Talk:Meningitis/Archive 1

Ethics

While lookin' at this article, it occurred to me that people may be using this and an emergency source of information (e.g. a worried mother who supects her child has contracted the disease). So I suggest that the inportant information in diagnosis be included first - in bullet point veiw - and the the infected brain be moved towards the end of the artcle, or replaced by a picture of visual symptoms in a live patient. Just thinking of morality, that's all.

Wikipedia does not profess to be an emergency medical manual, and we have a medical disclaimer. The intro should clearly mention the most important telltale signs (fever, neck stiffness, photo- and phonophobia and petechiae), as should be the case in all medical articles. The remainder should remain unchanged.

I agree the infected brain should be lower down in the article.

I dispute that Wikipedia has a moral duty beyond its stated objective to provide unbiased, sourced and verifiable information. JFW | T@lk 22:34, 29 October 2005 (UTC)

I agree that the tell tale signs should be listed at the top of the page - it would be useful for one (and yes I did just come here looking for them, not a true emergency but it'd be nice if that information was on wikipedia) 137.222.10.58 00:45, 8 February 2006 (UTC)

I added the most common signs/symptoms and (imho) the most relevant and important things about meningitis in the heading. Hopefully it will be more helpful. --Andrewr47 04:16, 26 June 2006 (UTC)

"and Listeria monocytogenes is associated with poor nutritional state and alcoholism" referance for that? looking at the Listeria monocytogenes page there is no mention of poor nutritional state or alcoholism as being related, and it actually says that it is more commonly assocated with food borne illness 71.231.122.233 (talk) 09:37, 30 May 2008 (UTC)Kris

Listeria is more common in extremes of age (ie, infants, elderly). Homelessness is a risk factor, but I agree there should be a reference, as it can occur without poor nutrition. rhetoric (talk) 21:25, 13 September 2008 (UTC)

I agree with this suggestion. This is a pragmatic matter; you may not like it, but people will come here looking for this specific information; I think it is appropriate to make this information more immediately accessible. Electrosaurus (talk) 08:33, 6 October 2008 (UTC)

Suggestions

I'm completely out of my league with this article, and thus I'm not going to edit it. But I am aware of a few things that seem to be missing from this article:

1. What is meningococemia?

2. How long is the vacination effective? (i.e. is it once per lifetime, or yearly boost, or...?)

--Sdfisher 14:58, 26 Jan 2005 (UTC)

• Just got a meningitis shot. The nurse said it was effective for 10 years. 72.230.61.217 23:52, 16 June 2006 (UTC)

Answers:

1. Meningococcemia is also known as meningococcal septicemia ie blood-borne infection with considerably higher mortality rate than the meningitis disease.
2. Duration of effect depends on what vaccine you had - i.e. for which bacteria, and in the case of meningococcus, which strain of the bacteria. Also depends upon one's age (young children mount less of a response and so often need multiple courses to provoke a full protection. See Vaccination schedule for full details
   • Haemophilus influenzae vaccination (HiB) is routinely given as 3 shots to infants in UK, adults needing protection (eg asplenia following splenectomy) need just one dose for lifetime cover
   • Meningococcus - the Men A&C strain mix used for travel vaccinations lasts just 3 years.
   • Conjugated Meningococcus C (conj Men C) - given thrice to infants in UK, but for adults (again for asplenia but also in the catch up program to cover all school leavers), just a single dose is thought to give perminant protection ("perminant" is as yet somewhat ill defined)
   • There are other vaccines for other strains of Meningococcus - but I can't advise as to their duration of effects. David Ruben ^Talk 01:35, 17 June 2006 (UTC)

CT before lumbar puncture

Removed the advise to make a CT scan before all lumbar punctures. Evidence for this: PMID 10597758 PMID 11742046 PMID 8448711 PMID 16010480 --WS 01:23, 1 August 2005 (UTC) dfkgerlkj is known for its brjrhjvlrg inside. —Preceding unsigned comment added by 12.168.59.85 (talk) 03:15, 8 November 2007 (UTC)

Treatment of Viral meningitis

I'm not going to edit this article, as medicine is way out of my league, but the article seems to suggest the treatment for meningitis is always the use of broad spectrum antibiotics. Clearly, that can't be the case with viral meningitis.

On the Meningitis Foundation of America website, they state:

Unfortunately, there is no specific treatment for viral meningitis at this time. Medical Doctors recommend plenty of rest, relaxation, fluids, and medicine to relieve a fever or headache.

[1]

This seems to be a pretty important point for an article for the general public. Mmmbeer 14:06, 25 September 2005 (UTC)

• I disagree, although fully agreeing with your logical reading of the artice that such information is currently missing :-) - I would point out that the "general public" never themselves make a decision, or should even have suggested to them, on how to self-treat viral meningitis. All cases exibiting signs of meningism need to be urgently admitted to hospital, on the basis that there may be a progressive bacterial cause. UK guidelines are that any General Practitioner seeing a suspected case of menigitis should give an antibiotic injection even before the ambulance transports the patient to the hospital - such is the rapid risk of fatality from bacterial cases and the importance of early treatment being started. Of course, if subsequent lumbar puncture tests suggest a viral cause then further antibiotics need not be given and suitable advice can be given, but it should be remembered that whilst usually not fatal, viral meningitis very occassionally may be.
• Like all internet/book articles on medical topics, it is legally (and ethically) not possible to make diagnosis or give precise advice on an individual's treatment. Readers do and will erroneously interpret advice given, whatever disclaimers & cautions might be given. Therefore WP needs to take great care with this article (in particular) not to suggest that "Mild" symptoms might correlate with less serious causes of meningitis and thereby in anyway delay people from taking the necessary action, namely that all suspected cases, however mild, need emergency medical attention.
• I would suggest that the article, whilst mentioning that antibiotics must be promptly given for bacterial causes, does not explicity suggest that no treatment (ie no antibiotic) is needed for viral cases ("treatment" in the public's mind means seeing a doctor for all the things they do, so "no treatment" would be interpreted as "no need to see a doctor")
• If you can think of a round-about method of mentioning the points you raised, have a go (eg "Following treatment of meningitis cases, people often feel tired for some time for which rest is important and pain-killers for any continuing mild headadache may be advised.") But I think most doctors would be fairly concerned about the wording chosen, most of us will have seen cases that started with a "mild viral-like illness" that soon became something quite different :-) - David Ruben^talk 01:10, 26 September 2005 (UTC)
  • Your points are well taken. However, it seems that there are at the very least two things that can be distilled from what you said: 1) clarify that the treatment is for bacterial (you don't have to say that it excludes viral) 2) state in the first sentence all suspected cases, however mild, need emergency medical attention. Just a thought. Mmmbeer 01:40, 26 September 2005 (UTC)
    • Ok - so incorporated - David Ruben^talk 03:00, 26 September 2005 (UTC)

• • I agree with David Ruben. Doctors will be fairly concerned with the wording chosen. Most of us will have seen cases which have been mild and then progressed to life threatening or fatal consequences. Most of us will also have seen cases which seemed like the most florid meningitis which have turned out to be something else. So ... questions:
  • Are we happy with a statement that it is a medical emergency? Should we bold/italicize it or otherwise draw further attention? Maybe add something saying All Suspected Cases should be brought to see a doctor? Would that not possibly further swamp the already overworked GP's and emergency departments?
  • Please bear in mind that in some cases we are talking about a public that needs "Warning - may contain nuts" on packets of peanuts or they might sue.
  • Orinoco-w (talk) 00:34, 26 October 2008 (UTC)

