Meningitis

Meningitis is inflammation of the membranes that wrap the brain and spinal cord. It is nearly always caused by an infection, and everything depends on which one: viral meningitis usually settles by itself within a week or ten days, while the bacterial form can become life-threatening within hours. The two cannot be told apart by how the person looks, so when meningitis is suspected nobody waits and watches at home — an ambulance is called.

Why it is counted in hours

The membranes around the brain are bathed in cerebrospinal fluid. Once bacteria get into it they multiply almost unchecked, because there are few defence cells there. The membranes swell, pressure inside the skull rises, and the nerves and blood vessels running nearby suffer.

At the same time those bacteria can enter the bloodstream and cause sepsis, with falling blood pressure and poor circulation to the limbs and organs. Meningococcal infection sometimes runs without meningitis at all, as sepsis alone, and then what dominates is not headache and a stiff neck but pale blotchy skin, ice-cold hands and feet, muscle pain and a rash. Hence the central rule: the person's condition worsens very fast, sometimes literally within hours, and an hour of delay changes the outcome more than any effort made later.

Signs in teenagers and adults

The illness usually starts abruptly and unfolds in front of you. Take note of:

• a high temperature, often with shivering, together with cold hands and feet;
• a severe headache, unlike the usual sort;
• a stiff neck — the chin cannot be brought down to the chest;
• dislike of bright light, wanting to turn to the wall;
• nausea and vomiting;
• severe pain in muscles, legs and joints;
• drowsiness, confusion, difficulty waking, odd behaviour;
• rapid breathing, a seizure;
• a rash, dealt with separately below.

All the signs together are rare, and they can appear in any order. The classic combination of fever, headache and stiff neck may be missing altogether, particularly in older people and in anyone whose immunity is weakened by illness or medicines. In them meningitis often shows itself simply as confusion or unusual drowsiness with no fever, and that is precisely why it is most often missed in this group.

What it looks like in a baby

A small child will not complain of headache or of the light hurting, so parents have to go by behaviour and appearance.

• refusing feeds, posseting, vomiting;
• an unusual cry — high-pitched, moaning, not the normal one;
• irritable when picked up or, conversely, floppy, listless and unresponsive;
• the soft spot on the head bulging and tense;
• a stiff body, the head arching back, twitching movements;
• pale, blotchy skin with cold hands and feet;
• fast or irregular breathing, grunting;
• a high temperature or, in the very young, a temperature below normal.

A parent's sense that the child is "not like this in any illness before" is a weighty argument, and there is no need to feel awkward about saying so.

The rash and the glass test

The rash of meningococcal infection starts as tiny red or purple spots resembling pinpricks, which later merge into blotches and bruises. Its distinguishing feature is that it does not fade: press a clear glass against it and the spots go on showing through.

Two things need to be understood about this test. First: a rash that does not fade under a glass points to severe blood infection and means calling an ambulance at once. Second, and far more important: the opposite result proves nothing. The rash appears late, does fade under pressure at the very beginning, and in some people never develops at all. Waiting for a rash before deciding to call for help is the most dangerous mistake on this page.

On brown and black skin the rash is harder to see. Look where the skin is paler: palms, soles, tummy, the inside of the eyelids, the lining of the mouth, the whites of the eyes.

When to call an ambulance

Call an ambulance (112 across European countries), or take the person straight to the nearest emergency department, if you suspect meningitis or blood poisoning. Do not wait for all the signs to gather. Reasons to call at once:

• fever together with severe headache, a stiff neck or dislike of light;
• a rash that does not fade under a glass, or bruises spreading quickly;
• confusion, delirium, unusual drowsiness, being impossible to rouse;
• a seizure;
• in a child: a high-pitched cry, a bulging soft spot, a floppy body, cold limbs with a high temperature;
• any rapid deterioration over a matter of hours.

While help is on its way, lay the person on their side if they are vomiting or losing consciousness, dim the lights and give nothing to eat or drink.

There is a middle step as well. Seek same-day advice if a child keeps a temperature and seems flat but has none of the signs above, or if a severe headache with fever appears in someone with weakened immunity, after a head injury or after surgery on the head. And remember: advice to "watch at home" stops applying the moment things get worse. You then seek help again, without worrying about being a nuisance.

What causes it

Viral meningitis is the commonest and the mildest. It is caused by enteroviruses, herpes simplex viruses and the mumps virus, and usually clears within one to two weeks.

The bacterial form is less common, but it is the reason the illness is regarded as dangerous. The usual organisms are meningococcus, pneumococcus and Haemophilus influenzae type b. In newborns, group B streptococcus and Escherichia coli occur; in older people, pregnant women and those with weakened immunity, listeria.

Tuberculous meningitis deserves separate mention: it develops over weeks rather than hours, beginning with a mounting headache, listlessness, weight loss and a mild fever, which makes it especially easy to mistake for something else. In people with severe immune deficiency fungal meningitis occurs, also slow. Finally, the membranes can become inflamed without any infection: as a reaction to certain medicines, in autoimmune disease, or with tumours. Such cases are rare, but they explain why the hospital examines the cerebrospinal fluid rather than stopping at a blood test.

How it spreads and who is at greater risk

The bacteria that cause meningitis live in the nose and throat of a great many healthy people without causing any trouble. They pass on in droplets of saliva and mucus: coughing, sneezing, kissing, sharing a cigarette, drinking from the same bottle. Catching it from someone who is ill is possible too, but happens less often than catching it from a healthy carrier, and only a very few of those who pick up the bacterium go on to fall ill.

