Meningitis Misdiagnosis

meningitis

Meningitis is most commonly caused by viral infections and often get better without treatment. Viral meningitis usually affects children and adults under the age of 30 with most infections reported in children under 5 years of age. The exact incidence rate of bacterial meningitis is unknown but is estimated to be 3 per 100,000 in Western countries, with viral meningitis being more prevalent at 10.9 per 100,000.

The exact prevalence is difficult to determine as the number of disease cases changes annually. Approximately 1500 Americans are infected annually. But, unlike most disease, this one ranges wildly. Annual reported cases range from a low of 900 cases to a high of 3000 cases.

Several viruses can cause meningitis including enteroviruses, herpes virus and West Nile virus, among others. Bacterial meningitis are more serious and infections may result in brain damage or death, even with treatment. Other causes of meningitis include fungus, chemical irritation, drug allergies and tumors.

Often, the severity of injury in meningitis cases is the result of medical malpractice. These claims usually involve an infection from a delay in diagnosis or failure to properly treat the meningitis to stop the infection. Too many doctors chalk up meningitis as simply a headache or a simple fever.

Types of Meningitis

Types of meningitis include:

  • CSF leak related meningitis (spinal fluid leak)
  • Aseptic meningitis
  • Cryptococcal meningitis
  • Gram negative meningitis
  • H. influenza meningitis
  • Meningitis due to cancer (carcinomatous meningitis)
  • Meningococcal meningitis
  • Pneumococcal meningitis
  • Staphylococcal meningitis
  • Syphilitic aseptic meningitis
  • Tuberculous meningitis
Symptoms

Symptoms often have a quick onset and may include fever and chills, nausea and vomiting, sensitivity to light, severe headache, stiff neck, changes in mental status, sleepiness, difficulty awakening, agitation / irritability, rapid breathing, unusual posture with head and neck arched backwards, decreased consciousness and bulging fontanelles (soft-spots on the head of infants). Symptoms of bacterial meningitis is dependent on the condition of the patient's immune system and response, which is influenced by age and immuno-compromising conditions such as underlying infections.

Diagnosis typically includes a physical examination which generally shows a fever, stiff neck and change in mental status. Patients may also have symptoms of nausea, vomiting and lethargy. If a person is suspected of having meningitis a spinal tap should be conducted to collect spinal fluid for testing glucose, protein, cell count and culture. Other tests that may be performed include blood culture, chest x-ray, CT scan of the head, stains to determine bacterial presence and identification. Unfortunately, the initial assessment for fever, stiff neck and change in mental status only effectively captures 44%-66% of patients with meningitis. A recent study suggested that history of headache should be included in physical examinations and suggested that in the 696 subjects studied, the presence of the 4 symptoms would have captured 95% of patients rather than 44%. Some doctors are just a little too stingy with blood cultures, too. it is not invasive and it gives you a chance to begin to rule out a potentially fatal condition.

Diagnosis of newborns and infants is much more difficult than older children and adults as they often present with atypical symptoms such as fever, lethargy, irritability, jaundice, diarrhea, reduced appetite and respiratory effect. Further, bulging fontanelles and seizures only occur in a minority of newborns and infants.

Patients over the age of 65 are another population that are difficult to diagnose. Published articles have found that this group of subjects typically have a lower incidence of fever, stiff neck and headaches than their younger counterparts. As diagnosis is initially based on the presence of stiff neck and fever, many patients may go undiagnosed. An important indicator in this group of patients is the change in mental status which is usually present. In a recent study, 95% of patients over the age of 65 presented with only two of the four indicative symptoms.

Immuno-compromised patients are another group of patients who are at high risk of misdiagnosis due to the suppressed immune system which leaves them vulnerable to infections and presentation of bacterial infections do not illicit strong presentation of the indicative symptoms.

Lumbar Puncture

Lumbar puncture is the gold standard for diagnosis of bacterial meningitis. Typical diagnosis may be based on elevated opening pressure on lumbar puncture, white blood cell count of 100-10,000 cells/mm3 predominately polymorphonuclear leukocytes, elevated proteins >50mg/dL and a cerebral spinal fluid to plasma glucose ratio <0.6. However, there are several other biological markers which can be used to make an informed diagnosis of meningitis included elevated cerebral spinal fluid lactate, serum procalcitonin and serum C-reactive protein. Cerebral spinal fluid gram staining for the presence of bacteria is effective 92% of the time due to the various bacteria which may be involved in the meningitis.

PCR testing may have the greatest accuracy with a positive predictive value of 94.4%, and a negative predictive value of 100%. However, this testing is not widely available nor routine in standard practice.

Antibiotics are the course of action for meningitis with the type of antibiotic dependent on the bacteria causing the infection, which may require a lumbar puncture to determine. Viral meningitis is usually left untreated as antibiotics are not effective for viruses and the infection will generally subside on its own. In suspect bacterial meningitis cases, antibiotics are recommended to be prescribed with or without diagnosis by lumbar puncture and should not be delayed until results of a lumbar puncture can be obtained. Depending on the severity of the infection, hospitalization may be necessary and medications and intravenous fluids may be given to treat symptoms such as brain swelling, seizures and shock.

Reports indicate that delays in lumbar puncture account for up to 35% of all missed diagnosis cases. Misdiagnosis may also occur due to the reliance on the "gold standard" lumbar puncture. A publication in 2009 in the Journal of Emergency Medicine warned of reported cases of negative bacterial cerebral spinal fluid tests and normal leukocyte counts in young patients found later to have meningitis. The article recommended that, although follow-up testing is cumbersome, it should be standard practice to ensure that patients are diagnosed correctly and receive proper treatment. Further, due to the diversity of symptoms that may or may not be present due to age and health status, many cases may go undiagnosed or time to diagnosis and treatment may be delayed.

Misdiagnosis or delay in diagnosis of bacterial meningitis is of great concern as early diagnosis of bacterial meningitis and treatment is key to prevent permanent damage such as brian damage, hearing loss, seizures, intracranial pressure, decreased intelligence, kidney damage, amputation, or death. Risk of death from bacterial meningitis is estimated to be 20-30% in newborns, 2-14% in older children and adolescents and 19-37% in adults.

Meningitis Medical Malpractice Claims in Maryland

If you or someone you love has suffered as the result of a medical misdiagnosis or failure to properly treat an meningitis, call a Maryland malpractice attorney at 800-553-8082 or get a free on-line no obligation medical misdiagnosis consultation.

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