Um, I know that generally steroids are given, lost of pain medication and waiting. I can't really find a source though. I just know cause I had Meningitus...--Coffeegirlyme (talk) 07:32, 22 December 2007 (UTC)

extreme cold and meningitis

I've read somewhere that extreme cold (like going around without a hat, at -30 C) increases the risk of meningitis? And in the article it says that meningitis is purely viral. Which of the statements is true? --rydel 15:38, 24 January 2006 (UTC)

Well, not purely viral. There are bacterial, viral and parasitic forms of meningitis. Apart from a very rare hereditary condition (CINCA/Muckle-Wells) there is no association between cold exposure and meningitis to my knowledge. JFW | T@lk 16:56, 24 January 2006 (UTC)

Removal of reference

I've removed: Hill, A. Edward. "Benign Lymphocytic Meningitis." "Caribbean Medical Journal", Vol. XI, No. 1, pp. 34-37. for several reasons. Mostly what has this to do with the current contents of the article ('Benign Lymphocytic Meningitis' is not mentioned) ? I could not find the reference in PubMed - the year of publication would have been helpful, is there on online copy of the article anywhere?

As best as I can tell from a quick search of PubMed [2] for 'Benign Lymphocytic Meningitis', the presence of lymphocytes may be associated with a number of different viruses. In the case of a meningitis outbreak, the quick identification of lymphocytes highlights viral cases from bacterial, given that full viral studies may take some time to undertake. However only a minority of cases with lymphocytes identified seem to be proved to be of any viral cause - "of 208 cases of aseptic lymphocytic meningitis seen over a nine-year period, 24 were diagnosed as viral infections" Becq-Giraudon B, Cremault A, Marechaud R, Abadie JC, Castets M, Sudre Y (1982). "[Viral etiology of aseptic lymphocytic meningitis. Twenty-four cases seen over a nine-year period (author's transl)]". Sem Hop. 58 (12): 739–45. PMID 6283647.{{cite journal}}: CS1 maint: multiple names: authors list (link). David Ruben ^Talk 01:43, 7 May 2006 (UTC)

Re-adding the "See also" links

I've re-added the list of "See also" links. Andrewr47 and other editors/contributors, please leave this list on the page. Thank you. -- 201.78.233.162 16:50, 5 July 2006 (UTC)

What about amoebic meningitis?

There's no mention at all of this form of meningitis. Anyone able to provide some info on it?

It is excessively rare, and has a 100% mortality. Nice, innit? JFW | T@lk 15:54, 2 September 2007 (UTC)

Diffrences B/w types of meningitis !

Hello...

well although the topic is very good... but i could't find the differences b/w different types of meningitis like Viral,acute bacterial and tuberculous meningitis.... will u plz help me out :) thanx. Jinn

This has probably been answered for you, but basically the CSF results help you differentiate. The types you listed should clue you in to what the cause is.  ;) Bacterial is usually much more serious. rhetoric (talk) 19:57, 12 September 2008 (UTC)

What is Graham sign?

Article refers to "Graham sign" which is not defined or linked. I can't Google anything about it. Probably should be removed. Gypsydoctor 22:51, 9 November 2006 (UTC)

Think this was just some nonsense applied by an anon editor in these edits - I have now fully reverted back (I had previously only reverted 1 out of their 2 edits).David Ruben ^Talk 01:27, 10 November 2006 (UTC)

So...

I've had viral meningitis, the doctor said if I did not come in that day i would have died. I am wondering if there are any long term effects viral meningiis could have had on my brain? SwiftGeneration 22:40, 17 November 2006 (UTC)

Also, I don't see any mention of a symptom I had, dark red splothes under my skin, as if the vessels were filled with dye and you could see them easily and quite clearly

---

That surprises me. Usually bacterial is much more serious (ie, leading to death). That said, I suppose a bad viral infection can lead to increased intracranial ("in the skull") pressure, causing neurologic (nerve) problems such as seizures. Generally viral meningitis shouldn't have any long term sequelae (effects). rhetoric (talk) 20:00, 12 September 2008 (UTC)

PCR for clinical or research only?

I have seen 2 cases of meningitis in the last 3 years which had cloudy fluid from the lumbar puncture but which never cultured anything, so antibiotics for a wide variety of bacteria were administer IV: gram positive, gram negative, Legionaire's disease, etc. The infectious disease doctor refused to do PCR, saying it was never used for clinical applications, only for research. This was at a teaching hospital affiliated with a medical school. My question is, could a reference be added showing that PCR is an appropriate technique when the csf does not show any bacteria in culture, to identify the infectious agent and reduce the risk of harm from unneeded antibiotics. Edison 01:14, 22 December 2006 (UTC)

Actually, I've studied cases where PCR was done to confirm a viral etiology; however, to be honest, I am not sure as to why exactly it is done... Probably to rule out a tuberculous or fungal cause —Preceding unsigned comment added by Wnb0518 (talk • contribs) 19:59, 20 February 2008 (UTC)

MCOTW

Ahh, this is now the MCOTW - for the last 2 weeks! There is a lot to be done here, and I cannot begin to see the things that need improving. There are no references, especially those very specific claims with regards to steroids (see PMID 17253505 for some developments). A useful recent review (community-acquired meningitis in adults, PMID 16394301) may be used as a backbone.

Some ideas:

• What signs and symptoms predict the presence of meningitis; is there such a thing as asymptomatic/atypical meningitis? How do children differ in their presentation from adults?
• How is meningitis diagnosed. Is a CT scan necessary pre-lumbar puncture?
• What are the forms (e.g. bacterial, viral, tuberculous/mycobacterial, parasitic, aseptic, autoimmune, traumatic). Can they be distinguished clinically (e.g. Listeria causing early cranial nerve pathology) and epidemiologically (again Listeria in alcoholics).
  • What are the commonest causative agents for each form?
  • How are these forms distinguished?
  • How is it related to meningoencephalitis?
• What are the complications (e.g. hydrocephalus)
• Pathogenesis: how does meningitis arise, is it different from infection of other organs and why (discuss blood-brain-CSF barrier). Discuss the peculiar phenomenon re. worsening of inflammation by bacterial breakdown products after commencement of antibiotics and benefit from glucocorticoids in particular forms.
• Treatment: discuss need for broad-spectrum empirical antibiotics, interference with lumbar puncture results, need to add viral or parasitic cover when suspected, the corticosteroid controversy (adults and Western world children only etc), the treatments for complications (neuromonitoring, pressure bolts/Ommaya reservoirs, ventriculosystemic shunts) etc etc.
• Prognosis: discuss natural history and prognosis with treatment (mention poor prognosis tuberculous and Listeria)
• Epidemiology: which populations are at risk (mention children, immunocompromised, pilgrims e.g. for the Hajj). What determines the Meningitis Belt?
• Vaccination: what strains are amenable to vaccination
• History: discovery, major historical developments. Perhaps also mention here any famous patients, significant mentions in world literature (e.g. Phillip in My Cousin Rachel, including mention of therapeutic LP) etc.

Whew. JFW | T@lk 22:23, 29 January 2007 (UTC)

JAMA - how to interpret CSF results! PMID 17062865. JFW | T@lk 22:27, 29 January 2007 (UTC)

Viral Meningitis is very cool to study. I am studying it right now.

