Meningism

The term "meningism" is a syndrome that occurs in some common infectious pathologies under the influence of irritation of the meninges. Meningism is characterized by such signs as headache, stiffness of the cervical muscles, an increase in intracranial pressure against the background of an unchanged composition of cerebrospinal fluid.

The name of the syndrome was first introduced into medical use by the French doctor Ernest Dupre.

Meningism syndrome

Among the many nonspecific syndromes, meningism is diagnosed quite often. Pathology usually develops during the acute course of the disease or during the exacerbation of chronic processes. It is characterized by headache, vomiting, hypersensitivity, meningeal symptoms of varying intensity. 

The basic clinical symptoms are the rigidity of the occipital muscles, the symptoms of Kernig and Brudzinsky.

• The stiffness of the occipital muscles is determined after checking the absence of instability of the cervical vertebrae (for example, this is possible with trauma or rheumatoid arthritis). The patient takes a horizontal position on the back, the head is level with the body. One hand is holding the patient's chest, and the other hand is placed under the back of the head and trying to bring the chin to the chest. With a positive symptom of rigidity of the occipital muscles, such an attempt causes resistance and pain on the part of the patient. In severe cases, opisthotonus may occur when checking for a symptom.
• Brudzinsky's symptom (upper) is to bring the chin to the chest, which causes involuntary bending of the legs in the hip and knee joints. The same bending occurs when the pubic articulation is pressed (lower symptom).
• Kernig's symptom involves bending the patient's leg in the hip joint (angle 90 °), followed by an attempt to straighten it in the knee joint. With a positive Kernig symptom, such straightening becomes impossible, the patient resists and complains of pain. This symptom is always bilateral (extends to both limbs).

In infancy up to 1 year, the Lesach symptom (suspension) is also taken into account: the child pulls the legs to the tummy while lifting and holding it in the armpits. Swelling and tension of the large fontanelle is noted. 

It is important to differentiate meningeal symptoms in young children from tonic-labyrinth reflexes, which are sensitive to changes in body position and physiological increased tone of the flexor muscles.

Often with meningism, dissociative meningeal syndrome is noted: against the background of a rigid occipital muscle and a positive upper Brudzinsky symptom, the lower Brudzinsky symptom and Kernig's symptom are absent.

To distinguish it from meningitis, a study of the cerebrospinal fluid is mandatory. In the course of lumbar puncture, in most patients, increased intracranial pressure (up to 250 mm century) is noted. Typical for meningism is the rather rapid disappearance of symptoms after a decrease in temperature and a decrease in toxic effects on tissues. [1]

Epidemiology

To date, there is no opportunity to clearly voice the absolute incidence of meningism in all countries of the world: such statistical information is not always kept and practically not published. And there are several reasons for this.

First, meningism combines a number of features characteristic of different etiopathogenetic and clinical aspects, and most experts consider meningism not a disease, but a syndrome, or symptom complex.

Second: in the course of maintaining and systematizing medical statistics, increases and decreases in the detection of pathological meningeal signs are regularly recorded, and the main diagnosis is taken as a basis, and not manifestations of meningism. [2]

It is known that in underdeveloped countries the incidence rate is about 50 times higher than in developed countries. The risk of developing meningism is equally distributed between representatives of both sexes, different races and nationalities, and different age categories. Nevertheless, among patients, there is a slight predominance of men (especially the elderly, over 55-60 years old) and children. Children of preschool and primary school age suffer from meningism with a frequency of about 1 in ten thousand. The level of development of complications against the background of the syndrome is estimated at approximately 15%.

Causes of the meningism

Human immunity is able to protect the body from many diseases: the structures of the brain are also protected. However, sometimes a failure occurs, the immune defense weakens, and all the body's efforts to resist the violation are either insufficient or completely futile. As a result, a state of meningism develops. [3]

A similar problem may be associated with the following reasons:

• toxic effects, poisoning (especially with chemicals);
• hypersensitivity reactions, allergic processes (in particular, drug allergies);
• fungal, viral lesions;
• parasitic diseases;
• benign and malignant tumor processes;
• otorhinolaryngological pathologies, diseases of structures located in the immediate vicinity of the brain;
• alcoholic, drug addiction;
• uncontrolled intake of potent medications;
• diabetes mellitus, obesity.

Children's meningism can develop even as a result of hypertension or ARVI.

SARS and meningism

ARVI is a number of acute respiratory viral infections, the causative agents of which can be a wide variety of representatives of a viral nature. Regardless of the type of virus, ARVI is always accompanied by a toxic effect on the patient's body. When it enters the vascular network, the infection begins to multiply, metabolic products are released into the bloodstream. As a result, characteristic signs of intoxication appear. If the brain becomes a kind of target organ, then intoxication is accompanied by symptoms of meningism. [4]

Complications against the background of an acute respiratory viral infection develop quite often. This is usually due to untimely therapy or a weakened patient's immune defenses. Meningism is spoken of if single or multiple meningeal signs are found in the absence of laboratory confirmation of inflammatory lesions of the pia mater of the brain.

