Meningismus

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Specialty scores for Meningismus

Overview

Meningismus is a clinical syndrome characterized by a set of symptoms caused by irritation of the meninges (three layers of protective tissue called the dura mater, arachnoid mater, and pia mater that surround the brain and spinal cord). In this syndrome, signs and symptoms of meningitis are seen but no pathological abnormalities are seen with the meninges.

Causes:

The cause of meningism can be inflammation of meninges, increased intracranial pressure, brain edema (traumatic brain injury, uremia), subarachnoid hemorrhage and infectious diseases. Meningismus can be caused due to infection (influenza, pneumonia, typhus, HIV infection, measles, scarlet fever, typhoid fever, tick-borne encephalitides), poisoning (food poisoning, occupational poisoning), and brain injury after a lumbar puncture. Meningismus is also found to be the important clinical syndrome in chronic tension-type headaches in children and adolescents. The condition is more commonly found in young patients with systemic infections, such as pneumonia, flu etc.

Meningeal irritation occurs usually due to increased intracranial pressure, caused by increased cerebrospinal fluid production, usually associated with acute edema and swelling of the protective membranes and substance of the brain. Head injury (closed trauma of a skull) may lead to symptoms of concussion with meningismus accompanied by brain edema; these can present either in the initial period, or sometime after the injury, if the condition aggravates due to improper bed rest and other disease exacerbating factors. Meningismus can also occur during a hypertensive crisis, in which there is spasm of blood vessels of the brain and meninges, leading to acute brain edema. Meningismus may also occur with loss of large quantities of cerebrospinal fluid with lumbar puncture, as a result of the spinal fluid drainage.

The medical conditions that might mimic meningismus clinically may include cervical spondylosis, parkinson’s disease, acute dystonic reaction, strychnine poisoning, and tetanus.

Signs and symptoms:

Meningismus is characterized by the signs and symptoms of nuchal rigidity (neck stiffness), photophobia (sensitivity to bright light), and headache. Other symptoms include headache, stiff neck, vomiting, and dizziness. Other related clinical signs include Kernig's sign and Brudzinski's sign. Nuchal rigidity is the inability to perform the neck flexion forward due to rigidity of neck muscles. In case if flexion of the neck is painful but achievable, and complete range of neck motion is present, nuchal rigidity is said to be absent. Kernig's sign is said to be positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent knee extension is painful (giving rise to resistance). Patients may also display features of opisthotonus in which the whole body undergoes spasm that leads to bending back of the legs and head and bowing forward of the body.

Brudzinski's neck sign is positive when the patient, while lying supine, involuntarily lifts the legs when examiner attempts to lift the patient's head off the examining couch. Meningismus may also be associated with positive symphyseal sign, in which exertion of pressure on the pubic symphysis gives rise to abduction of the leg and reflexive flexion of the hip and knee joint. The cheek sign may be present, in which exertion of pressure on the cheek below the zygoma may lead to forearm rising and flexion. Brudzinski's reflex may also be seen in meningismus, in which passive flexion of one knee into the abdomen leads to involuntary flexion of the knee in the opposite leg also, and stretching of a limb that was previously flexed leads to extension in the opposite side also. Many persons may display neurocognitive symptoms, such as fatigue, mood disturbances, memory disturbance, and other related symptoms.

Diagnosis:

Diagnosis of meningismus is associated with clinical examination of meningeal signs, including nuchal rigidity, Kernig's sign, Brudzinski's three signs (upper, middle, and lower), tripod sign, and Guillain's and facial signs. Diagnosis of meningismus is based on the study of cerebrospinal fluid, and rapid disappearance of symptoms. CSF examination reveals the amount of protein to be usually within normal limits. Differential diagnosis of meningismus is especially difficult with suspected tuberculous meningitis in the initial period, when meningeal symptoms are not present and there is no pleocytosis. Serology tests can be done to explore the underlying infective etiology and work up the diagnosis. Neuroimaging (CT scan & MRI scan of brain) is required to be done to formulate the definitive diagnosis as meningismus is not a disease, but due to an underlying disorder, which must be treated. Meningismus is a clinical constellation of symptoms and signs rather than an individual and specific disorder in itself.

Management:

Management of meningismus includes treatment of the underlying disease and the therapeutic measures aimed at achievement of reduction in intracranial pressure. In most cases, a lumbar puncture gives effective therapeutic outcome. Due to the presence of swelling of the brain and meninges, intravenous infusion of hypertonic solutions is recommended in many cases. Management may include appropriate pharmacological agents for bacterial, viral or fungal agents. Patient must be subjected to strict bed rest and continuous clinical monitoring is essential to ensure detection of complications. In the cases of meningismus, hospital care is required for supportive care, to stop the progression of underlying pathology and limit brain damage. Treatment may include medicines, surgery or catheter-based therapy, supportive management and treatment aimed at prevention of complications.

Achievement of clinical stabilization of the person is the first priority. Patients with profound drowsiness and depressed consciousness may need to be mechanically ventilated. It is essential to monitor the vital parameters, such as blood pressure, pulse, respiratory rate frequently. Nutrition is a clinical priority, with by mouth or nasogastric tube feeding. Pain control must be achieved with less-sedating agents. Management may include benzodiazepines, antiemetics, antihypertensives, antibiotics, catheter based treatment, hydration and surgery. In case of subarachnoid hemorhage, prevention of rebleeding is essential. In case a subarachnoid hemorrhage is suspected, its origin needs to be determined by cerebral angiography. If cerebral aneurysm is diagnosed on angiography, risk of further bleeding from the same aneurysm can be reduced by clipping and coiling. In case of a significant hemorrhage, surgical removal of the blood or occlusion of the bleeding site is undertaken in a timely manner to provide best clinical outcomes.

Other names of the condition:

Meningism