The risk is higher:

• in babies and children under five;
• in teenagers and young adults, especially those living in halls of residence and barracks;
• in older people;
• in anyone without a spleen or with a poorly working one, and in sickle cell disease;
• with immune deficiency, immunosuppressive medicines or chemotherapy;
• after a skull fracture with fluid leaking from the nose or ear, after surgery on the head or spine, and with a cochlear implant;
• when travelling to regions where meningococcal infection is common, and to mass gatherings.

Having had meningitis gives no protection: it can happen again, and repeated episodes are in themselves a reason to look for a cause, such as a defect in the membranes after an injury or an inherited quirk of the immune system.

How the diagnosis is made

In hospital the doctor examines the person, checks their level of consciousness, looks for meningeal signs and a rash, and takes blood: full blood count, inflammatory markers, cultures and identification of the organism from its genetic material.

What settles the diagnosis, though, is a lumbar puncture. A fine needle passed between the vertebrae in the lower back draws off a little cerebrospinal fluid, which is examined for how many cells it contains and of what kind, how much protein and how much sugar, and then cultured and tested for the DNA of organisms. It is this test that separates bacterial from viral meningitis and shows which antibiotic to use; neither blood tests nor scans can take its place. There is no good reason to refuse it for fear that "they will damage the spinal cord": the needle goes into the lower back, below the level at which the cord ends.

A head scan before the puncture is not done for everyone, only where certain features are present — focal neurological signs, seizures, a deeply altered level of consciousness, marked immune deficiency. And the rule here is strict: waiting for a scan must not delay the antibiotic. Blood cultures are taken and the drug given first; the imaging follows.

How it is treated

Where bacterial meningitis is suspected, an antibiotic goes into a vein immediately, without waiting for results. If tests later show a viral cause it is stopped — whereas hours lost cannot be regained. At the same time, where pneumococcus is suspected, a steroid is given: it reduces swelling around the membranes and lowers the chance of hearing loss.

The rest of the treatment is supportive: fluids by drip, oxygen, pain relief, anti-sickness medicines and anticonvulsants where needed. If breathing falters or blood pressure drops, the person is moved to intensive care. Treatment of bacterial meningitis lasts at least a week, sometimes considerably longer, and all of that time is spent in hospital.

If a herpes cause is suspected an antiviral drug is added, and that situation admits of no delay either. Tuberculous meningitis is treated with a combination of antituberculous drugs over months.

Mild viral meningitis is managed at home: rest, fluids, painkillers and something for the nausea. But that decision is made by a doctor after examining the patient, not by the patient alone.

What is left afterwards

After viral meningitis most people recover fully, although headache and exhaustion can linger for several weeks.

After the bacterial form, a noticeable proportion of survivors are left with problems. The commonest is hearing loss, which can go as far as complete deafness. That is why everyone who has had bacterial meningitis is booked for a hearing test, and as early as possible: where the loss is profound, the decision about a cochlear implant has a limited window, before the cochlea becomes filled with bone, and here again delay is expensive.

Repeated seizures also occur, along with difficulties with memory and concentration, easy tiredness, problems with balance, loss of vision and, in children, difficulties with learning and behaviour. After meningococcal sepsis there may be deep scarring, kidney damage and, where circulation was severely compromised, the loss of fingers or limbs. A psychological mark remains too: fear of doctors and hospitals, disturbed sleep, bedwetting in a child, anxiety in parents. That is a normal reaction to what has been lived through, and it is dealt with like any other consequence.

Vaccines and protecting those around you

Vaccines exist against the most dangerous causes of meningitis and remain the best protection. They include vaccines against several groups of meningococcus, against pneumococcus and against Haemophilus influenzae type b, together with those preventing illnesses in which meningitis can be a complication: measles, mumps, rubella and chickenpox. The first doses are given during the first year of life, boosters follow, and teenagers and young adults are offered a meningococcal dose. The exact timings and the set of vaccines differ from country to country, so check your national schedule and ask your doctor whether you and your child have had everything.

Vaccination is considered separately before travel to regions where meningococcal infection is common and before moving into shared accommodation; extra doses are provided for people without a spleen and with immune disorders.

When meningococcal infection is confirmed, those who were in close contact are given a short course of antibiotics: household members, a partner, room-mates, sometimes a nursery group. It should be started as quickly as possible, and who falls within that circle is decided by the public health service, not by the family. Casual contacts, such as fellow passengers or colleagues sharing an office, do not need it. In everyday life simple things lower the risk: not drinking from someone else's bottle, not sharing cigarettes, not smoking near a child, and airing rooms where many people live or study.

Online consultation

First and most importantly: where meningitis is suspected, an online consultation is the wrong route. Examination and study of the cerebrospinal fluid are what is needed, and time spent typing works against the patient. If the signs in the ambulance section are present, call for an ambulance.

An online appointment does, however, suit everything surrounding that situation. Beforehand: going through which vaccines you and your child have already had, what is missing, what is advisable before travel or before moving into shared accommodation, and what to do if someone around you has fallen ill. Afterwards: discussing the discharge summary and the instructions in it, finding out when and where to have hearing tested, what to do about lingering tiredness and headache, and how to return to study and work. Have the discharge summary, the vaccination record and the list of medicines ready.

This material is for information only and does not replace medical advice.