Lecture meningitis syndrome

2021-02-05 12:00 AM

Meningeal syndrome combined with focal neurological symptoms requires finding physical causes in the brain by computed tomography.

The meningeal syndrome is caused by many causes, regardless of the clinical cause, there are a number of symptoms grouped into three groups, namely, meningitis syndrome, cerebrospinal fluid syndrome and brain damage symptoms. To decide the diagnosis is based on the change in cerebrospinal fluid, if there is a stimulant syndrome but the CSF is normal, it is not a meningeal syndrome, it is a meningeal reaction.

Symptom learning

The meningeal syndrome includes mechanical and physical symptoms.

Mechanical symptoms:

It is the meningeal triangle consisting of the following three signs:

Headache: Common, severe, diffuse or localized pain, intermittent but occasional, increased with noise, light or sudden movement, so patients often lie still with their head turned blackness. Using pain relievers is mild, but the withdrawal of cerebrospinal fluid is less rapid.

Vomiting: Vomiting, especially when changing positions, vomiting is less headache.

Constipation: no bloating, laxatives do not help.

Note: the elderly sometimes have no headache and vomiting but instead are restless, insomnia and then gradually go into a coma and less general irritant syndrome; children sometimes have diarrhoea.

Physical symptoms (symptoms of general irritation):

Muscle spasticity:

Trigger pose: Head back, legs retracted in the abdomen and turned into the dark; if it is typical.

Nape mark: The patient is lying on his back; his knees are not. The physician let the hand under the head lift slightly, normally the chin touches the nipple. If there is a stiff nape, the nape is stretched, the chin does not bend to the chest. Sometimes lift up the chest. Or place two fingers under the neck and lift, normally the head is tilted back; If positive, the head does not protrude, however, the patient must be excluded, so he must do it again and again. Distinguished from cervical spine pain, trauma, low cervical vertebrae.

How to examine the stiff neck

Kernig's mark: Lie on his back without knees, legs straightened, the physician inserted his hands under his heels and slowly raised his legs. Normally raised to over 700 feet and still straight. If when raised below 700, but two legs shrink is Kernig (+).

Positive Kernig sign

Brudzinski mark: top and bottom.

Upper Brudzinski: The patient is lying on his back with his legs straightened, with his head up normally, his legs are still straight. If the legs are contracted when the head is raised, it is positive.

Look for the above Brudzinski sign

Lower Brudzinski: Lie on your back without knees, with your leg folded into your abdomen (one by one), normally the other leg is straight. If the opposite leg is contracted it is positive.

Look for the lower Brudzinski sign

Increased feeling of pain all over the body, so sometimes to touch and squeeze gently to complain of pain.

Fear of light is caused by increased pain when seeing light.

Increased tendon reflexes.


Face when red when pale.

Meningeal (+) mark when the line on the abdomen is redder, spread at the mark and keep for a long time, usually over 1-3 minutes.

Signs of brain damage

Optional, may have one or more of the following:

Mental disorders:

Lethargy, lethargic, or delirious.

Circular muscle disorder:

Secret or urinary incontinence.

Movement disorders:

Paralysis or damage to the cranial cords.

Epilepsy is especially for meningitis in children.

Cerebrospinal fluid syndrome: 

This syndrome is very important for the definitive diagnosis and diagnosis of the cause.

Pressure usually increases from 25cm H20 or more when lumbar puncture in a lying position (normal 7-20 cm H20).

Colour: Normally clear. The following colours can be seen in meningeal syndrome: Red (pink): End to end due to meningeal haemorrhage, meningitis due to traumatic brain injury, hypertension, rupture of vasculature, disease blood, acute meningitis. Need to exclude puncture of blood vessels in this case, at first the redness then fades, leaving will be active. Yellow: Due to bleeding for a long time (after 4-5 days) but still see red blood cells on microscopy; or meningitis. Cloudy: Due to meningitis (meningococcal tissue, pneumococcus, staphylococcus ...). Clear colour: Maybe due to tuberculosis, virus ... so have to wait for test results.

Germ cells:

Red blood cells: Due to bleeding.

Leukocytes of more than 10 cells / mm3 in adults are pathological.

Neutrophils> 50% in meningitis.

Lymphocytes (50% of meningitis caused by tuberculosis, viruses, syphilis, fungi ...

Abnormal cells due to metastatic cancer.

Acid-loving cells are caused by allergies or by parasites (swine fluke).

Microscopy or culture can detect bacteria or viruses.


Normally albumin 14 - 45mg%, glucose 50 - 75mg% (equal to 1/2 or 1/3 of blood glucose), NaCl 110mEq / L. Protein always increases (over 50 mg%) regardless of the cause, however, the level There are different increases, most notably in meningitis. Glucose and salt are reduced in meningitis and tuberculosis, and normal in meningitis and viral. BW is positive in meningeal syphilis.

Typical clinical form

The meningeal syndrome is full of physical, physical and cerebrospinal fluid changes as mentioned above.

The atypical clinical form

In a nursing baby: Symptoms of bulging head clearly, epilepsy may occur. Signs of meningeal irritation (stiff neck, Kernig) are sometimes not obvious. Less common signs of constipation can cause diarrheal.

In the elderly: Headache, vomiting may not be faint. Often present with psychosis, insomnia, forgetfulness, confusion, mood changes. Clinical symptoms such as meningeal signs are sometimes unknown.

In the comatose patient: The physical symptoms are atypical, the process of the disease should be meticulously asked, the functional symptoms to guide the diagnosis.

Headache meningitis due to antibiotic treatment in advance, physical symptoms are discreet or absent.

Meningeal syndrome combined with focal neurological symptoms requires finding physical causes in the brain by computer tomography or brain magnetic resonance imaging and cerebrospinal fluid testing (if there are no concentrations).

Differential diagnosis with meningeal reaction

There are also clinical symptoms such as meningeal syndrome. However, the fundamental difference is that in the meningeal reaction there is no change in the cerebrospinal fluid composition (can be repeated many times to avoid omitting early meningitis).

Meningeal reactions are common in children with botulism. In the meningeal reaction after aspiration of about 10 ml of cerebrospinal fluid, the clinical symptoms improved.

Differential diagnosis with some cases of meningitis

Due to myalgia, spinal pain, bone pain, viral infections, arthritis, osteomyelitis or cervical spine injury.

Diagnose the cause

Meningitis: clinical symptoms occur suddenly with high fever, manifestations of toxic infection, signs of meningitis. The Colour of cerebrospinal fluid is cloudy like rice water, biochemical tests: Glucose, salt can be reduced, especially glucose can be traces, found degenerated poly neutrophils. Cerebrospinal water culture looks for purulent bacteria.

TB meningitis: Clinical symptoms of the meningeal syndrome are subacute. Patients with highly infected manifestations: loss of weight, loss of appetite, fatigue, often mild fever in the afternoon. Colour of cerebrospinal fluid or lemon yellow, assay shows increased protein; moderate decrease in salt and glucose; predominantly lymphocyte proliferation cells, culture can find tuberculosis bacteria.

Clearwater meningitis (viral meningitis): Meningitis occurs in a frantic acute. Cerebrospinal fluid is clear, albumin increases; glucose, normal salt, increased lymph cells.

Subarachnoid haemorrhage (any membrane bleeding): Sudden manifestation, severe headache, possibly accompanied by disturbed consciousness, clear meningeal signs. Puncture of cerebrospinal fluid found blood to not clot all 3 tubes. Cranial tomography can show blood in the subarachnoid space (increased density). In young people, meningeal haemorrhage often due to angioplasty, now need to conduct brain angiography to determine.