What is meningitis? What is encephalitis?

Infections, and less commonly other causes, in the brain and spinal cord can cause dangerous
inflammation. This inflammation can produce a wide range of symptoms, including fever,
headache, seizures, chang in behavior or confusion and, in extreme cases, can cause brain
damage, stroke, or even death.
Infection of the meninges, the membranes that surround the brain and spinal cord, is called
meningitis and inflammation of the brain itself is called encephalitis. Myelitis refers to
inflammation of the spinal cord. When both the brain and the spinal cord are involved, the
condition is called encephalomyelitis.
What causes meningitis and encephalitis?


Infectious causes of meningitis and encephalitis include bacteria, viruses, fungi, and parasites.
Many of these affect healthy people. For others, environmental and exposure history, recent
travel or immunocompromised state (such as HIV, diabetes, steroids, chemotherapy) are
important elements. There are also non-infectious causes such as autoimmune causes and
medications.
Meningitis
Meningitis is most often caused by a bacterial infection. It also may be caused by a virus, fungal
infection, parasite, a reaction to certain medications or medical treatments, a rheumatologic
disease such as lupus, some types of cancer, or a traumatic injury to the head or spine.
Bacterial meningitis is a rare but potentially fatal disease. It can be caused by several types of
bacteria that first cause an upper respiratory tract infection and then travel through the blood
stream to the brain. The disease can also occur when certain bacteria invade the meninges
directly. The disease can cause stroke, hearing loss, and permanent brain damage.
Pneumococcal meningitis is the most common form of meningitis and is the most serious form
of bacterial meningitis. Some 6,000 cases of pneumococcal meningitis are reported in the United
States each year. The disease is caused by the bacterium Streptococcus pneumoniae, which also
causes pneumonia, blood poisoning (septicemia), and ear and sinus infections. At particular risk
are children under age 2 and adults with a weakened or depressed immune system, including the
elderly. Persons who have had pneumococcal meningitis often suffer neurological damage
ranging from deafness to severe brain damage. There are immunizations available for certain
strains of the Pneumococcal bacteria.
Meningococcal meningitis is caused by the bacterium Neisseria meningitides. Each year in the
United States about 2,600 people get this highly contagious disease. High-risk groups include
infants under the age of 1 year, people with suppressed immune systems, travelers to foreign
countries where the disease is endemic, and college students (freshmen in particular) who reside
in dormitories. Between 10 and 15 percent of cases are fatal, with another 10-15 percent causing
brain damage and other serious side effects. If this is diagnoses, people who come in close
contact with the affected individual should be given preventative antibiotics.
Haemophilus meningitis was at one time the most common form of bacterial meningitis.
Fortunately, the Haemophilus influenzae b vaccine has greatly reduced the number of cases in
the United States. Those most at risk of getting this disease are children in child-care settings and
children who do not have access to the vaccine.
Other forms of bacterial meningitis include Listeria monocytogenes meningitis. Certain foods
such as unpasteurized dairy or deli meats are sometimes implicated. Escherichia coli meningitis,
which is most common in elderly adults and newborns and may be transmitted to a baby through
the birth canal, and Mycobacterium tuberculosis meningitis, a rare disease that occurs when the
bacterium that causes tuberculosis attacks the meninges.
Viral, or aseptic, meningitis is usually caused by enterovirusescommon viruses that enter the
body through the mouth and travel to the brain and surrounding tissues where they multiply.
Enteroviruses are present in mucus, saliva, and feces and can be transmitted through direct
contact with an infected person or an infected object or surface. Other viruses that cause
meningitis include varicella zoster (the virus that causes chicken pox and can appear decades
later as shingles), influenza, mumps, HIV, and herpes simplex type 2 (genital herpes).
Many fungal infections can affect the brain. The most common form of fungal meningitis is
caused by the fungus cryptococcus neoformans (found mainly in dirt and bird droppings).
Cryptococcal meningitis mostly occurs in immunocompromised individuals such as in AIDS
patients but can also occur in healthy people Some of these cases can be indolent and smolder
for weeks. Although treatable, fungal meningitis often recurs in nearly half of affected persons.
Parasitic causes include cysticercosis, which is common in other parts of the world as well, and
cerebral malaria.
There are rare cases of amoebic meningitis, sometimes related to fresh water swimming, which
can be rapidly fatal.
Encephalitis
Encephalitis can be caused by the same infections listed above. However, up to 60 percent of
cases remain undiagnosed, so this is an active area of research. Several thousand cases of
encephalitis are reported each year, but many more may actually occur since the symptoms may
