Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Meningitis

Last updated: August 18, 2021

Summarytoggle arrow icon

Meningitis is a serious infection of the meninges in the brain or spinal cord that is most commonly viral or bacterial in origin, although fungal, parasitic, and noninfectious causes are also possible. Enteroviruses and herpes simplex virus are the leading causes of viral meningitis, while Neisseria meningitidis and Streptococcus pneumoniae are the pathogens most commonly responsible for bacterial meningitis. Rarer forms of bacterial meningitis include tuberculous meningitis and Lyme-associated meningitis. The classic triad of meningitis is fever, headache, and neck stiffness. In infants and young children, the presentation is often nonspecific. Patients may also present with neurological deficits, altered mental status, and seizures, indicating increased intracranial pressure (ICP). The diagnosis is confirmed with lumbar puncture (LP) and CSF analysis. If increased ICP is suspected, a CT of the head should be performed first. Bacterial meningitis requires rapid initiation of empiric treatment. A life-threatening complication of bacterial meningitis (especially meningococcal meningitis) is Waterhouse-Friderichsen syndrome, which is characterized by disseminated intravascular coagulation and acute adrenal gland insufficiency. Viral meningitis typically resolves on its own and has a far less severe course than bacterial meningitis, which is generally fatal if left untreated. When N. meningitidis or S. pneumoniae are identified as the pathogen, the CDC should be notified and preventative measures taken to prevent dissemination of the infection.

  • In the pediatric population, meningitis most often occurs in children < 1 year of age. [1]
  • The median age of adult patients with meningitis is 43 years. [2]
  • Worldwide, the incidence of meningitis caused by N. meningitidis is highest in sub-Saharan Africa, collectively referred to as the “meningitis belt.” [3]

Epidemiological data refers to the US, unless otherwise specified.

Common causes

Risk factors

Common bacterial pathogens by patient group [4][5]

Patient population Pathogen
By age
< 1 month [1]
1 month – 2 years [2]
2–50 years [2][8]
> 50 years [2][9]
By underlying state
Immunocompromized [10]
Basilar skull fracture [9]
Penetrating trauma [9]
Healthcare-associated [11]

Less common bacterial pathogens

Other etiologies

Causes of meningitis in immunocompromised individuals

References:[19][20][21][22][23][24]

Pathways of infection

  • Most pathogens that cause meningitis colonize the nasopharynx or the upper airways before entering the CNS via:
    • Hematogenous dissemination . [25]
    • Contiguous spread of infections in nose, eyes, and ears
    • Retrograde transport along or within peripheral or cranial nerves
  • Direct infection (e.g., due to trauma or head surgery) [26]

Incubation periods

  • Bacterial meningitis: usually 3–7 days [27]
  • Viral meningitis: usually 2–14 day, depending on the type of virus

References:[20][22][27]

Clinical features of bacterial and viral meningitis are similar, although viral meningitis is less acute and usually self-limiting within 7–10 days.

Neonates (neonatal meningitis)

In neonates, meningitis often manifests with nonspecific symptoms and without the classic triad of meningitis.

Children and adults

Subarachnoid hemorrhage can manifest with the classic triad of meningitis but has a more sudden onset and patients often lose consciousness.

The classical features of acute bacterial meningitis are fever, neck stiffness, and headache. However, this triad of symptoms only manifests in approx. 50% of cases.

Physical examination [20][31]

Features suggestive of meningoencephalitis [34][35]

In addition to the features of meningitis, meningoencephalitis is characterized by signs of inflammation of the brain parenchyma (encephalitis).

References:[19][31][36][37]

General approach

Do not delay empiric antibiotic therapy in patients suspected of having bacterial meningitis.

Challenges

  • Diagnosis
  • Treatment
    • Bacterial meningitis can be rapidly progressive and life-threatening.
    • Patients may present as critically ill and with complications (e.g., sepsis, multiorgan failure) requiring early aggressive supportive care.
    • Empiric antibiotic treatment must be initiated as soon as possible (i.e., often prior to diagnosis).