Vaccine question

(moved from article page by MarcoTolo 22:24, 24 March 2007 (UTC))

It is a mistake made in this pages under vaccination. Pneumovax and Prevnar / Prevenar are two very different vaccines. Pneumovax- made by Merck is a polisacharid 23 valent vaccine (also Pneumo23 Pasteur). Prevnar / Prevenar - made by Wyeth is a conjugated 7 valent vaccine.—Preceding unsigned comment added by 219.89.184.36 (talk • contribs)

needs indolent meningitis

cryptococcus neoformans causes meningitis in immunosuppressed host and can indolent meningitis in immuno-competent hosts. Could someone please write a section on indolent meningitis?

Other complications: limb loss?

I recently saw a news story about a man who apparently "lost both legs" to meningitis. Is this a common complication of the disease, and if so, what is the mechanism for it? It is not mentioned at all in the article. 217.155.20.163 14:52, 8 April 2007 (UTC)

A person who graduated two years ahead of me from my high school conracted meningitis as a freshman in college, and lost all his limbs as a result. I'm not sure of the specifics but I do know that the case you saw is not an isolated one. PaladinWhite 23:45, 26 April 2007 (UTC)

That would have been from meningococcal septicemia, a blood infection that accompanies meningococcal meningitis. That's also what causes the rash. cyclosarin (talk) 02:43, 16 March 2008 (UTC)

Page Merge

The Bacterial meningitis article is too small to sustain its own and should instead be merged into this one and elaborated upon within its own section. --I Are Scientists 01:15, 12 April 2007 (UTC)

After looking at the content of the page I would agree. It's just a pile of signs, symptoms, and treatment (OH THE BANALITY!). For now it deserves a little home on the Meningitis page. -- Serephine ♠ talk - 01:27, 12 April 2007 (UTC)

This merge has since been actioned. LeeVJ (talk) 23:19, 29 September 2008 (UTC)

Image a bit too graphic?

Am I the only one that thinks the infobox image may be a bit too graphic for the very top of the page? It is of course very informational, but I don't have what I would call a "weak stomach," and I did get some creepy-crawlies when I hit this page. PaladinWhite 23:44, 26 April 2007 (UTC)

I must admit to agreeing, my first thought was "Oh god, tell me that's not a brain, it can't be!" I think it a good and valuable image, but perhaps a bit further down, not right in ones face so to speak? --Brideshead 18:47, 1 May 2007 (UTC)

Yup, that's all I'm saying - don't remove the great image, just give people a chance to decide whether they really want to learn about meningitis before hitting them with the graphics! PaladinWhite 03:27, 2 May 2007 (UTC)

Agreed... I have a strong stomach, but seeing that makes me feel sick. Whstchy 22:54, 11 May 2007 (UTC)

I think the picture is informative, and even if you take it from the top of the page then keep it in another section. --Gak 11:34, 20 May 2007 (UTC)

My dad is a surgeon and we have a real human skull in the house, I wasn't very impressed. Most people see worse things on shows like CSI or ER, but it's the fact that the pic is REAL that makes people sick. So leave the pic alone, if the infobox said that it was a fake no one would complain that much... XXX

Haha.. oh... sorry. I put the image there, didn't think it would freak out the general traffic to Meningitis (I assumed it would be mainly medical students). Personally it doesn't look gross to me at all, it's mainly just blood, neural tissue and some connective tissue? I've seen worse at the local deli! In any case, it's still in a good position so its all good -- Serephine ♠ talk - 00:42,

I don't consider myself to be sensitive regarding the details of the human anatomy, but I don't think the image should be shown without a warning of some kind. Somebody else investigating meningitis, could be far less "relaxed" about this image. I guess this could be said about many other images on wikipedia, so maybe there should be a general rule for explicit images like these. Anyway, I would suggest that a warning label, a link or some other method could be used to remove this image to a less exposed place. 24 September 2008 (UTC)

YES. You are absolutely right. It is inappropriate to accost the reader with the image, much less display it on the front page when the article is featured! I visit Wikipedia on a daily basis and see the featured article image many times a day, it is really unpleasant. 99.140.59.128 (talk) 06:52, 2 April 2009 (UTC)

23 May 2007 (UTC) could there be a warning added above where the picture is stating that the image may be considered too graphic?

Yeah, even just perusing the page, I really wasn't expecting that image. Spirit Stiff 23:12, 3 July 2007 (UTC)

Agreed, I wasn't expecting this image. I'm not that squeamish but this image is particularly disturbing, especially when not expecting it. Is there some way we could link to it or have it expand upon warning? I came looking for general info on Meningitis, not knowing what it was, and I suspect most traffic here will not be from medical students who are accustomed to looking at things like the said image.

It's probably a very nice, and informative picture, but I think that most users would be disturbed enough, and not expecting it enough, to warrant moving it. James Lednik (talk) 02:40, 19 November 2007 (UTC)

Just because it has educational value does not mean the image isn't also just plain gruesome. This is the sort of thing you'd expect to find on rotten.com, not wikipedia. Maybe the article could just link to the picture, with a brief warning, giving the reader a choice about whether they really want to see it? 216.161.145.199 (talk) 07:40, 14 January 2008 (UTC)

Anthrax

I was reading this book about Amerithrax recently, and one of the symptoms of anthrax inhilation was Meningitis. Could someone add this?

Completement deficiency

Complement deficiency is not presently mentioned as a cause for recurrent meningitis. PMID 16026838 seems to deal with this, but does it mention meningitis specifically? JFW | T@lk 11:05, 2 September 2007 (UTC)

Recurrent meningitis is not mentioned at all in the article yet. It may be caused by cranial defects or immunodeficiencies. Of the immunodeficiencies, deficiencies of complement factors C7, C8 and C9 are associated with N. meningitidis meningitis. --WS 17:46, 2 September 2007 (UTC)

My question was whether that review (PMID 16026838) on complement deficiencies made any specific mention of meningitis. If that is the case, it could be included as a source. Obviously, any form of immunocompromise, as well as fistulae between the nasal cavity and the neurocranium, can predispose to meningitis. I just remember reading that complement deficiencies were particularly likely to cause recurrent bacterial meningitis because the membrane attack complex (MAC) is needed to destroy capsulated organisms. JFW | T@lk 09:01, 4 September 2007 (UTC)

We're not doing very well, are we?

Goodness, not many edits for MCOTW. Seems we're all too busy doing other things... Some articles that we can integrate: Does this adult patient have acute meningitis? (JAMA Rational Clinical Examination series) and How Do I Perform a Lumbar Puncture and Analyze the Results to Diagnose Bacterial Meningitis? (ditto) JFW | T@lk 21:02, 5 September 2007 (UTC)

Clinical prediction rule

doi:10.1016/j.jinf.2006.06.009 - distinguishes between viral and bacterial meningitis. JFW | T@lk 03:08, 29 November 2007 (UTC)

interesting

Meningitis is very interesting. This will help my firends and I with our projects. :) —Preceding unsigned comment added by Kkhoneybee (talk • contribs) 02:27, 23 January 2008 (UTC)

Remember to reference appropriately ;) —CycloneNimrod^Talk? 11:05, 18 July 2008 (UTC)

treatment regimens

I think the section saying Listeria coverage goes until age 3 is questionable. I've read that ampicillin (for Listeria) can be discontinued somewhere between 1 and 6 months of age...