be mild to non-existent in most patients.
Most diagnosed cases of encephalitis in the United States are caused by enteroviruses, herpes
simplex virus types 1 and 2, rabies virus (this can occur even without a known animal bite, such
as for example due to exposure to bats), or arboviruses such as West Nile virus, which are
transmitted from infected animals to humans through the bite of an infected tick, mosquito, or
other blood-sucking insect. Lyme disease, a bacterial infection spread by tick bite, more typically
causes meningitis, and rarely encephalitis.
Herpes simplex encephalitis (HSE) is responsible for about 10 percent of all encephalitis cases,
with a frequency of about 2 cases per million persons per year. More than half of untreated cases
are fatal. About 30 percent of cases result from the initial infection with the herpes simplex virus;
the majority of cases are caused by reactivation of an earlier infection. Most people acquire
herpes simplex type 1 (the cause of cold sores or fever blisters) in childhood so it is a ubiquitous
exposure.
HSE due to herpes simplex virus type 1 can affect any age group but is most often seen in
persons under age 20 or over age 40. This rapidly progressing disease is the single most
important cause of fatal sporadic encephalitis in the U.S. Symptoms can include headache and
fever for up to 5 days, followed by personality and behavioral changes, seizures, hallucinations,
and altered levels of consciousness. Brain damage in adults and in children beyond the neonatal
period is usually seen in the frontal (leading to behavioral and personality changes) and temporal
lobes (leading to memory and speech problems) and can be severe.
Type 2 virus (genital herpes) is most often transmitted through sexual contact. Many people do
not know they are infected and may not have active genital lesions. An infected mother can
transmit the disease to her child at birth, and through contact with genital secretions. In
newborns, symptoms such as lethargy, irritability, tremors, seizures, and poor feeding generally
develop between 4 and 11 days after delivery.
Powassan encephalitis is the only well-documented tick-borne arbovirus in the United States
and Canada. Symptoms are noticed 7-10 days following the bite (most people do not notice tick
bites) and may include headache, fever, nausea, confusion, partial paralysis, and coma.
Four common forms of mosquito-transmitted viral encephalitis are seen in the United States:
Equine encephalitis affects horses and humans. Eastern equine encephalitis also infects
birds that live in freshwater swamps of the eastern U.S. seaboard and along the Gulf
Coast. In humans, symptoms are seen 4-10 days following transmission and include
sudden fever, general flu-like muscle pains, and headache of increasing severity,
followed by coma and death in severe cases. About half of infected patients die from the
disorder. Fewer than 10 human cases are seen annually in the United States. Western
equine encephalitis is seen in farming areas in the western and central plains states.
Symptoms begin 5-10 days following infection. Children, particularly those under 12
months of age, are affected more severely than adults and may have permanent
neurologic damage. Death occurs in about 3 percent of cases. Venezuelan equine
encephalitis is very rare in this country. Children are at greatest risk of developing severe
complications, while adults generally develop flu-like symptoms. Epidemics in South and
Central America have killed thousands of persons and left others with permanent, severe
neurologic damage.
LaCrosse encephalitis occurs most often in the upper midwestern states (Illinois,
Wisconsin, Indiana, Ohio, Minnesota, and Iowa) but also has been reported in the
southeastern and mid-Atlantic regions of the country. Most cases are seen in children
under age 16. Symptoms such as vomiting, headache, fever, and lethargy appear 5-10
days following infection. Severe complications include seizure, coma, and permanent
neurologic damage. About 100 cases of LaCrosse encephalitis are reported each year.
St. Louis encephalitis is most prevalent in temperate regions of the United States but can
occur throughout most of the country. The disease is generally milder in children than in
adults, with elderly adults at highest risk of severe disease or death. Symptoms typically
appear 7-10 days following infection and include headache and fever. In more severe
cases, confusion and disorientation, tremors, convulsions (especially in the very young),
and coma may occur.
West Nile encephalitis was first clinically diagnosed in the United States in 1999; 284
people are known to have died of the virus the following year. There were 9,862 reported
cases of human West Nile disease in calendar year 2003, with a total of 560 deaths from
this disorder over 5 years. The disease is usually transmitted by a bite from an infected
mosquito, but can also occur after transplantation of an infected organ or transfusions of
infected blood or blood products. Symptoms are flu-like and include fever, headache, and
joint pain. Some patients may develop a skin rash and swollen lymph glands, while others
may not show any symptoms. At highest risk are elderly adults and people with
weakened immune systems.
Who is at risk for encephalitis and meningitis?