Approach [5][29][30][38][39]


Start empiric antibiotics immediately after obtaining blood cultures and CSF samples. If LP is delayed for any reason (e.g., the need for a CT or hemodynamic stabilization), obtain blood cultures and administer antibiotics until it can be performed.

Laboratory studies [5][29][30][38]

Neuroimaging [26][38][39]

Imaging is not necessary to establish the diagnosis of meningitis in most patients and should only be considered in patients with significant risk factors for complications.

  • Indications
    • To assess the risk of brain herniation precipitated by LP [38]
    • Identify abscesses or other localized lesions (e.g., in postsurgical patients in whom infection is suspected) [26]
    • Suspected healthcare-associated ventriculitis/meningitis [26]
    • Patients with devices (e.g., CSF shunts) [26]
  • Recommended criteria for imaging prior to LP in suspected meningitis [38][39][40]
  • Modalities
    • CT head (with or without IV contrast): before LP if increased ICP is suspected [41]
    • MRI brain with IV contrast and diffusion: especially useful in patients with devices or after surgery [26]
  • Supportive findings
    • Usually normal or showing mild meningeal enhancement
    • May identify predisposing factors for the infection (e.g., fractures, mastoiditis) or complications (e.g., abscess)
    • See “Subtypes and variants” for characteristic findings of specific pathogens.

To remember the indications for imaging before LP, think of LP FAILS: Focal neurological deficits, Altered mental status, Immunocompromised or ICP, Lesions (space-occupying lesions in the brain), Seizures.

Cerebrospinal fluid analysis

Lumbar puncture is indicated in all patients with suspected meningitis (see “Lumbar puncture” for details on indications, LP contraindications, procedural steps, and complications).

Approach to interpretation

Routine testing [38][39][40]

Cerebrospinal fluid analysis in meningitis [38][40]
Normal Bacterial meningitis Viral meningitis
Appearance
  • Clear fluid
  • Clear fluid
Cell count and differential
  • Cell count < 5/mm3
Opening pressure [42]
  • 5–18 cm H2O
  • ↑↑
  • Normal or ↑
Lactate [39]
  • 1.2–2.1 mmol/L
  • ↑↑
  • Variable
Protein
  • 15–45 mg/dL
  • Normal or ↑
Glucose
  • 40–75 mg/dL
  • Normal
Gram stain and culture [39][40]
  • No organisms present
  • No organisms present

Atypical pathogen testing

Atypical pathogen testing is not necessary for all patients and should be performed as directed by clinical suspicion.

Cerebrospinal fluid analysis in meningitis due to atypical pathogens [40]
Tuberculous meningitis [43] Lyme meningitis [44] Cryptococcal meningitis [45]
Appearance
  • Clear fluid with a spiderweb clot
  • Clear fluid
  • Cloudy fluid
Cell count and differential
Opening pressure
  • ↑↑
  • ↑↑
  • ↑↑
Lactate [39]
  • Variable
Protein
  • Normal or ↑ [44]
  • [45]
Glucose
  • Normal or ↓
  • [45]

Additional microbiological testing

Approach

Do not delay administering antibiotics if neuroimaging is indicated prior to LP. Obtain blood cultures, start antibiotics (and steroids, if needed) immediately, then proceed with the CT and LP.

Patient stabilization

Antimicrobial therapy

Empiric antibiotic therapy [38]

  • The choice of initial empiric therapy depends primarily on the prevalence of organisms in certain age groups and individual patient risk factors for resistant organisms.
  • Factors to consider:
    • Epidemiological factors (e.g., local flora, resistance patterns)
    • Bioavailability: Antimicrobial agents should cross the blood-brain barrier and higher doses may be needed.
    • Individual patient risk factors and comorbidities
Empiric antibiotic therapy for bacterial meningitis [38]
Patient characteristics Recommended regimen

Age < 1 month

Age > 1 month to < 50 years
Age > 50 years

Immunocompromised

(E.g., as a result of HIV, AIDS, use of immunosuppressants, or following transplantation) [47]

Healthcare-associated infections [26]

Suspected rickettsial (e.g., RMSF) or ehrlichial infection [48]

Basilar skull fracture
Penetrating head trauma

Ampicillin is added if patients are at risk of Listeria spp. infection (e.g., newborns, pregnant women, the elderly, or immunocompromised patients) because cephalosporins are ineffective against Listeria spp.