Furthermore, though the section listing appropriate antibiotics is nicely detailed, I think it loses the point. Basically here's how to think of it:

1) 3rd generation cephalosporin for everyone, with or without vancomycin (it's easier to just say with) 2) add ampicillin for extremes of age to cover Listeria 3) add dexamethasone (before giving antibiotics) if Pneumococcus or TB meningitis are suspected

I hope this is helpful. rhetoric (talk) 19:55, 12 September 2008 (UTC)

Ideally we should base these sections on national guidelines by professional bodies, or at least the conclusions of recent reviews, rather than relying on our own expertise or experience. JFW | T@lk 20:02, 13 September 2008 (UTC)

Ideally, yes.  ;) If I find the time, I'll reference an article, but I'm just basing what I said on my textbooks/lectures. rhetoric (talk) 21:23, 13 September 2008 (UTC)

MCOTW again

I think most of the points from the last MCOTW are unchanged. There is still quite a lot of ground to cover, but it is possible to get this article to GA status with some dedicated effort. Most of my edits are likely to reflect doi:10.1053/jinf.2002.1110 - which are the guidelines I'm using in practice (or try to). JFW | T@lk 23:42, 25 September 2008 (UTC)

I might try and find a good paper on paediatric meningitis and focus on that. —Cyclonenim (talk · contribs · email) 06:49, 26 September 2008 (UTC)

I've decided to try and write about recurrent bacterial meningitis as caused by aquired and congenital anatomic defects or disorders in immune mechanisms. I've got a textbook on paediatric neurology available but it's information is very likely to be outdated in terms of guidelines for treatment. I'll likely only use it for general information, signs and symptoms and causes etc. —Cyclonenim (talk · contribs · email) 10:24, 27 September 2008 (UTC)

For treatment I would prefer to stick to professional guidelines by the major bodies:

• Infectious diseases society of America
• British Infection Society
• SIGN guideline (children)

Those of other countries could be included, but US and UK sources are the minimum. JFW | T@lk 21:28, 27 September 2008 (UTC)

Sepsis disambiguation and chronic bacterial meningitis

• I think the article should have at the top "This article is about infection of the meninges. For meningococcal septicaemia, see Sepsis. Either that or a disambiguation would be useful, because I only realised that the two things were different when I started my medical education.
• There is a type of meningitis called chronic bacterial meningitis, associated with several organisms, including spirochetes and mycobacteria, and with much less mortality than acute pyogenic. It's in Robbin's 8th ed Basic Pathology. Should the article be changed to reflect this? Electrosaurus (talk) 08:40, 6 October 2008 (UTC)

Meningitis is meningitis. I don't think we need to disambiguate so prominently for meningococcal disease. Bear in mind that other bacteria can cause meningitis.

Please add information about chronic meningitis. This is relevant to the subject. JFW | T@lk 23:20, 6 October 2008 (UTC)

 Question: Isn't 'chronic bacterial meningitis' the same thing as recurrent bacterial meningitis? If so, we have a section on it. —Cyclonenim (talk · contribs · email) 06:49, 7 October 2008 (UTC)

No, they are different things. Recurrent bacterial meningitis is sudden and severe, then responds to treatment but comes back again. There are various causes, such as infections in the head & neck area and immune problems. Chronic meningitis is meningitis with less severe symptoms that is still caused by infection of the meninges. It is caused by different pathogens, and requires a slightly different approach to treatment. JFW | T@lk 17:27, 7 October 2008 (UTC)

Ah fair enough :) I look forward to seeing the content added then. —Cyclonenim (talk · contribs · email) 20:56, 7 October 2008 (UTC)

Before we leave

I have removed the pusbrain picture (Image:Streptococcus pneumoniae meningitis, gross pathology 33 lores.jpg). I really don't find it particularly useful or illustrative, apart from the gross factor that I'm not even particularly worried about. If people disagree we can also try to find a slightly more informative gross pathology picture (with "gross" here meaning non-microscopic pathology images).

I'm not particularly thrilled by the fact that the article now has various references to online FAQ pages rather than peer-reviewed journal articles. Is there no way we can replace the Seattle and King County Public Health Department source with something that has more teeth? JFW | T@lk 12:04, 12 October 2008 (UTC)

When were those references added, and where? I'll try and search for some alternative sources. —Cyclonenim (talk · contribs · email) 13:19, 12 October 2008 (UTC)

PMID 18598630 might be a good candidate. —Cyclonenim (talk · contribs · email) 13:26, 12 October 2008 (UTC)

I am not sure when the references appeared. The PMID is interesting, but it is a primary research study focused on Turkey. Perhaps there are reviews or other sources in the references that might be useful instead. PMID 832730, for instance, is a meta-analysis focused on outcomes in children. It's from 1993, so if that meta-analysis has been updated we should cite that preferentially.

PMID 12826449 is the last Lancet review on bacterial meningitis in children. I can't presently afford the £ 30 they charge for it, but I might be able to pull it from my hospital library. JFW | T@lk 14:23, 12 October 2008 (UTC)

Sounds good. Let me know if you get hold of it. —Cyclonenim (talk · contribs · email) 14:49, 12 October 2008 (UTC)

I've got a copy of it, if you'd like. - Jeyradan (talk) 14:54, 12 October 2008 (UTC)

That'd be great :) —Cyclonenim (talk · contribs · email) 15:42, 12 October 2008 (UTC)

I refer you here: [redacted; inquire if needed]. - Jeyradan (talk) 16:07, 12 October 2008 (UTC)

Thanks for that, it's a great read! —Cyclonenim (talk · contribs · email) 16:11, 14 October 2008 (UTC)

Delays

The IDSA article, to which I hope to be sourcing some of the content, states that there is no unequivocal evidence that delayed administration of antibiotics leads to worse outcomes. PMID 1576092, which appeared a year later, supports this suspicion. Any opinions on using this new primary source against the IDSA source? JFW | T@lk 03:08, 19 October 2008 (UTC)

Is that the correct link, JFW ?! On the other hand if it does support the older source, then use them both ! LeeVJ (talk) 17:28, 19 October 2008 (UTC)

PMID 15760921 is the correct link. Sorry. JFW | T@lk 18:40, 19 October 2008 (UTC)

:) Ahhh! Source looks ok, having been based on 7yr old data, presented at a conference and having a few years since to be objected to. Did you mean the IDSA article says there isn't evidence, so the QJM article is at odds with it, if so still looks ok though? LeeVJ (talk) 19:50, 19 October 2008 (UTC)

The NEJM review goes to town on that observational study. It is now referenced appropriately. JFW | T@lk 22:02, 10 November 2008 (UTC)

Non-infectious meningitis

The intro mentions non-infectious causes of meningitis, but the "Causes" section doesn't discuss this. We need to find a reliable source to fuel this (probably a textbook, such as Harrison's). Skimming some sources (such as Emedicine), the most important causes are meningitis carcinomatosa, lupus, and drugs (NSAIDs and antibiotics). JFW | T@lk 03:32, 19 October 2008 (UTC)

Nice edits on the article - thanks for all your work! I think I've a textbook that might discuss this in some detail, so I'll look it up and get back to the article if I can find anything informative. -Jeyradan (talk) 19:50, 19 October 2008 (UTC)

Please do, because Harrison's doesn't say a word about this, at least not in a nice and useful list. JFW | T@lk 20:20, 19 October 2008 (UTC)

 Done (Ginsberg} JFW | T@lk 11:48, 29 October 2008 (UTC)

Doing a "pathogenesis" section

The article presently doesn't have a "pathogenesis"/"disease mechanism" section. The Lancet article has a fine section on this, which is not exactly full of useful references but gives a coherent picture of how the infectious insult sets off a forceful cascade of inflammatory response that may cause more damage than the infection itself. I think this needs to be discussed, especially because it will make sense later on why dexamethasone is now advocated in the pretreatment of bacterial meningitis, especially in adults.

