A 19-year-old university student is brought to A&E by his roommate at 2am. He has had fever and severe headache since yesterday afternoon. His roommate reports he has become increasingly confused over the last 3 hours.
Examination: Temp 39.8°C, HR 118, BP 96/60, RR 22, SpO2 96%. GCS 12 (E3V3M6). Neck stiffness present. A non-blanching purpuric rash is noted on both lower limbs.
You have 60 seconds to make a decision. What do you do?
The Non-Blanching Rash — Act Immediately
The non-blanching purpuric rash in this context is meningococcal septicaemia until proven otherwise. Do not wait for LP results. Do not wait for CT. Give IV antibiotics immediately — the delay of even 30 minutes worsens outcomes significantly.
Suspected bacterial meningitis with purpuric rash: IV ceftriaxone 2g STAT immediately — before LP, before CT, before anything else. Then dexamethasone 0.15mg/kg IV. Then resuscitate. Then investigate. The antibiotic comes first.
What is Meningitis?
Meningitis is inflammation of the meninges — the three membrane layers (dura, arachnoid, pia mater) covering the brain and spinal cord. It is classified by cause: bacterial, viral, fungal, or tuberculous. Bacterial meningitis carries 20–30% mortality and leaves 10–15% of survivors with permanent disability — it is one of the most dangerous infections you will encounter.
Causes by Age Group
| Age Group | Common Organisms | Key Features |
|---|---|---|
| Neonates (<3 months) | Group B Streptococcus, E. coli, Listeria | Subtle signs — poor feeding, bulging fontanelle, high-pitched cry |
| Children (3mo–5yr) | N. meningitidis, S. pneumoniae, H. influenzae | Classic triad + purpuric rash in meningococcal disease |
| Young adults (15–25yr) | N. meningitidis (meningococcus) | University students, crowded living — highest risk group |
| Adults | S. pneumoniae (pneumococcus) | Most common bacterial cause in adults, highest mortality |
| Elderly/Immunocompromised | S. pneumoniae, Listeria, Gram-negatives | Add ampicillin to cover Listeria |
| HIV/Immunocompromised | Cryptococcus neoformans | Subacute onset, raised ICP, India ink positive CSF |
Clinical Features
Classic Triad + Additional Features
- Classic triad: Fever + Headache + Neck stiffness. Present in only 44% of cases — absence does not exclude meningitis.
- Photophobia and phonophobia — meningeal irritation
- Kernig's sign — inability to extend knee with hip flexed at 90°
- Brudzinski's sign — involuntary knee flexion on neck flexion
- Purpuric rash — non-blanching, pathognomonic of meningococcal septicaemia. Can be anywhere — check everywhere including mucosae.
- Altered consciousness — from raised ICP and cerebral oedema
- Focal neurological deficits — CN palsies, hemiplegia — suggest complications
- Seizures — 20–40% of bacterial meningitis
Lumbar Puncture — When and How
LP is essential for diagnosis — but never delay antibiotics for LP. If there are signs of raised ICP or focal neurology, do CT first. In uncomplicated meningitis, LP can be done immediately.
| CSF Finding | Bacterial | Viral | TB/Fungal |
|---|---|---|---|
| Appearance | Turbid/cloudy | Clear | Clear/xanthochromic |
| Opening pressure | Raised | Normal/mildly raised | Raised (especially cryptococcal) |
| White cells | >1000, neutrophils | 10–1000, lymphocytes | 10–500, lymphocytes |
| Protein | Raised (>1g/L) | Normal/mildly raised | Raised |
| Glucose (CSF:serum) | <0.5 (low) | Normal (>0.6) | Low |
Management
Bacterial Meningitis — Treatment
- Antibiotics immediately: Ceftriaxone 2g IV 12-hourly (adults). Add ampicillin 2g IV 4-hourly if Listeria possible (age >50, immunocompromised, pregnant).
- Dexamethasone 0.15mg/kg IV 6-hourly for 4 days: Reduces mortality and neurological sequelae in pneumococcal meningitis. Give with or before first antibiotic dose. Stop if not pneumococcal.
- Resuscitation: Aggressive fluid resuscitation if septic shock. ICU if GCS ≤8 or haemodynamic instability.
- Raised ICP management: Head up 30°, analgesia, avoid hypotension. Mannitol if signs of herniation.
- Duration: N. meningitidis 7 days, S. pneumoniae 10–14 days, Listeria 21 days.
- Contacts: Rifampicin or ciprofloxacin prophylaxis for close contacts of meningococcal meningitis.
Complications
Despite treatment, bacterial meningitis causes devastating complications in survivors: sensorineural hearing loss (most common — 10%), cognitive impairment, epilepsy, hydrocephalus, cerebrovascular events (vasculitis, venous sinus thrombosis), and limb loss from purpura fulminans in meningococcal disease.
Non-blanching rash + meningism + septic picture = meningococcal disease. IV ceftriaxone 2g given immediately (before any further investigation). Dexamethasone started. Aggressive fluid resuscitation. LP after stabilisation confirmed N. meningitidis on culture. Contacts identified and given ciprofloxacin prophylaxis. Patient recovered with no neurological deficit after 7 days IV antibiotics — an outcome that depended entirely on the speed of the first antibiotic dose.
Non-blanching rash + fever + headache = meningococcal septicaemia — antibiotics immediately. Never delay antibiotics for LP or CT. Classic triad (fever, headache, neck stiffness) present in only 44%. Bacterial CSF: turbid, neutrophils, high protein, low glucose. Ceftriaxone 2g IV + dexamethasone. Add ampicillin if Listeria possible. Contact prophylaxis with ciprofloxacin for meningococcal cases.
References
- van de Beek D et al. Clinical features and prognostic factors in adults with bacterial meningitis. NEJM. 2004;351(18):1849–1859.
- Tunkel AR et al. Practice Guidelines for the Management of Bacterial Meningitis. Clinical Infectious Diseases. 2004;39(9):1267–1284.
- de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. NEJM. 2002;347(20):1549–1556.