Ceftriaxone is contraindicated in patients aged < 1 month because of a higher risk of biliary sludging and kernicterus. Cefotaxime or ceftazidime can be used instead. [46]

Empiric therapy for viral meningitis [19][48]

Most cases of viral meningitis (e.g., caused by enteroviruses) can be treated supportively. Specific antiviral therapy is only warranted if viral encephalitis is also suspected (see HSV encephalitis for further details).

Treatment with acyclovir should be started in all patients who present with typical clinical signs of viral meningoencephalitis and only discontinued after PCR and antibody tests are negative for HSV and VZV, even if CSF is initially normal.

Pathogen-specific therapy

The decision to narrow therapy should be guided by final culture and sensitivity results, as well as local resistance patterns. We list a few examples of antimicrobial agents that may be used against specific pathogens.

Pathogen-specific therapy in meningitis [38]
Pathogen Examples of antimicrobial agents

S. pneumoniae (penicillin-resistant strains)
MRSA
S. epidermidis
H. influenzae
N. meningitidis
L. monocytogenes
S. agalactiae
E. coli
Enterococcus spp.
P. aeruginosa
R. rickettsii
Herpesviruses
Less frequent pathogens, e.g., M. tuberculosis, C. neoformans, B. burgdorferi
  • See “Subtypes and variants”.

Corticosteroids [39][49]

Do not delay antibiotics to administer adjuvant therapy. If dexamethasone is not readily available, start antibiotics immediately.

Supportive therapy

Monitoring and disposition

  • Most patients with meningitis require admission; select patients may be considered for outpatient therapy with close follow-up. [38]
  • Serial neuro examinations
  • Consultations:
    • Infectious disease
    • Consider also ICU , neurology, neurosurgery as needed.

Tuberculous meningitis

Cryptococcal meningitis


Tick-borne diseases

North America

Eurasia: Tick-borne meningoencephalitis

  • Pathogen: tick-borne encephalitis virus (TBEV)
    • TBEVs are part of the Flaviviridae family and occur predominantly in parts of Europe, Russia, and Asia.
    • TBEV is very closely related to the Powassan virus in the US and Russia, which is a rare cause of encephalitis.
  • Route of infection: tick-borne
    • Ixodid tick acts as a vector; therefore, transmission is predominantly in June/July and September/October.
    • Occasional transmission via unpasteurized dairy products from infected livestock
  • Incubation period: usually 7–14 days
  • Clinical features:
    • Nearly 90% of cases are asymptomatic.
    • Biphasic course: initial flu-like symptoms and fever, followed (after ∼ 8 days) by a fever-free interval and subsequent increase in temperature, which is associated with the onset of meningoencephalitis
  • Treatment: symptomatic
  • Prognosis:
    • Full recovery is common (particularly in children and adolescents).
    • In symptomatic disease, residual symptoms may occur.
  • Prevention: A vaccine is not available in the US.

Primary amoebic meningoencephalitis [55]

References:[20][57][58][59][60][61][62][63][64]

Neurologic

Waterhouse-Friderichsen syndrome

References:[19][31][65][66][67][68][69][70]

We list the most important complications. The selection is not exhaustive.

  • Bacterial meningitis
    • Fatal if left untreated
    • Prognosis in treated patients depends on age, overall condition, immune status and the pathogen(s) involved.
  • Viral meningitis
  • Fungal meningitis
    • Associated with neurological sequelae and a high mortality rate
    • Treatment adherence is very important to avoid relapse.