We should probably also discuss how the pathogens enter the subarachnoid space to begin with. I've made a brief mention of the obvious causes in "signs and symptoms", but we need to clarify why 30% of us can carry N. meningitides in our nasal cavity, yet most do not get meningitis.

Perhaps "pathogenesis" is also the point to explain why meningitis might cause long-term neurological damage, such as deafness or learning disability. JFW | T@lk 21:11, 19 October 2008 (UTC)

Created under 'Mechanism'. —Cyclonenim (talk · contribs · email) 20:17, 26 October 2008 (UTC)

Medmos heading structure

Have just rearranged the current headings into the suggested order, an important section Prognosis, is missing, but could 'complications' be the basis for this? LeeVJ (talk) 20:29, 20 October 2008 (UTC)

I feel that short-term complications should go under "signs and symptoms". This is only because they usually occur together. With regards to deafness and cognitive impairment I would suspect that "prognosis" should contain a section called "sequelae" or somesuch. JFW | T@lk 23:57, 23 October 2008 (UTC)

Amoebic meningitis

Orinoco-w (talk · contribs) added a section on public health campaigns in Australia following a series of cases of amoebic meningitis. Frankly, I think this is overdoing it a bit: this is otherwise a rare cause and it seems to have been an incident. Much more could be written about other public health campaigns surrounding the recognition of meningococcal disease, vaccination of Hajj pilgrims etc. JFW | T@lk 08:03, 26 October 2008 (UTC)

Blanking the "history" section

The briefest of internet searches shows that meningitis was not discovered by people in al-Andalus. There are a few users going around Wikipedia telling on every page that these clever medieval doctors knew all there is to know about medicine. Not here. The sources don't back the claims, and one of them failed WP:MEDRS by a mile.

According to the WHO, the syndrome was first recognised in 1805 (including its epidemic nature in some settings). 1887 saw the discovery of N. meningites. This information needs to be reintroduced and newly sourced, preferably from a peer-reviewed paper.

As for the Japanese royal family, no source I found mentions this in any detail, and despite requests nobody has been able to provide a source for this paragraph.

We might be able to get some context from PMC 2037206, a 1903 account of a meningitis epidemic in London. This web page discusses the use of penicillin for meningitis in 1942; there must be a direct source we can find. This page is full of references that we can lift. JFW | T@lk 12:00, 26 October 2008 (UTC)

In any case, Attia et al seem to think that Hippocrates already had meningitis figured out. I'm not entirely sure if we should cite that. JFW | T@lk 12:04, 26 October 2008 (UTC)

The Revista de Neurología article seemed quite reliable. My Spanish is serviceable enough to read the full text, and it looks like a pretty comprehensive review backed by decent sources. Surely meningitis has been described since antiquity—we should look for when it was first recognized as a distinct entity. Fvasconcellos (t·c) 15:50, 26 October 2008 (UTC)

Is there really no similar source in English? JFW | T@lk 19:42, 26 October 2008 (UTC)

A couple came up on a Google search, but none in an actual peer-reviewed medical journal :) Maybe in books? I couldn't really do an in-depth search as I'm fighting a deadline to the death right now. Fvasconcellos (t·c) 00:59, 27 October 2008 (UTC)

Here's one

Another one from the Rational Clinical Examination series:

Straus SE, Thorpe KE, Holroyd-Leduc J (2006). "How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis?". JAMA : the journal of the American Medical Association. 296 (16): 2012–22. doi:10.1001/jama.296.16.2012. PMID 17062865. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Can be used to source the laboratory values from a highly regarded series of EBM-guided papers. JFW | T@lk 22:06, 26 October 2008 (UTC)

Still to cover

Gotta dash. Still need to cover (in "causes"):

• Malignant meningitis (carcinoma, lymphoma, leukaemia)
• Subarachnoid haemorrhage
• Chemical meningitis (see text)
• Sarcoidosis
• Other chronic inflammatory diseases (see text)
• Drugs
• Mollaret’s meningitis (see text)

(See text) refers to Ginsberg, from which this list derives. JFW | T@lk 07:28, 27 October 2008 (UTC)

 Done JFW | T@lk 23:41, 27 October 2008 (UTC)

Free image available

There's a free image here:  http://www.casesjournal.com/content/1/1/180. I just don't have time to upload it right now. If you'd like to upload it but don't know how, I'm glad to help, just drop me a note on my talk page. delldot ∇. 07:52, 27 October 2008 (UTC)

I don't find the images particularly striking... We ought to have a photo of meningococcus under the microscope. JFW | T@lk 14:42, 27 October 2008 (UTC)

There is one available from Phil image 6423 --WS (talk) 19:20, 27 October 2008 (UTC)

 Done Been on Commons since Jan 2007... Silly me... Image:Neisseria meningitidis.jpg. JFW | T@lk 20:41, 27 October 2008 (UTC)

Removed from "diagnosis"

The following content is not sourced, and none of the main sources I have consulted mention the tests listed:

If a person is immunocompromised, testing the CSF for toxoplasmosis, Epstein-Barr virus, cytomegalovirus, JC virus and fungal infection may be performed.

Ginsberg mentions cryptococcus (well recognised in severe AIDS), and we need to mention crag and India ink staining. HIV itself can cause viral meningitis. Ginsberg mentions EBV and toxoplasma reactivation. To my knowledge, JC virus causes PML and not meningitis. Ginsberg doesn't readily address the kind of investigations one would do in unexplained aseptic meningitis. JFW | T@lk 18:07, 27 October 2008 (UTC)

I have also removed the following:

The Bacterial Meningitis Score predicts reliably whether a child (older than two months) may have infectious meningitis. In children with at least 1 risk factor (positive CSF Gram stain, CSF absolute neutrophil count ≥ 1000 cell/µL, CSF protein ≥ 80 mg/dL, peripheral blood absolute neutrophil count ≥ 10,000 cell/µL, history of seizure before or at presentation time) it had a sensitivity of 100%, specificity of 63.5%, and negative predictive value of 100%.

The main reason being that this rule is only applicable in children, it is not mentioned in any secondary sources (okay, most of them predate the paper), and it seems a bit of a WP:HOWTO. JFW | T@lk 21:00, 27 October 2008 (UTC)

My expansion: some final points

I have now expanded most sections. The following is still on my "to do list":

• Mechanism - this could be updated further from the Lancet paper
  •  Done JFW | T@lk 01:01, 3 November 2008 (UTC)
• Complications - I'd prefer to work this into a general section on prognosis, given that the acute complications are already discussed in "signs and symptoms"; I would like to merge "recurrent meningitis" into the "causes" section, given that we are already discussing Mollaret's over there as well
  •  Done JFW | T@lk 01:01, 3 November 2008 (UTC)
• Epidemiology - needs fleshing out (but specific sources would be useful)
  •  Done Had great difficulty finding a source addressing meningitis epidemiology as a whole! See points below about neonatal meningitis.
• Prevention - I have found a nice comprehensive review on the use of vaccination in the prevention of meningitis: doi:10.1093/bmb/ldh041
  •  Done Found another source in the process.
• History - needs to be written, using sources I have indicated above
  •  Done Using Walker and Swartz. Can't get Walker fully on Google Books, so anyone with access to that book is invited to add more information from there if needed.

