04.04 Neuro

Written By Joan

04.04 Neuro [PDF link]: Bacterial & viral meningitis – Kernig’s sign, Brudzinski’s sign, Encephalitis – Herpes simplex encephalitis, Autoimmune encephalitis – paraneoplastic encephalitis, anti-NMDA receptor encephalitis, etc; Brain abscess.

Internal links

More on bacterial meningitis

  • NICE guidelines NG240, published Mar 2024, and the NICE CKS page on similar topic (last updated Aug 2025) – covering bacterial meningitis and meningococcal disease

    • Another reference guideline from the UK, in 2016. McGill F, Heyderman RS, Michael BD, Defres S, Beeching NJ, Borrow R, et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. Journal of Infection 2016;72:405–38. https://doi.org/10.1016/j.jinf.2016.01.007.

  • There is quite a comprehensive list of symptoms in NG240 1.1 that are worrying for meningitis (including in children)

  • If causative agent of meningitis is known, NG240 1.6 also has a list of recommended abx

  • Follow-up appointments are recommended in 4-6 weeks time, where a full clinical review should be done. Specifically hearing tests and testing for residual neurological deficits should be done.

  • Management of close contacts is not mentioned in NG240 but in the CKS page. The choice of prophylactic agent isn’t mentioned in CKS, but the UK Health Security Agency recommends a single dose of ciprofloxacin (or rifampicin as a second-line agent)

Meningococcal disease

  • Refers specifically to meningococcal sepsis (caused by Neisseria meningitidis) with or without meningococcal meningitis.

  • S/smx more specific to meningococcal disease include

    • Haemorrhagic rash, with lesions ≥2mm (purpura)

    • Rapidly progressive

    • Above in combination with s/smx of bacterial meningitis

      • Red flag combination: fever, headache, neck stiffness, altered level of consciousness / altered cognition / changed behaviour

      • Non-blanching rash can also occur in only bacterial meningitis (either purpuric or petechial)

  • Increased suspicion in patients with the following risk factors

    • Reduced or absent spleen function (reduced ability to clear encapsulated organisms like N meningitidis)

    • Complement deficiency (again related to decreased ability to clear encapsulated organisms)

    • Student in university, close contact of other people who have had similar illness, recent outbreak of meningitis (spread)

  • Treatment for suspected/confirmed meningococcal disease

    • Same as bacterial meningitis: ceftriaxone first line, if delay in reaching hospital, give IM benzylpenicillin

    • If pen-allergy, second line options include co-trimoxazole or chloramphenicol

  • References – see above section on bacterial meningitis

More on viral meningitis

  • No specific NICE guidance on viral meningitis, and no other real guidelines on viral meningitis

    • The closest I got was one on viral encephalitis, published in 2012 – Solomon T, Michael BD, Smith PE, Sanderson F, Davies NWS, Hart IJ, et al. Management of suspected viral encephalitis in adults – Association of British Neurologists and British Infection Association National Guidelines. Journal of Infection 2012;64:347–73. https://doi.org/10.1016/j.jinf.2011.11.014.

  • In the literature, viral meningitis is sometimes referred to as a subtype of aseptic meningitis (aseptic meaning that no bacterial agent is found in CSF in patients with clinical meningitis).

More on (infectious) encephalitis

  • No guidelines really on this topic.

  • For more reading, I recommend(?) Beckham JD, Tyler KL. Encephalitis. In: Blaser MJ, Cohen JI, Holland SM, Doi Y, Falsey AR, Garret WS, et al., editors. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Tenth edition. Philadelphia, PA: Elsevier; 2025.

    • This is heavy reading, and goes through a tonne of possible infective agents, but also does offer expert opinion on how specific causative agents should be managed

More on autoimmune encephalitis

  • References

  • Nice case presentation but major spoiler alert… Restrepo JA, Mojtahed A, Morelli LW, Venna N, Turashvili G. Case 22-2025: A 19-Year-Old Woman with Seizurelike Activity and Odd Behaviors. New England Journal of Medicine 2025. https://doi.org/10.1056/NEJMcpc2412531.

More on brain abscesses

  • No guidelines (unsurprisingly); in such cases I refer to the BMJ Best Practice page on this and Uptodate (for my non-British friends). If you want to do some serious reading, see the following:

    • Gea-Banacloche JC, Grill MF, Tunnel AR. Brain Abscess. In: Blaser MJ, Cohen JI, Holland SM, Doi Y, Falsey AR, Garret WS, et al., editors. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. Tenth edition. Philadelphia, PA: Elsevier; 2025.

P.S. There used to be a section here on spinal epidural abscess, but I have now merged it with the same topic in 08.09 to make space for autoimmune encephalitis.

Joan
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