References:[67]

Postexposure chemoprophylaxis for bacterial meningitis
Pathogen Indications Recommended regimen
N. meningitidis [72][73][74]
  • Close contact with the index patient in the 7 days before the onset of symptoms
    • All household and/or day-care members
    • Anyone exposed to secretions, including:
H. influenzae [71][75]
  • Household contacts (≥ 4 hours of contact/day): If any of the contacts are unvaccinated children ≤ 4 years of age or immunocompromised, administer prophylaxis to all members of the household except pregnant women.
  • Day-care facility (if attended 5–7 days before the onset of symptoms): If there are children ≤ 2 years of age, unvaccinated children, or ≥ 2 cases within 60 days, administer prophylaxis for all children and personnel PLUS vaccines when indicated.

For N. meningitidis, ceftriaxone is the chemoprophylaxis of choice during pregnancy.

  1. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice Guidelines for the Management of Bacterial Meningitis. Clinical Infectious Diseases. 2004; 39 (9): p.1267-1284. doi: 10.1086/425368 . | Open in Read by QxMD
  2. Mount HR, Boyle SD. Aseptic and Bacterial Meningitis: Evaluation, Treatment, and Prevention.. Am Fam Physician. 2017; 96 (5): p.314-322.
  3. Bamberger. Diagnosis, Initial Management, and Prevention of Meningitis. American Family Physician. 2010 .
  4. Ku LC, Boggess KA, Cohen-Wolkowiez M. Bacterial Meningitis in Infants. Clin Perinatol. 2015; 42 (1): p.29-45. doi: 10.1016/j.clp.2014.10.004 . | Open in Read by QxMD
  5. Stoll BJ, Hansen NI, Sanchez PJ, et al. Early Onset Neonatal Sepsis: The Burden of Group B Streptococcal and E. coli Disease Continues. Pediatrics. 2011; 127 (5): p.817-826. doi: 10.1542/peds.2010-2217 . | Open in Read by QxMD
  6. Thigpen MC, Whitney CG, Messonnier NE, et al. Bacterial Meningitis in the United States, 1998–2007. N Engl J Med. 2011; 364 (21): p.2016-2025. doi: 10.1056/nejmoa1005384 . | Open in Read by QxMD
  7. Wenger JD, Hightower AW, Facklam RR, Gaventa S, Broome CV. Bacterial Meningitis in the United States, 1986: Report of a Multistate Surveillance Study. J Infect Dis. 1990; 162 (6): p.1316-1323. doi: 10.1093/infdis/162.6.1316 . | Open in Read by QxMD
  8. Castelblanco RL, Lee M, Hasbun R. Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study. Lancet Infect Dis. 2014; 14 (9): p.813-819. doi: 10.1016/s1473-3099(14)70805-9 . | Open in Read by QxMD
  9. Bamberger DM. Diagnosis, initial management, and prevention of meningitis.. Am Fam Physician. 2010; 82 (12): p.1491-8.
  10. Brouwer MC, Tunkel AR, van de Beek D. Epidemiology, Diagnosis, and Antimicrobial Treatment of Acute Bacterial Meningitis. Clin Microbiol Rev. 2010; 23 (3): p.467-492. doi: 10.1128/cmr.00070-09 . | Open in Read by QxMD
  11. Srihawan C, Castelblanco RL, Salazar L, et al. Clinical Characteristics and Predictors of Adverse Outcome in Adult and Pediatric Patients With Healthcare-Associated Ventriculitis and Meningitis. Open Forum Infectious Diseases. 2016; 3 (2): p.ofw077. doi: 10.1093/ofid/ofw077 . | Open in Read by QxMD
  12. Hasbun R, Rosenthal N, Balada-Llasat JM, et al. Epidemiology of Meningitis and Encephalitis in the United States, 2011–2014. Clinical Infectious Diseases. 2017; 65 (3): p.359-363. doi: 10.1093/cid/cix319 . | Open in Read by QxMD
  13. Miskin DP, Koralnik IJ. Novel syndromes associated with JC virus infection of neurons and meningeal cells. Curr Opin Neurol. 2015; 28 (3): p.288-294. doi: 10.1097/wco.0000000000000201 . | Open in Read by QxMD