I hope to be completing the work in a week or so. Anyone still happy to help is invited! With a bit of luck we can submit this for good article candidacy in a little while. Some sections can still be streamlined, and we could use some more images. JFW | T@lk 00:21, 28 October 2008 (UTC)

Which source do you suggest for history? —Cyclonenim (talk · contribs · email) 11:27, 29 October 2008 (UTC)

I have also found doi:10.1136/jnnp.2007.139725 - this is quite recent and I plan to use it as background reading more than anything else. JFW | T@lk 11:01, 2 November 2008 (UTC)

Neonates?

The Lancet review gives a very high figure for neonatal meningitis (2-10/10,000 livebirths). Now it seems most of those are secondary meningitis due to systemic sepsis, but this figure is much higher than any other figure cited in other papers with regards to general epidemiology. Does that mean the neonatal cases are not being included in the general statistics? Or is the figure diluted? The figure is based on a single 1986 source. At the moment I'm not entirely sure if it should be cited. JFW | T@lk 09:15, 29 October 2008 (UTC)

I'm not sure we should be citing a statistic from 1986. Are there no recent statistics on neonatal meningitis? —Cyclonenim (talk · contribs · email) 11:23, 29 October 2008 (UTC)

Not as far as I could find. JFW | T@lk 11:48, 29 October 2008 (UTC)

Epocrates is citing PMID 12118843 as a resource for neonatal and infact cases but I can only access the abstract, so I can't check to see if it holds any statistics. I've requested a copy at WP:WRE. —Cyclonenim (talk · contribs · email) 12:20, 29 October 2008 (UTC)

Damn, no luck in that article. Nevermind. We may have to cope with an old source. —Cyclonenim (talk · contribs · email) 22:40, 29 October 2008 (UTC)

PMID 16772416 gives a number of 4-8/10,000 cases of meningococcal disease in <1 year olds (based on confirmed lab reports nationwide in England and Wales). --WS (talk) 23:57, 29 October 2008 (UTC)

Apparently, in Canada the incidence is only a tenth of that, 0.5/10,000 <1yrs PMID 17691125 So there is a wide range of reported incidence rates. --WS (talk) 00:11, 30 October 2008 (UTC)

I think the range is so wide as to question their validity. I think Logan & MacMahon have already demonstrated that statistics for meningitis are not reliable. I have just pulled PMID 16394301 (most recent NEJM review) - hopefully this will give slightly more useful stats for adults. JFW | T@lk 08:25, 2 November 2008 (UTC)

Things to do before taking this to GAC

This edit concludes my 2-week editing spree (started on 19 October) to push this article up to GA status. I now have a very thick envelope with meningitis articles sitting on my desk; hopefully they will one day be useful. At any rate, there are a few more things that need to happen before I submit this one to GAC.

• Thorough copyedit to check for clumsy wording, redundancies, spelling/grammar errors and jargon.
• Identifying any important content we are not currently covering. I can think of a few things:
  •  Not done Is there any morbidity/mortality data on aseptic meningitis? No, apparently not.
  •  Done How to cover the matter of hydrocephalus?
  •  Not done Can we say anything else about the pathogenesis of aseptic meningitis? No, we can't because it's a mixed bag and evidence extends from bacterial meningitis
  •  Not done Are there any cultural representations we need to cover? No, unless we include Daphne de Maurier as alluded to before.
  •  Done Is the history paragraph thorough enough? Could still find a secondary source for dexamethasone in bacterial meningitis
•  Not done See if an image can be found for the "mechanism" section. Probably won't add much

Hopefully I'll be done by Thursday. JFW | T@lk 01:09, 3 November 2008 (UTC)

This from the AAFP has a good section on paediatric aseptic meningitis. Still looking for adult stats. —Cyclonenim (talk · contribs · email) 07:32, 3 November 2008 (UTC)

Good to know

Tonight I attended a most useful teaching session at the Royal College of Physicians, where 30 minutes were spent discussing meningitis and viral encephalitis. The meningitis content resonated closely with the content we are presently covering in this article. In my mind, that means that we're offering a pretty comprehensive view of this disease. JFW | T@lk 23:07, 4 November 2008 (UTC)

External peer review

I sent an email to the authors of PMID 18625686, who kindly sent me a copy of their very comprehensive and thorough review. One of the authors was kind enough to provide some comments that I will gradually be working into the article. Once this is done, I will be reassured that the content is considered reliable by a specialist. JFW | T@lk 01:11, 9 November 2008 (UTC)

Tripod position

Attia mentions the "tripod position", in which the patient assumes a characteristic position by extending the neck, arching the spine backwards, and flexing the knees and hips. This was part of the article, and then got horribly mixed up into the description of the "jolt accentuation manoeuvre". I'm not actually sure how common it is, and whether its presence is of any relevance to the person making the diagnosis. For the moment I think it needs to be left out, unless others feel differently. JFW | T@lk 11:31, 9 November 2008 (UTC)

Quick question

Shouldn't treatment of Naegleria infection/PAM be mentioned at least briefly in "Other infections"? I know it's not well established and of practically no use (not to mention the rarity of PAM), but I still think it warrants a note. I am also tempted to rename the section "Non-bacterial"—sounds simpler and clearer than "Other infections" :) Fvasconcellos (t·c) 22:30, 12 November 2008 (UTC)

Ginsberg, to whom I sourced the content on Naegleria, doesn't discuss the treatment of amoebic meningitis. A separate source would be necessary. I have no definite opinion on "non-bacterial" as opposed to "other infections". JFW | T@lk 23:32, 12 November 2008 (UTC)

If you'd like to add something, [3] and [4] are probably good sources: CDC references (which we can "steal") and recommendations respectively. Again, this is just my opinion; if you think this is undue weight given to a very rare and eminently intractable cause of meningitis, feel free to ignore me :) Fvasconcellos (t·c) 00:53, 13 November 2008 (UTC)

Nice new stuff

doi:10.1136/jnnp.2008.157396 the same Ginsberg has written usefully about chronic and recurrent meningitis. A useful source if we ever wanted to talk more about chronic meningitis. JFW | T@lk 22:43, 17 November 2008 (UTC)

Stuff

Does Menigitis only effect humans? —Preceding unsigned comment added by 70.119.255.202 (talk) 21:47, 23 November 2008 (UTC)

Nope, lots of animals can get meningitis, too: dogs, cats, rats, horses, monkeys - the list goes on. I'd assume that any and all vertebrates are susceptible. -- MarcoTolo (talk) 21:54, 23 November 2008 (UTC)

If there was a useful source on this topic we should probably discuss it in the article. JFW | T@lk 22:46, 23 November 2008 (UTC)

Petechial description?

I am concerned about the following line: "The (petechial) rash is typically non-blanching: the redness disappears briefly when pressed with a finger or a glass tumbler."

Is this true of petechial rash? Shouldn't this read: "The rash is typically non-blanching: it does not disappear when pressure is applied to the skin. This can be tested by pressing a glass tumbler against the skin and looking at the rash through the glass to see if the color has disappeared from it."

I could be wrong about this, but just thought I'd check as it's a pretty important detail.

Cheers Sarah

Well spotted, Sarah. I don't know how that crept in, but I agree this is a crucial piece of information. I have fixed this now. JFW | T@lk 19:57, 24 November 2008 (UTC)

Another image

Main symptoms of meningitis. Additional signs are positive Kernig's sign and/or Brudzinski's sign.

I think we should include this image in the article. It's always easier to get an overview of the symptoms when being able to locate them anatomically. Images is something I think Wikipedia generally lacks, mainly a consequence of the strict image policy.