Anyone can get encephalitis or meningitis. People with weakened immune systems, including
those persons with HIV or those taking immunosuppressant drugs, are at the highest risk of
contracting the diseases.
How are these disorders transmitted?


Some forms of bacterial meningitis and encephalitis are contagious and can be spread through
contact with saliva, nasal discharge, feces, or respiratory and throat secretions (often spread
through kissing, coughing, or sharing drinking glasses, eating utensils, or such personal items as
toothbrushes, lipstick, or cigarettes). For example, people sharing a household, at a day care
center, or in a classroom with an infected person can become infected. College students living in
dormitoriesin particular, college freshmenhave a higher risk of contracting meningococcal
meningitis than college students overall. Children who do not have access to childhood vaccines
are at increased risk of developing certain types of bacterial meningitis.
Because these diseases can occur suddenly, anyone who is suspected of having either meningitis
or encephalitis should immediately contact a doctor or go to the hospital.
What are the signs and symptoms?


The hallmark signs of meningitis are sudden fever, severe headache, nausea/vomiting, double
vision, drowsiness, sensitivity to bright light, and a stiff neck; encephalitis can be characterized
by fever, seizures, change in behavior, confusion and disorientation, and related neurological
signs depending on which part of the brain is affected by the encephalitic process, as some of
these are quite focal (locally centered) while others are more global.
Meningitis often appears with flu-like symptoms that develop over 1-2 days. Distinctive rashes
are typically seen in some forms of the disease. Meningococcal meningitis may be associated
with kidney and adrenal gland failure and shock.
Individuals with encephalitis often show mild flu-like symptoms. In more severe cases, patients
may experience problems with speech or hearing, double vision, hallucinations, personality
changes, loss of consciousness, loss of sensation in some parts of the body, muscle weakness,
partial paralysis in the arms and legs, sudden severe dementia, seizures, and memory loss.
Important signs of meningitis or encephalitis to watch for in an infant include fever, lethargy, not
waking for feeding, vomiting, body stiffness, unexplained or unusual irritability, and a full or
bulging fontanel (the soft spot on the top of the head).
How are meningitis and encephalitis diagnosed?