  14. Pires SAP, Lemos AP, Pereira EPMN, Maia PA da SV, Agro JP de S e AB do. IBUPROFEN-INDUCED ASEPTIC MENINGITIS: A CASE REPORT. Revista Paulista de Pediatria. 2019; 37 (3): p.382-385. doi: 10.1590/1984-0462/;2019;37;3;00016 . | Open in Read by QxMD
  15. Overturf GD. Indications for the Immunological Evaluation of Patients with Meningitis. Clinical Infectious Diseases. 2003; 36 (2): p.189-194. doi: 10.1086/345527 . | Open in Read by QxMD
  16. Chadwick DR. Viral meningitis. Br Med Bull. 2005; 75-76 (1): p.1-14. doi: 10.1093/bmb/ldh057 . | Open in Read by QxMD
  17. Charalambous LT, Premji A, Tybout C, et al. Prevalence, healthcare resource utilization and overall burden of fungal meningitis in the United States. J Med Microbiol. 2018; 67 (2): p.215-227. doi: 10.1099/jmm.0.000656 . | Open in Read by QxMD
  18. Baliu C, Sanclemente G, Cardona M, et al. Toxoplasmic encephalitis associated with meningitis in a heart transplant recipient. Transplant Infectious Disease. 2014; 16 (4): p.631-633. doi: 10.1111/tid.12242 . | Open in Read by QxMD
  19. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  20. Agabegi SS, Agabegi ED. Step-Up To Medicine. Wolters Kluwer Health ; 2015
  21. Le T, Bhushan V. First Aid for the USMLE Step 1 2015. McGraw-Hill Education ; 2014
  22. Bacterial Meningitis. https://www.cdc.gov/meningitis/bacterial.html. Updated: January 25, 2017. Accessed: March 28, 2017.
  23. Tunkel AR. Epidemiology of bacterial meningitis in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/epidemiology-of-bacterial-meningitis-in-adults.Last updated: September 9, 2016. Accessed: March 28, 2017.
  24. Gluckman SJ. Viral Encephalitis in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/viral-encephalitis-in-adults.Last updated: October 15, 2017. Accessed: May 7, 2018.
  25. Alex Guri, Eric Scheier, Meital Adi, Mikhael Chigrinsky. Biot’s breathing associated with acute bacterial meningitis in a child. BMJ Case Reports. 2018 .
  26. Van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical Features and Prognostic Factors in Adults with Bacterial Meningitis. N Engl J Med. 2004; 351 (18): p.1849-1859. doi: 10.1056/nejmoa040845 . | Open in Read by QxMD
  27. Weisfelt M, Van De Beek D, Spanjaard L, Reitsma JB, De Gans J. Community-Acquired Bacterial Meningitis in Older People. J Am Geriatr Soc. 2006; 54 (10): p.1500-1507. doi: 10.1111/j.1532-5415.2006.00878.x . | Open in Read by QxMD
  28. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2015
  29. Tunkel AR. Clinical features and diagnosis of acute bacterial meningitis in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-acute-bacterial-meningitis-in-adults.Last updated: August 17, 2016. Accessed: March 28, 2017.
  30. Tsai J, Nagel MA, Gilden D. Skin rash in meningitis and meningoencephalitis. Neurology. 2013; 80 (19): p.1808-1811. doi: 10.1212/wnl.0b013e3182918cda . | Open in Read by QxMD
  31. Daroff RB, et al.. Bradley's Neurology in Clinical Practice. Elsevier
  32. Silva MTT. Viral encephalitis. Arq Neuropsiquiatr. 2013; 71 (9B): p.703-709. doi: 10.1590/0004-282x20130155 . | Open in Read by QxMD
  33. Edwards MS, Baker CJ. Meningitis in the Neonate: Clinical Features and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/bacterial-meningitis-in-the-neonate-clinical-features-and-diagnosis.Last updated: January 18, 2016. Accessed: March 24, 2017.