Or perhaps there need to be some modification of the image before inclusion? Please let me know. Mikael Häggström (talk) 18:58, 16 February 2009 (UTC)

I don't think this image adds much to the text already explaining the symptoms and signs. There is already a very real example of purpura, and I personally think it would be disrespectful to Charlotte Cleverley-Bisman to add this image. I would much more appreciate if you asked a friend to demonstrate Kernig and Brudzinski on you and took a picture of that. --Steven Fruitsmaak (Reply) 19:24, 16 February 2009 (UTC)

Very well. With all respect to Cleverley-Bisman, it might be better to let the text and existing images speak for themselves. They could be made more informative by adding similar labels, but I don't have any compatible pre-existing template for it. Mikael Häggström (talk) 19:33, 16 February 2009 (UTC)

I have watched the proliferation of these diagrams with some concern. If it is meant to illustrate meningitis, I'm pretty sure most people with meningitis don't look quite as cheerful as you do in the image. The caption you added is wrong: Kernig's and Brudzinski's signs have a very low sensitivity and their absence is of no aid in the evaluation of the patient. JFW | T@lk 20:19, 17 February 2009 (UTC)

I can assure you the project is a serious one, although there might be a slight smile discerned in the picture. I'm aware of that the images are not perfect, but until we can find something even better out there with the right licensing, I think this is the best solution. In this article, however, there happened to be a very telling picture already, and although I think an overview of the adult form would fit as well, the article might already be well enough illustrated. I appreciate your comments on the project. Good to keep them free of errors. And indeed, it is likely a good idea to proceed carefully with it, learning from the reception of current pictures. Mikael Häggström (talk) 17:38, 18 February 2009 (UTC)

Time for a FAC

After all the work last year I believe this article achieved rather high quality. It passed GA without much difficulty, and I received some useful external comments from Dr Marc Tebruegge of the University of Melbourne (available upon request).

Going over the featured article guidelines in WP:WIAFA:

1. General criteria: I believe it is well-written, comprehensive, factually accurate, neutral and stable
2. Style guidelines: the article has a lead, an appropriate structure (consistent with WP:MEDMOS) and consistent citations
3. Images: it has a number of relevant images with useful captions
4. Length: I don't think it should be any shorter, and I believe all useful detail is included

I have already looked at links to disambiguation pages. The only ones I could find was lactate (now links to lactic acid) and meningeal artery (which appropriately links to a disambiguation page and cannot be resolved further). JFW | T@lk 12:14, 1 March 2009 (UTC)

This edit

While strictly true, there is a long list of possible causes for all of the symptoms on the page. I don't think it's helpful to add such qualifying statements in this way - it distracts from subject. The page would become unreadable if we follow this path. However, I see this as a judgment call, and I respect the other editor...so let's see what others say. --Scray (talk) 18:59, 1 March 2009 (UTC)

I think one must bear in mind that the primary readership of this article is going to be people who know somebody who has or is suspected of having meningitis, or wonder if they have it themselves. I see it as more important to give them the information they need than to get the Latin names and genera of all the bacteria right -- one hopes that physicians are not going to be depending on this article, however good it is. However, I agree with you that this is a judgement call and that one can't cover everything, and I won't fight about it if the consensus is that this doesn't belong. Looie496 (talk) 19:20, 1 March 2009 (UTC)

This style change would mean identifying all reasonably common symptoms here (headache, fever, rash, stiff neck, photophobia, phonophobia, etc) and juxtaposing a list (to each) of possible alternative diagnoses. If one examines our list of causes for photophobia alone, we could include a couple of dozen. I do think some discussion of differential diagnosis would be reasonable, in a separate section or subsection with an appropriately specific heading, but certainly not in the lead paragraph and I suggest that we reach some consensus before doing so. Alternatively, one could argue that linking to the symptoms article, as in the case of photophobia, provides access to such alternatives. I'm a relatively young Wikipedian, and welcome other perspectives. --Scray (talk) 21:44, 1 March 2009 (UTC)

No, I think this article should not discuss the differential diagnosis of headache, photo- and phonophobia, neck stiffness. There are separate articles for this. JFW | T@lk 20:06, 1 March 2009 (UTC)

As I pointed out on the FAC page, there is not normally a need to provide a differential diagnosis for each and every symptom. That's what their own pages are for. The only exception would be if a disease has mimics that would need to be excluded in the clinical setting. JFW | T@lk 22:14, 1 March 2009 (UTC)

Perhaps I should have conducted this discussion on the FAC page (sorry if this location was a mistake) but I did not want to clutter that page with every little comment (since this was a comment about an edit, not a comment on the article overall). I have removed the edit, feeling better about it since Looie496 said he did not feel too strongly. Discussion appreciated. --Scray (talk) 22:52, 1 March 2009 (UTC)

Some suggestions

Looking at this version

Mechanism

The Mechanism section would benefit from an introductory paragraph on the anatomy of the meninges. Without this, many of the terms are unfamiliar and meaningless. We should describe the three layers (the tiny picture in the lead should not be relied on - the text should explain the layering too). The subarachnoid space and cerebrospinal fluid can also be explained here. Here's my attempt at summarising the accompanying articles (but I'm no expert):

The meninges comprise three membranes that, together with the cerebrospinal fluid, enclose and protect the brain and spinal cord (the central nervous system). The pia mater is a very delicate impermeable membrane that firmly adheres to the surface of the brain, following all the minor contours. The arachnoid mater (so named because of its spider-web-like appearance) is a loosely fitting sac on top of the pia matter. The subarachnoid space lies between the arachnoid and pia mater membranes, and is filled with cerebrospinal fluid. The outermost membrate, the dura mater, is a thick durable membrane, which is attached to both the arachnoid membrane and the skull.

The Mechanism section deals only with bacterial meningitis. I'm guessing the viral and other causes produce similiar immune responses, and that it is this response that causes the trouble. Can you include viruses and other causes?

Weirdly, my sources were very vague about pathophysiology of viral meningitis. My main review on viral meningitis (LoganMacmahon) does not dwell on pathophysiology. I think there have been fewer studies in viral meningitis because it tends to take a milder course. Harrison's (16th edition, 2477-2450) doesn't discuss pathophysiology of viral meningitis in its discussion of the disease. In contrast, its section on bacterial meningitis has 1.5 collumns on pathophysiology. At the moment, all I can say is that parenchymal involvement is unusual in viral meningitis. JFW | T@lk 11:56, 8 March 2009 (UTC)