Following a physical exam and medical history to review activities of the past several
days/weeks (such as recent exposure to insects or animals, any contact with ill persons, recent
travel, or preexisting medical conditions and medications list), the doctor may order various
diagnostic tests to confirm the presence of infection and inflammation. Early diagnosis is vital, as
symptoms can appear suddenly and escalate to brain damage, hearing and/or speech loss,
blindness, or even death.
A neurological examination involves a series of tests designed to assess motor and sensory
function, nerve function, hearing and speech, vision, coordination and balance, mental status, and
changes in mood or behavior. Doctors may test the function of the nervous system through tests
of strength and sensation, with the aid of items including a tuning fork, small light, reflex
hammer, and pins.
Laboratory screening of blood, urine, and body secretions can help detect and identify brain
and/or spinal cord infection and determine the presence of antibodies and foreign proteins. Such
tests can also rule out metabolic conditions that have similar symptoms. For example, a throat
culture may be taken to check for viral or bacterial organisms that cause meningitis or
encephalitis. In this procedure, the back of the throat is wiped with a sterile cotton swab, which is
then placed on a culture medium. Viruses and bacteria are then allowed to grow on the medium.
Samples are usually taken in the physicians office or in a laboratory setting and sent out for
analysis to state laboratories or to the U.S. Centers for Disease Control and Prevention. Results
are usually available in 2 to 3 days.
Analysis of the cerebrospinal fluid that surrounds and protects the brain and spinal cord can
detect infections in the brain and/or spinal cord, acute and chronic inflammation, and other
diseases. In a procedure known as a spinal tap (or lumbar puncture), a small amount of
cerebrospinal fluid is removed by a special needle that is inserted into the lower back. The skin is
anesthetized with a local anesthetic prior to the sampling. The fluid, which is completely clear in
healthy people, is tested to detect the presence of bacteria or blood, as well as to measure glucose
levels (a low glucose level can be seen in bacterial or fungal meningitis) and white blood cells
(elevated white blood cell counts are also a sign of infection). The procedure is done in a hospital
and takes about 45 minutes.The individual will most often be placed on antibiotics and an
antiviral drug while awaiting the final microbiology results as delay in treatment can be life-
threatening.
Brain imaging can reveal signs of brain inflammation, internal bleeding or hemorrhage, or other
brain abnormalities. Two painless, noninvasive imaging procedures are routinely used to
diagnose meningitis and encephalitis.
Computed tomography, also known as a CT scan, combines x-rays and computer
technology to produce rapid, clear, two-dimensional images of organs, bones, and tissues.
Occasionally a contrast dye is injected into the bloodstream to highlight the different
tissues in the brain and to detect signs of encephalitis or inflammation of the meninges.
CT scans can also detect bone and blood vessel irregularities, certain brain tumors and
cysts, herniated discs, spinal stenosis (narrowing of the spinal canal), blood clots or
intracranial bleeding in patients with stroke, brain damage from a head injury, and other
disorders. If the individual has abnormal results on a neurological examination, often a
CT scan is performed to look for brain swelling, hemorrhage, or abscess which if present,
could make a spinal tap unsafe.
Magnetic resonance imaging (MRI) uses computer-generated radio waves and a strong
magnet to produce detailed images of body structures, including tissues, organs, bones,
and nerves. Thee is no radiation involved in this test and it gives a much better picture of
the actual brain tissue. this may not be available in the emergency setting so a CT scan is
usually performed first in very ill individuals. The pictures, which are clearer than those
produced by CT, can help identify brain and spinal cord inflammation, infection, tumors,
eye disease, and blood vessel irregularities that may lead to stroke. A contrast dye may be
injected prior to the test to reveal more detail.
Electroencephalography, or EEG, can identify abnormal brain waves by monitoring electrical
activity in the brain through the skull. Among its many functions, EEG is used to help diagnose
seizures or patterns that may suggest specific viral infections such as herpes virus. This painless,
risk-free test can be performed in a doctors office or at a hospital or testing facility.
How are these infections treated?