  34. Cutrer FM. Evaluation of the adult with headache in the emergency department. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/evaluation-of-the-adult-with-headache-in-the-emergency-department.Last updated: May 11, 2015. Accessed: March 28, 2017.
  35. Novak RT, Ronveaux O, Bita AF, et al. Future Directions for Meningitis Surveillance and Vaccine Evaluation in the Meningitis Belt of Sub-Saharan Africa. J Infect Dis. 2019; 220 (Supplement_4): p.S279-S285. doi: 10.1093/infdis/jiz421 . | Open in Read by QxMD
  36. Van de Beek D, Cabellos C, Dzupova O, et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clinical Microbiology and Infection. 2016; 22 : p.S37-S62. doi: 10.1016/j.cmi.2016.01.007 . | Open in Read by QxMD
  37. Tunkel et al. 2017 Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis. Clinical Infectious Diseases. 2017; 64 (6): p.e34-e65. doi: 10.1093/cid/ciw861 . | Open in Read by QxMD
  38. Seehusen, et al. Cerebrospinal Fluid Analysis. American Family Physician. 2003 .
  39. Kastrup O, Wanke I, Maschke M. Neuroimaging of infections. NeuroRX. 2005; 2 (2): p.324-332. doi: 10.1602/neurorx.2.2.324 . | Open in Read by QxMD
  40. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  41. Thwaites G. Neurological aspects of tropical disease: Tuberculous meningitis. Journal of Neurology, Neurosurgery & Psychiatry. 2000; 68 (3): p.289-299. doi: 10.1136/jnnp.68.3.289 . | Open in Read by QxMD
  42. Krawczuk K, Czupryna P, Pancewicz S, Ołdak E, Król M, Moniuszko-Malinowska A. Comparison of Neuroborreliosis Between Children and Adults. Pediatr Infect Dis J. 2020; 39 (1): p.7-11. doi: 10.1097/inf.0000000000002493 . | Open in Read by QxMD
  43. Bahr NC, Boulware DR. Methods of rapid diagnosis for the etiology of meningitis in adults. Biomarkers in Medicine. 2014; 8 (9): p.1085-1103. doi: 10.2217/bmm.14.67 . | Open in Read by QxMD
  44. Pacifici GM. Pharmacokinetics of cephalosporins in the neonate: a review. Clinics. 2011; 66 (7): p.1267-1274. doi: 10.1590/s1807-59322011000700024 . | Open in Read by QxMD
  45. Van de Beek D, Brouwer MC, Thwaites GE, Tunkel AR. Advances in treatment of bacterial meningitis. Lancet. 2012; 380 (9854): p.1693-1702. doi: 10.1016/s0140-6736(12)61186-6 . | Open in Read by QxMD
  46. Tunkel AR, Glaser CA, Bloch KC, et al. The Management of Encephalitis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2008; 47 (3): p.303-327. doi: 10.1086/589747 . | Open in Read by QxMD
  47. De Gans J, van de Beek D. Dexamethasone in Adults with Bacterial Meningitis. N Engl J Med. 2002; 347 (20): p.1549-1556. doi: 10.1056/nejmoa021334 . | Open in Read by QxMD
  48. Sexton DJ. Neurologic complications of bacterial meningitis in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/neurologic-complications-of-bacterial-meningitis-in-adults.Last updated: September 1, 2015. Accessed: March 28, 2017.
  49. WebMD. A 30-Year-Old Woman With Fever and a Rash. A 30-Year-Old Woman With Fever and a Rash. New York, NY: WebMD. http://www.medscape.org/viewarticle/586310_2. Updated: March 29, 2017. Accessed: March 29, 2017.
  50. Tunkel AR. Initial therapy and prognosis of bacterial meningitis in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/initial-therapy-and-prognosis-of-bacterial-meningitis-in-adults.Last updated: December 21, 2016. Accessed: March 28, 2017.
  51. Scheld WM, Whitley RJ, Marra CM. Infections of the Central Nervous System. Wolters Kluwer ; 2014
