Meningitis 2.0
Tue Feb 03 2026
We review diagnosing and managing bacterial meningitis in the ED.
Hosts:
Sarah Fetterolf, MD
Avir Mitra, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Meningitis_2_0.mp3
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Tags: CNS Infections, Infectious Diseases, Neurology
Show Notes
Core EM Modular CME Course
Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below.
Course Highlights:
Credit: 12.5 AMA PRA Category 1 Credits™
Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics.
Cost:
Free for NYU Learners
$250 for Non-NYU Learners
Click Here to Register and Begin Module 1
Patient Presentation & Workup
Patient: 36-year-old male, currently shelter-domiciled, presenting with 3 weeks of generalized weakness, fevers, weight loss, and headaches.
Vitals (Initial): BP 147/98, HR 150s, Temp 100.2°F, RR 18, O2 99% RA.
Clinical Evolution: Initial assessment noted cachexia and a large ventral hernia. Following initial workup, the patient became acutely altered (A&O x0) and febrile to 102.9°F.
Physical Exam Findings:
Brudzinski Sign: Positive (knees flexed upward upon passive neck flexion).
Kernig Sign: Discussed as highly specific (resistance/pain during knee extension with hip flexed at 90°).
Meningeal Triad: Fever, nuchal rigidity, and AMS (present in 40% of cases; 95% of patients have at least two of the four cardinal symptoms including headache).
Imaging:
Chest X-ray: Scattered opacities (pneumonia) and a small pneumothorax.
CT Abdomen/Pelvis: Confirmed asplenia (secondary to 2011 GSW/exploratory laparotomy).
Head CT: Ventricle enlargement concerning for obstructive hydrocephalus and diffuse sulcal effacement.
CSF Analysis & Microbiology
Bacterial Meningitis
Opening Pressure: Elevated (Normal is 1000–2000/mm3 WBC); dominated by neutrophils (>80% PMN).
Glucose: Low (200 mg/dL).
Cytology: Negative.
Viral Meningitis
Opening Pressure: Normal.
Color: Clear or bloody.
Gram Stain: Negative.
Cell Count: Slightly elevated (200 mg/dL).
Cytology: Negative.
Neoplastic (Cancer-related) Meningitis
Opening Pressure: Normal.
Color: Clear or cloudy.
Gram Stain: Negative.
Cell Count: Elevated (200 mg/dL).
Cytology: Positive (this is the key differentiator).
Management Protocol
Immediate Treatment: Early administration of antibiotics/antivirals is critical to reduce mortality.
Antibiotics: Ceftriaxone 2g IV q12h + Vancomycin (or Rifampin in cephalosporin-resistant areas).
Listeria Coverage: Add Ampicillin for patients > 50 years old.
Antivirals: Acyclovir 10 mg/kg q8h.
Steroids: Dexamethasone 10 mg IV q6h for 4 days (proven to reduce mortality and improve outcomes).
Surgical Intervention: Neurosurgery performed an emergent EVD in the ED to relieve pressure from obstructive hydrocephalus.
Post-Exposure Prophylaxis: Indicated only for N. meningitidis (not S. pneumoniae) for contacts 24 hours from diagnosis.
Regimens: Rifampin for 2 days, single-dose Ciprofloxacin, or IM Ceftriaxone (if pregnant).
Stats & Clinical Pearls: Austrian Syndrome
The Triad: Concurrent pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae.
Risk Factors: Asplenia (due to the spleen’s role in filtering encapsulated bacteria), alcohol use disorder, and immunosuppression.
Mortality Rate: Extremely high at 28%; mortality is highest when there is CNS involvement.
Incidence: Worldwide, S. pneumoniae is the leading cause of bacterial meningitis, accounting for 3,000–6,000 cases annually.
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We review diagnosing and managing bacterial meningitis in the ED. Hosts: Sarah Fetterolf, MD Avir Mitra, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Meningitis_2_0.mp3 Download Leave a Comment Tags: CNS Infections, Infectious Diseases, Neurology Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: Credit: 12.5 AMA PRA Category 1 Credits™ Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics. Cost: Free for NYU Learners $250 for Non-NYU Learners Click Here to Register and Begin Module 1 Patient Presentation & Workup Patient: 36-year-old male, currently shelter-domiciled, presenting with 3 weeks of generalized weakness, fevers, weight loss, and headaches. Vitals (Initial): BP 147/98, HR 150s, Temp 100.2°F, RR 18, O2 99% RA. Clinical Evolution: Initial assessment noted cachexia and a large ventral hernia. Following initial workup, the patient became acutely altered (A&O x0) and febrile to 102.9°F. Physical Exam Findings: Brudzinski Sign: Positive (knees flexed upward upon passive neck flexion). Kernig Sign: Discussed as highly specific (resistance/pain during knee extension with hip flexed at 90°). Meningeal Triad: Fever, nuchal rigidity, and AMS (present in 40% of cases; 95% of patients have at least two of the four cardinal symptoms including headache). Imaging: Chest X-ray: Scattered opacities (pneumonia) and a small pneumothorax. CT Abdomen/Pelvis: Confirmed asplenia (secondary to 2011 GSW/exploratory laparotomy). Head CT: Ventricle enlargement concerning for obstructive hydrocephalus and diffuse sulcal effacement. CSF Analysis & Microbiology Bacterial Meningitis Opening Pressure: Elevated (Normal is 1000–2000/mm3 WBC); dominated by neutrophils (>80% PMN). Glucose: Low (200 mg/dL). Cytology: Negative. Viral Meningitis Opening Pressure: Normal. Color: Clear or bloody. Gram Stain: Negative. Cell Count: Slightly elevated (200 mg/dL). Cytology: Negative. Neoplastic (Cancer-related) Meningitis Opening Pressure: Normal. Color: Clear or cloudy. Gram Stain: Negative. Cell Count: Elevated (200 mg/dL). Cytology: Positive (this is the key differentiator). Management Protocol Immediate Treatment: Early administration of antibiotics/antivirals is critical to reduce mortality. Antibiotics: Ceftriaxone 2g IV q12h + Vancomycin (or Rifampin in cephalosporin-resistant areas). Listeria Coverage: Add Ampicillin for patients > 50 years old. Antivirals: Acyclovir 10 mg/kg q8h. Steroids: Dexamethasone 10 mg IV q6h for 4 days (proven to reduce mortality and improve outcomes). Surgical Intervention: Neurosurgery performed an emergent EVD in the ED to relieve pressure from obstructive hydrocephalus. Post-Exposure Prophylaxis: Indicated only for N. meningitidis (not S. pneumoniae) for contacts 24 hours from diagnosis. Regimens: Rifampin for 2 days, single-dose Ciprofloxacin, or IM Ceftriaxone (if pregnant). Stats & Clinical Pearls: Austrian Syndrome The Triad: Concurrent pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae. Risk Factors: Asplenia (due to the spleen’s role in filtering encapsulated bacteria), alcohol use disorder, and immunosuppression. Mortality Rate: Extremely high at 28%; mortality is highest when there is CNS involvement. Incidence: Worldwide, S. pneumoniae is the leading cause of bacterial meningitis, accounting for 3,000–6,000 cases annually. Read More