Persons who are suspected of having meningitis or encephalitis should receive immediate,
aggressive medical treatment. Both diseases can progress quickly and have the potential to cause
severe, irreversible neurological damage.
Meningitis
Early treatment of bacterial meningitis is important to its outcome, with antibiotics that can cross
the protective blood-brain lining. Appropriate antibiotic treatment for most types of meningitis
can reduce the risk of dying from the disease to below 15 percent.
Infected sinuses may need to be drained. Corticosteroids such as prednisone may be ordered to
relieve brain pressure and swelling and to prevent hearing loss that is common in patients with
Haemophilus influenza meningitis. Lyme disease is treated with intravenous antibiotics.
Unlike bacteria, viruses cannot be killed by antibiotics; generally there is no specific treatment
for viruses except for the herpes virus, which can be treated with the antiviral drug acyclovir.
The physician may prescribe anticonvulsants such as dilantin or phenytoin to prevent seizures
and corticosteroids to reduce brain inflammation. If inflammation is severe, pain medicine and
sedatives may be prescribed to make the person more comfortable.
Acute disseminated encephalomyelitis is treated with steroids. Fungal meningitis is treated with
intravenous antifungal medications.
Encephalitis
Antiviral drugs used to treat viral encephalitis include acyclovir and ganciclovir.
Anticonvulsants may be prescribed to stop or prevent seizures. Corticosteroids can reduce brain
swelling. Individuals with breathing difficulties may require artificial respiration.
Individuals should receive evaluation for comprehensive rehabilitation that might include
cognitive rehabilitation, physical, speech, and occupational therapy once the acute illness is
under control.
Can meningitis and encephalitis be prevented?


Avoid sharing food, utensils, glasses, and other objects with a person who may be exposed to or
have the infection. Wash hands often with soap and rinse under running water.
Effective vaccines are available to prevent pneumonia, H. influenza, pneumococcal meningitis,
and infection with other bacteria that can cause meningococcal meningitis.
People who live, work, or go to school with someone who has been diagnosed with bacterial
meningitis may be asked to take antibiotics for a few days as a preventive measure.
To lessen the risk of being bitten by an infected mosquito or other insect, people should limit
outdoor activities at night, wear long-sleeved clothing when outdoors, use insect repellents that
are most effective for that particular region of the country, and rid lawn and outdoor areas of
free-standing pools of water, in which mosquitoes breed. Do not over-apply repellants,
particularly on young children and especially infants, as chemicals such as DEET may be
absorbed through the skin.
What is the prognosis for these infections?


Outcome generally depends on the particular infectious agent involved, the severity of the
illness, and how quickly treatment is given. In most cases, people with very mild encephalitis or
meningitis can make a full recovery, although the process may be slow.
Individuals who experience only headache, fever, and stiff neck may recover in 2-4 weeks.
Those with bacterial meningitis typically show some relief 48-72 hours following initial
treatment but are more likely to experience complications caused by the disease. In more serious
cases, these diseases can cause hearing and/or speech loss, blindness, permanent brain and nerve
damage, behavioral changes, cognitive disabilities, lack of muscle control, seizures, and memory
loss. These patients may need long-term therapy, medication, and supportive care. The recovery
from encephalitis is variable depending on the cause and extent of brain inflammation.
What research is being done?


The National Institute of Neurological Disorders and Stroke (NINDS), a component of the
National Institutes of Health (NIH) within the U.S. Department of Health and Human Services,
conducts and supports a wide range of research on neurological disorders, including meningitis
and encephalitis. Current research efforts include gaining a better understanding of how the
central nervous system responds to inflammation and the role of T cells (blood cells involved in
immune system response) in suppressing infection in the brain. Scientists hope to better
understand the molecular mechanisms involved in the protection and disruption of the blood-
brain barrier, which could lead to the development of new treatments for several
neuroinflammatory diseases such as meningitis and encephalitis. Other scientists hope to define,
at a molecular level, how certain viruses overcome the bodys defense mechanism and interact
with target host cells. A possible therapeutic approach under investigation involves testing
neuroprotective compounds that block the damage that accumulates after the infection and
inflammation of meningitis and encephalitis and can lead to potential complications including
loss of cognitive function and dementia.