  52. Apicella M. Clinical manifestations of meningococcal infection. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-meningococcal-infection.Last updated: September 3, 2015. Accessed: March 29, 2017.
  53. de Assis Aquino Gondim F. Meningococcal Meningitis. Meningococcal Meningitis. New York, NY: WebMD. http://emedicine.medscape.com/article/1165557. Updated: June 15, 2016. Accessed: March 29, 2017.
  54. AAP Committee on Infectious Diseases. Red Book 2018-2021. American Academy of Pediatrics ; 2018
  55. Gardner P. Prevention of Meningococcal Disease. N Engl J Med. 2006; 355 (14): p.1466-1473. doi: 10.1056/nejmcp063561 . | Open in Read by QxMD
  56. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP).. MMWR: Recommendations and reports. 2013; 62 (RR-2): p.1-28.
  57. Bilukha OO, Rosenstein N, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC).. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP).. MMWR: Recommendations and reports. 2005; 54 (RR-7): p.1-21.
  58. Saag MS et al. The Sanford Guide to Antimicrobial Therapy 2016. Antimicrobial Therapy, Inc ; 2016
  59. Sharma et al.. Incidence, predictors and prognostic value of cranial nerve involvement in patients with tuberculous meningitis: A retrospective evaluation. European Journal of Internal Medicine. 2011 .
  60. Cho B-H, Kim BC, Yoon G-J, et al. Adenosine deaminase activity in cerebrospinal fluid and serum for the diagnosis of tuberculous meningitis. Clin Neurol Neurosurg. 2013; 115 (9): p.1831-1836. doi: 10.1016/j.clineuro.2013.05.017 . | Open in Read by QxMD
  61. Ekermans P, Dusé A, George J. The dubious value of cerebrospinal fluid adenosine deaminase measurement for the diagnosis of tuberculous meningitis. BMC Infect Dis. 2017; 17 (1). doi: 10.1186/s12879-017-2221-3 . | Open in Read by QxMD
  62. Abassi M, Boulware DR, Rhein J. Cryptococcal Meningitis: Diagnosis and Management Update.. Current tropical medicine reports. 2015; 2 (2): p.90-99. doi: 10.1007/s40475-015-0046-y . | Open in Read by QxMD
  63. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/introduction?view=full. Updated: August 18, 2020. Accessed: December 18, 2020.
  64. Grace E et al.. Naegleria fowleri: Pathogenesis, Diagnosis, and Treatment Options. Antimicrobial Agents Chemother (Bethesda). 2015; 59 (11): p.6677-6681. doi: 10.1128/aac.01293-15 . | Open in Read by QxMD
  65. CDC — Primary Amebic Meningoencephalitis (PAM) — Treatment. https://www.cdc.gov/parasites/naegleria/treatment.htm. Updated: April 4, 2019. Accessed: July 21, 2020.
  66. Meyerhoff JO. Lyme Disease. In: Diamond HS, Lyme Disease. New York, NY: WebMD. http://emedicine.medscape.com/article/330178-workup#c7. Updated: March 14, 2016. Accessed: February 7, 2017.
  67. Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci. 2011; 11 (1): p.116-127.
  68. Cox GM, Perfect JR. Epidemiology, clinical manifestations, and diagnosis of Cryptococcus neoformans meningoencephalitis in HIV-infected patients. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-cryptococcus-neoformans-meningoencephalitis-in-hiv-infected-patients.Last updated: January 4, 2016. Accessed: March 28, 2017.
  69. Cox GM, Perfect JR. Clinical management and monitoring during antifungal therapy of the HIV-infected patient with cryptococcal meningoencephalitis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/clinical-management-and-monitoring-during-antifungal-therapy-of-the-hiv-infected-patient-with-cryptococcal-meningoencephalitis.Last updated: February 22, 2016. Accessed: March 28, 2017.
