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For further information, see CMDT Part 33-12: Meningococcal Meningitis

Key Features

Essentials of Diagnosis

  • Fever, headache, vomiting, delirium, convulsions

  • Petechial rash of skin and mucous membranes

  • Neck and back stiffness; positive Kernig and Brudzinski signs are characteristic

  • Purulent spinal fluid with gram-negative intracellular and extracellular diplococci

  • Culture of cerebrospinal fluid, blood, or petechial aspiration confirms the diagnosis

General Considerations

  • Caused by Neisseria meningitidis of groups A, B, C, Y, W-135, and others

  • Infection is transmitted by droplets

  • The clinical illness may take the form of meningococcemia (a fulminant form of septicemia) without meningitis, meningococcemia with meningitis, or predominantly meningitis

  • Chronic recurrent meningococcemia with fever, rash, and arthritis can occur, particularly in those with terminal complement deficiencies


  • The prevalence of strains of N meningitidis with intermediate resistance to penicillin in vitro (MICs 0.1–1 mcg/mL) is increasing, particularly in Europe

Clinical Findings

Symptoms and Signs

  • High fever, chills, nausea and vomiting, and headache as well as back, abdominal, and extremity pains are typical

  • In older adults, fever or stiff neck is often missing, and altered mental status may dominate the picture

  • Rapidly developing confusion, delirium, seizures, and coma can occur in some patients

  • Nuchal and back rigidity are typical

  • A petechial rash is found in most cases; it appears

    • All over the body, including on mucous membranes

    • On the lower extremities

    • At pressure points

  • Petechiae may vary from pinhead sized to large ecchymoses or even areas of skin gangrene that may later slough

Differential Diagnosis

  • Rickettsial, echovirus and, rarely, other bacterial infections (eg, staphylococcal infections, scarlet fever) can cause petechial rash


Laboratory Tests

  • The organism is usually found by smear or culture of the cerebrospinal fluid, oropharynx, blood, or aspirated petechiae


  • See Table 30–1

  • Typically, a cloudy or purulent fluid, with elevated pressure, increased protein, and decreased glucose content

  • Usually contains more than 1000 cells/mcL (1.0 × 109/L), with polymorphonuclear cells predominating and containing gram-negative intracellular diplococci

  • The absence of organisms in a Gram-stained smear does not rule out the diagnosis

  • The capsular polysaccharide can often be demonstrated in cerebrospinal fluid or urine by latex agglutination; this is especially useful in partially treated patients, though sensitivity is only 60–80%

Table 30–1.Typical cerebrospinal fluid findings in various central nervous system diseases (listed in alphabetical order after Normal).

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