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Dilemmas in the diagnosis of acute community-acquired bacterial meningitis
Abstract
Rapid diagnosis and treatment of acute community-acquired bacterial meningitis reduces mortality and neurological sequelae, but can be delayed by atypical presentation, assessment of lumbar puncture safety, and poor sensitivity of standard diagnostic microbiology. Thus, diagnostic dilemmas are common in patients with suspected acute community-acquired bacterial meningitis. History and physical examination alone are sometimes not sufficient to confirm or exclude the diagnosis. Lumbar puncture is an essential investigation, but can be delayed by brain imaging. Results of cerebrospinal fluid (CSF) examination should be interpreted carefully, because CSF abnormalities vary according to the cause, patient's age and immune status, and previous treatment. Diagnostic prediction models that use a combination of clinical findings, with or without test results, can help to distinguish acute bacterial meningitis from other causes, but these models are not infallible. We review the dilemmas in the diagnosis of acute community-acquired bacterial meningitis, and focus on the roles of clinical assessment and CSF examination.
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“Clinical data, such as headaches, photophobia, phonophobia, fever, or neck stiffness, were not collected for several reasons: (i) the clinical presentation can vary significantly from one patient to another, can be difficult to assess objectively, and may even be absent in some cases (19), (ii)”
From Optimized use of the FilmArray Meningitis/Encephalitis panel for early discontinuation of antibiotic therapy (2026) · cites this paper as [19]
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“Kernig's and Brudzinski's signs are often cited but their sensitivity can be as low as 5%.33”
From Community-acquired acute bacterial meningitis in adults: a clinical update (2019) · cites this paper as [33]
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Self-citationPormohammad, A., Lashkarbolouki, S., Azimi, T., Gholizadeh, P., Bostanghadiri, N., Safari, H., Armin, S. H., Mohtavinejad, N., & Fallah, F. (2019) · New Microbes and New Infections · doi:10.1016/j.nmni.2019.100594 · Cited by 18
van Zeggeren, I. E., ter Horst, L., Heijst, H., Teunissen, C. E., van de Beek, D., & Brouwer, M. C. (2022) · Scientific Reports · doi:10.1038/s41598-022-17643-9 · Cited by 15
Self-citationFrom cytokines to chemokines: Understanding inflammatory signaling in bacterial meningitis
Ibrahim, A., Saleem, N., Naseer, F., Ahmed, S., Munawar, N., & Nawaz, R. (2024) · Molecular Immunology · doi:10.1016/j.molimm.2024.07.004 · Cited by 16
Calderaro, A., Martinelli, M., Montecchini, S., Motta, F., Covan, S., Larini, S., Medici, M. C., Arcangeletti, C., Chezzi, C., & Conto, F. D. (2015) · Diagnostic Microbiology and Infectious Disease · doi:10.1016/j.diagmicrobio.2015.12.016 · Cited by 15
Clancy, E., Coughlan, H., Higgins, O., Boo, T. W., Cormican, M., Barrett, L. M., Smith, T., Reddington, K., & Barry, T. (2016) · Journal of Microbiological Methods · doi:10.1016/j.mimet.2016.06.017 · Cited by 15
Nestor, D., Hedberg, S. T., Lignell, M., Skovbjerg, S., Mölling, P., & Sundqvist, M. (2019) · Journal of Microbiological Methods · doi:10.1016/j.mimet.2019.01.003 · Cited by 15
Seizures in adults with suspected central nervous system infection
Olie, S. E., van Zeggeren, I. E., ter Horst, L., I.-PACE Study Group, Citroen, J., van Geel, B. M., Heckenberg, S. G. B., Jellema, K., Kester, M. I., Killestein, J., et al. (2022) · BMC Neurology · doi:10.1186/s12883-022-02927-4 · Cited by 15
Self-citationWith a little help from a computer
Gowin, E., Januszkiewicz‐Lewandowska, D., Słowiński, R., Błaszczyński, J., Michalak, M., & Wysocki, J. (2017) · Medicine · doi:10.1097/md.0000000000007635 · Cited by 13
Strelow, V. L., de Miranda, É. J. F. P., Kolbe, K. R., Framil, J. V. D. S., de Oliveira, A. C. P., & Vidal, J. E. (2016) · Arquivos de Neuro-Psiquiatria · doi:10.1590/0004-282x20160143 · Cited by 15
Groeneveld, N. S., Bijlsma, M. W., van de Beek, D., & Brouwer, M. C. (2024) · Clinical Microbiology and Infection · doi:10.1016/j.cmi.2024.12.009 · Cited by 17
Self-citationShangguan, L., Xue, L., Shang, J., & Wang, H. (2023) · BMC Infectious Diseases · doi:10.1186/s12879-023-08672-4 · Cited by 13
Lumbar puncture in adult bacterial meningitis: time to reconsider guidelines?
Glimåker, M., Lindquist, L., Sjölin, J., & For the working party of the Swedish Infectious Disease Society for bacterial CNS infections (2013) · BMJ · doi:10.1136/bmj.f361 · Cited by 13
Systematic review and validation of diagnostic prediction models in patients suspected of meningitis
van Zeggeren, I. E., Bijlsma, M. W., Tanck, M. W. T., van de Beek, D., & Brouwer, M. C. (2019) · Journal of Infection · doi:10.1016/j.jinf.2019.11.012 · Cited by 15
Self-citationCerebrospinal fluid ferritin in children with viral and bacterial meningitis
Rezaei, M., Mamishi, S., Mahmoudi, S., Pourakbari, B., Khotaei, G. T., Daneshjou, K., & Hashemi, N. (2013) · British Journal of Biomedical Science · doi:10.1080/09674845.2013.11669943 · Cited by 13
Metadata
- Authors
- Brouwer, M. C., Thwaites, G. E., Tunkel, A. R., & van de Beek, D.
- Affiliations
- Amsterdam UMC Location University of Amsterdam (NL)
- King's College London (GB)
- Monmouth Medical Center (US)
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2012-11
- Volume
- 380
- Issue
- 9854
- Pages
- 1684-1692
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2131707675
- Cited by
- 302
- References
- 78
- Citations by year
- 2026: 19 · 2025: 21 · 2024: 27 · 2023: 22 · 2022: 23 · 2021: 18 · 2020: 20 · 2019: 21 · 2018: 22 · 2017: 18 · 2016: 34 · 2015: 24 · 2014: 20 · 2013: 12 · 2012: 1
- FWCI
- 2.62
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Topics
- Life Sciences › Immunology and Microbiology › Microbiology › Bacterial Infections and Vaccines
- Health Sciences › Medicine › Microbiology (medical) › Bacterial Identification and Susceptibility Testing
- Health Sciences › Medicine › Infectious Diseases › Infectious Diseases and Tuberculosis
- Keywords
- community-acquired bacterial meningitis, cerebrospinal fluid analysis, diagnostic prediction model, atypical presentation, clinical evaluation, neuroimaging, diagnostic sensitivity
- MeSH terms
- Acute Disease, Anti-Bacterial Agents, Decision Support Techniques, Diagnosis, Differential, Humans, Medical History Taking, Physical Examination, Spinal Puncture, Tomography, X-Ray Computed, Biomarkers, Meningitis, Bacterial, Community-Acquired Infections
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