  70. Tick-borne Encephalitis (TBE). https://www.cdc.gov/vhf/tbe/index.html. Updated: March 31, 2014. Accessed: March 28, 2017.
  71. Travelers' Health: Tick-borne Encephalitis. https://wwwnc.cdc.gov/travel/diseases/tickborne-encephalitis. Updated: March 9, 2013. Accessed: March 28, 2017.
  72. Ramachandran TS. Tuberculous Meningitis. Tuberculous Meningitis. New York, NY: WebMD. http://emedicine.medscape.com/article/1166190. Updated: December 11, 2014. Accessed: March 28, 2017.
  73. Naegleria fowleri - Primary Amebic Meningoencephalitis (PAM). https://www.cdc.gov/parasites/naegleria/treatment.html. Updated: February 28, 2017. Accessed: March 30, 2020.
  74. Christensen H, May M, Bowen L, Hickman M, Trotter CL. Meningococcal carriage by age: a systematic review and meta-analysis. Lancet Infect Dis. 2010; 10 (12): p.853-861. doi: 10.1016/s1473-3099(10)70251-6 . | Open in Read by QxMD
  75. Epidemiology and Prevention of Vaccine-Preventable Diseases.
  76. Jenkins B, McInnis M, Lewis C. Step-Up to USMLE Step 2 CK. Lippincott Williams & Wilkins ; 2015
  77. 2017 Nationally Notifiable Conditions. https://wwwn.cdc.gov/nndss/conditions/notifiable/2017/. Updated: January 1, 2017. Accessed: March 22, 2017.
  78. Manual for the Surveillance of Vaccine-Preventable Diseases: Chapter 8: Meningococcal Disease.
  79. Cox GM, Perfect JR. Clinical manifestations and diagnosis of Cryptococcus neoformans meningoencephalitis in HIV-seronegative patients. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-cryptococcus-neoformans-meningoencephalitis-in-hiv-seronegative-patients.Last updated: June 7, 2016. Accessed: March 28, 2017.
  80. CSF Analysis. https://wiki.med.umich.edu/display/NEURO/CSF+Analysis. Updated: October 26, 2010. Accessed: March 28, 2017.
  81. CSF Analysis: Exams. https://labtestsonline.org/understanding/analytes/csf/csf-exams?start=1. Updated: March 2, 2017. Accessed: March 28, 2017.
  82. Management of bacterial meningitis. http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_by_Organ_System/Central_Nervous_System_(CNS)/Bacterial_Meningitis/. Updated: January 1, 2004. Accessed: October 6, 2017.
  83. 2018 National Notifiable Infectious Diseases. https://wwwn.cdc.gov/nndss/conditions/notifiable/2018/infectious-diseases/. Updated: January 1, 2018. Accessed: May 9, 2018.
  84. D’Souza RS, Mercogliano C, Ojukwu E, et al. Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute antiemetic drugs: a systematic review and meta-analysis. Emergency Medicine Journal. 2018; 35 (5): p.325-331. doi: 10.1136/emermed-2017-206944 . | Open in Read by QxMD
  85. Al‐Saffar A, Lennernäs H, Hellström PM. Gastroparesis, metoclopramide, and tardive dyskinesia: Risk revisited. Neurogastroenterology & Motility. 2019 : p.e13617. doi: 10.1111/nmo.13617 . | Open in Read by QxMD
  86. Wijemanne S, Jankovic J, Evans RW. Movement Disorders From the Use of Metoclopramide and Other Antiemetics in the Treatment of Migraine. Headache: The Journal of Head and Face Pain. 2015; 56 (1): p.153-161. doi: 10.1111/head.12712 . | Open in Read by QxMD
  87. Sheldon L Kaplan. Bacterial meningitis in children older than one month: Clinical features and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/bacterial-meningitis-in-children-older-than-one-month-clinical-features-and-diagnosis.Last updated: August 15, 2018. Accessed: February 28, 2020.