Diagnosis

• We already have a Diagnostic features sub-section in the Signs and symptoms section so we need to make it clear what the purpose of this section is. I think it is worth repeating here that a tentative diagnosis of meningitis is made clinically, based on the symptoms, and that treatment with antibiotics are started before a full diagnosis is made. The purpose of these tests is to identify which of the many possible causes is responsible and so adjust the treatment. Is my understanding correct?
  • I have renamed the first section "clinical features" as none are 100% diagnostic. Clinical diagnosis (why does a doctor suspect meningitis) and diagnostic testing (how does a doctor confirm the suspicion, distinguish between alternative causes and determine the best treatment) need separate coverage. The diagnosis of meningitis requires testing, as a normal LP even in someone with all the symptoms should lead to a revision in diagnosis. I agree that empirical treatment is usually given. JFW | T@lk 11:56, 8 March 2009 (UTC)
• Could you provide a wikilink to an article on what the pressure scale is for the lumbar puncture. What is the normal range?
  • There is no pressure scale even in the lumbar puncture article. I have clarified the normal range from Straus and removed the very specific range of 20-50 because it is unnecessarily precise (a pressure >50 is still possible). JFW | T@lk 11:56, 8 March 2009 (UTC)
• I don't know what a "cerebral mass lesion" is.
  • Rephrased. Brain tumor or abscess was intended. JFW | T@lk 11:56, 8 March 2009 (UTC)
• Could the CT/MRI be pulled out to its own paragraph, and keep the lumbar puncture stuff together. I think it would be easier to read if the CT/MRI bit began with "Lumbar puncture is contra indicated when ..." rather than describing lots of symptoms first and then saying why they are significant.
  • Rephrased as advised. JFW | T@lk 11:56, 8 March 2009 (UTC)
• The tests are split over two paragraphs with each test mentioned once in each paragraph (the first introduces the tests and the second gives the figures). Why? Wouldn't it be simpler to take us through each test: explain why XXX is elevated or lowered due to cause YYY, explain how the test detects this, mention the threshold used and then the sensitivity and specificity of the test.
  • Rephrased as advised. JFW | T@lk 11:56, 8 March 2009 (UTC)
• I don't know what latex agglutination test, the limulus lysate test and polymerase chain reaction tests are. See previous point for how to lead the reader through the what/why/how of each test. Colin°^Talk 17:15, 6 March 2009 (UTC)
  • This is more for the subarticles. I will expand on the indications for each. JFW | T@lk 11:56, 8 March 2009 (UTC)

Treatment

• Can you introduce "empiric therapy" such that the lay reader learns what it means.
  • Yes. JFW | T@lk 12:49, 8 March 2009 (UTC)
• The mechanism section discusses the use of glucocorticoids to dampen the immune response. The treatment section doesn't use that word but says "corticosteroids", particularly dexamethasone. A lay reader will not know that dexamethasone is a glucocorticoid, which in turn is a corticosteroid. It is probably worth repeating briefly, in the treatment section, why corticosteroid are used (not just that they reduce mortality/morbidity).
  • Yes. JFW | T@lk 12:49, 8 March 2009 (UTC)
• Do your sources indicate why there should be a difference in treatment recommendations for corticosteroids between children from high-income and low-income countries. It isn't obvious and the article teases with this unexplained fact.
  • The discussion of this phenomenon in the meta-analysis is mercifully brief, but it seems there are numerous possible reasons. I will simply state that the exact reason is unclear. JFW | T@lk 12:49, 8 March 2009 (UTC)

Prognosis

• This begins by saying mortality is "higher in the very young and the very old". Fair enough. And the figures of 20–30% in newborns but only 2% in older children support this. But the figures of "19–37% in adults" conflicts because even the lower-end of 19% for everyone 18 years to 100 years old is a pretty high mortality rate in my books! Based on those figures, it would be fair to say "mortality is low in children but very high in babies and adults", which probably isn't right. Can these be worked on?
  • I have simply removed the inappropriate generalisation. JFW | T@lk 12:49, 8 March 2009 (UTC)
• I assume these figures are for cases that receive appropriate treatment in a rich country. Can you say so in the article? Do you have figures for untreated meningitis, or for the rate in the third world?
  • No direct figures, no. The historical sources suggest that untreated bacterial meningitis is nearly always fatal. JFW | T@lk 12:49, 8 March 2009 (UTC)
• Suggest replacing phrases like "have been reported to occur" with just "occur". If we are confident in our facts, just present them as facts.
  • Agree. JFW | T@lk 12:49, 8 March 2009 (UTC)
• "In adults, 66% of all cases emerge with little or no disability." leaves me unsatisfied. What is "little disability" and what proportion has that? It is an odd way of putting the figures. Does it mean 36% have significant disability? Given such high figures for adverse long-term consequences, I'd like to see a bit more information here.

Colin°^Talk 11:02, 7 March 2009 (UTC)

• • I have rephrased this. Clearly, the 66% are people who are able to function without difficulty. The remainder have problems; these are broken down in the article. The NEJM article lists a number of other complications but they are much less common. JFW | T@lk 12:49, 8 March 2009 (UTC)

Epidemiology

• 10.9 per 100,000 sounds quite exact, which contradicts the lead sentence of this section.
  • That's because they are based on a single high-quality study by the Mayo clinic. I will make this clearer. JFW | T@lk 12:49, 8 March 2009 (UTC)
• Most of the stats seem to be (I can't read it) sourced to a rather old review, which focussed on diagnosis rather than epidemiology. Do we not have a better source?
  • There is no straightforward source that provides the numbers in a better fashion. The Attia source is the best I've got in this regard. JFW | T@lk 12:49, 8 March 2009 (UTC)
• "several recent epidemics" - the Hajj episode was 2000 and Burkina Faso as 2003. These are no longer recent in 2009 and are they significant?

Colin°^Talk 15:06, 7 March 2009 (UTC)

• • Well... Google "meningitis epidemic" gives a lot of hits for Burkina Faso. Before that, 1996 seems to have been an annus horriblis. Some minor sources point at a further Burkina epidemic in 2008. Need to verify. JFW | T@lk 12:49, 8 March 2009 (UTC)

Prevention

• The pneumococcal polysaccharide vaccine is only briefly mentioned by the source and I think most of the rest of the two sentences on streptococcus pneumoniae have got it confused with pneumococcal conjugate vaccine, which is expensive, and "does not cover all disease-causing serotypes". However, the journal article indicates that PCV "prevented 94% of invasive pneumococcal cases" in a large RCT which sounds like it is pretty effective. I suspect PPV shouldnt be mentioned and PCV should be discussed more positively, including mention that it is now routine in US, UK, etc.

Colin°^Talk 22:09, 8 March 2009 (UTC)

• • Need to look into this. JFW | T@lk 00:00, 9 March 2009 (UTC)
  • PMID 19144940 suggests that PCV7 has made an impact on pneumococcal disease but non-vaccine serotypes are now emerging. I have made some corrections and expanded using a 2006 Lancet Neurol review. Hope this is sufficient. JFW | T@lk 00:40, 9 March 2009 (UTC)

Sources

• The "Management of invasive meningococcal disease in children and young people: Summary of SIGN guidelines" source isn't free text until 14 June 2011. The full guidelines are available for free here, and more specifically this PDF. Could the full text of the guildelines replace the summary in the BMJ as a source here? Is it useful for anything else? Colin°^Talk 22:44, 8 March 2009 (UTC)
  • I linked to the BMJ summary because it is quite comprehensive and on PubMed. I will manually add a link to the actual SIGN guideline to the reference. JFW | T@lk 00:00, 9 March 2009 (UTC)

BTW, is the article in British or US English? Colin°^Talk 22:58, 8 March 2009 (UTC)

I've stuck to US English, but I may have introduced some inadvertent Britishisms. JFW | T@lk 00:00, 9 March 2009 (UTC)

EFNS

I have added some references to the European Federation of Neurological Societies guidelines. I'm still a bit unclear about how widely these guidelines have been adopted, and most of the information is covered in other sources in any case. JFW | T@lk 19:32, 8 March 2009 (UTC)

Table for causes of meningitis

The table would provide an overview into the Causes section and help commion readers relate to the rest of the article quickly.I believe a table speaks more clearly than lot of text. It could be expanded to include bacteria in age groups .DOCtraind (talk) 03:31, 9 March 2009 (UTC)

The problem with the table is that its source is not quite good enough (see WP:MEDRS). Also, the text provides much more context. JFW | T@lk 07:57, 9 March 2009 (UTC)