine	Adult Dose	Frequency	Duration
	benzylpenicillin iv	3g (5MU)	6 hourly	14 days
and	chloramphenicol iv	500mg	6 hourly	14 days
or	ceftriaxone iv	1g	12 hourly	14 days

Note: for paediatric doses see chapter on Paediatric conditions

Chemoprophylaxis for close contacts (meningococcal meningitis only):

Give as soon as diagnosis made in index case.

Medicine	Adult Dose	Frequency	Duration
Ceftriaxone im	500mg	once only	single dose

Note: for dose in children see chapter on Paediatric conditions

Further Management

The combination of fever and focal neurological signs is an indication for referral to a central hospital and CT scan of the head.

The differential diagnosis includes cerebral abscess, cryptococcal meningitis, tuberculoma, toxoplasma encephalitis, and other parasitic infection.

If a focal contrast-enhancing lesion or multiple lesions are present on scan and the patient is known to be HIV infected or is suspected to be infected on clinical grounds, start treatment for toxoplasmosis:

	Medicine	Adult dose	Frequency	Duration
	sulphadiazine po	2g	4 times a day	6 weeks
and	pyrimethamine po	200mg loading dose and then 50mg	once a day	6 weeks
or	clindamycin* po	600mg	4 times a day	6 weeks
and	pyrimethamine po	200mg loading dose and then 50mg	once a day	6 weeks
or	co-trimoxazole po	1920mg	3 times a day	6 weeks

*alternative to sulphadiazine

Note: for dose in children see chapter on Paediatric conditions

If there is no response (clinically and on CT scan), in two weeks , or if lesion appears atypical, consider anti-tuberculous treatment and neurosurgical intervention. (May need biopsy)