Risk factors

Risk factors for the development of meningism are:

• Age. Most often, meningism is found in preschool children and in elderly patients (over 55 years old).
• Wrong way of life. Meningism is often diagnosed in people with alcohol and drug addiction, sexually transmitted diseases, helminthiasis, chronic intoxication.
• Occupational hazards. Toxic brain damage is possible in people working in hazardous industries, regularly exposing themselves to varying degrees of intoxication.
• Strong weakening of immunity, immunodeficiency states. The risk of developing meningism increases in people with AIDS, alcoholism, diabetes mellitus, as well as in those who have been treated with immunosuppressants and other drugs that suppress the immune system.
• Traumatic brain injury.

Pathogenesis

Meningism develops in the following conditions:

• irritation of the membranes of the brain and changes in the pressure of the cerebrospinal fluid as a result of subarachnoid hemorrhage, acute hypertensive encephalopathy, occlusion syndrome in neoplasms inside the cranial cavity (tumor processes, intrathecal and parenchymal hematomas, abscesses), meningeal carotidoma, sarcoidosis (radiopharmaceutical);
• irritation of the meninges due to a toxic reaction provoked by exogenous intoxications (alcoholic, hyperhydration, etc.), endogenous intoxications (hypoparathyroidism, malignant processes), infectious pathologies in which the membranes of the brain are not affected (flu, salmonellosis, etc.);
• pseudomeningeal syndrome without direct irritation of the meninges (typical for mental disorders such as paratonia or for vertebrogenic disorders - for example, spondylosis).

Symptoms of the meningism

Symptoms for meningism may vary, depending on the underlying cause of the pathological condition, on the severity and severity of the underlying disease. Most often, it is possible to detect the following basic symptoms:

• severe headache;
• feverish condition;
• meningeal signs.

The patient is often lethargic, pain sensitivity dulls.

The stiffness of the occipital muscles is a basic indicator that determines the irritation of the lining of the brain. It demonstrates resistance to voluntary or involuntary flexion movements in the neck. Occipital rigidity does not always appear immediately, sometimes increasing gradually. Experts use the following clinical tests to determine the disorder:

• Kernig's symptom (loss of the ability to passively straighten the leg at the knee).
• Brudzinsky's symptom (adduction of the lower limb in the area of the thigh and knee when trying to bend the neck).
• Problem with bringing the chin to the sternum with the mouth closed.
• Problem with touching the frontal surface or chin to the knee.

The stiffness of the occipital muscles differs from that in osteoarthritis of the cervical spine or in a viral infection accompanied by a severe degree of myalgia. With these pathologies, the movement of the neck is disrupted in all directions. And meningism is characterized by the development of rigidity due to irritation of the membranes of the brain, which manifests itself mainly with flexion of the neck. It turns out that the patient can turn his neck to either side, but it is difficult for him to touch the chest with his chin. [5]

Symptom complex of meningism

Symptom complex, or meningism syndrome, consists of cerebral and meningeal symptoms directly. Cerebral symptoms include intense head pain (pressing, bursting, diffuse), nausea (until vomiting does not bring relief). A severe form of meningism can be accompanied by psychomotor agitation, delirium and hallucinations, convulsions, lethargy.

Directly meningeal signs are divided into several groups:

1. General hypersensitivity to light, tactile and sound irritants.
2. Rigidity of the occipital muscles, Kernig's and Brudzinsky's symptoms (upper, middle and lower).
3. Reactive pain symptoms (pain when pressing on the eyeballs and on the area of excretion of the branches of the trigeminal nerve, increased pain in the head when the zygomatic arches and cranium are tapped).
4. Changes in the activity of tendon, abdominal and periosteal reflexes.

Meningism is the presence of meningeal signs without inflammatory changes in the cerebrospinal fluid: its composition (both cellular and biochemical) remains unchanged. [6]

First signs

The initial symptoms of the development of meningism are associated with signs of the underlying disease. They are easy enough to recognize:

• feverish condition, chills, which is especially typical for childhood;
• clouding of consciousness, memory impairment, decreased concentration, hallucinations, in severe cases - mental disorders;
• nausea, up to its strong manifestations;
• sometimes - photophobia (the patient tries to close his eyes, or covers himself with a blanket "with his head", turns away from any light source);
• difficulty or impossibility of tilting the head with the chin to the chest;
• severe pain in the head, which becomes even more pronounced under the influence of loud sounds, movements, light stimuli;
• difficulty with movement and flexion of the lower extremities;
• involuntary bending of the legs of a lying patient when trying to bring his chin to the chest;
• blanching of the skin on the face (more pronounced in the nasolabial area);
• pulsation and protrusion of the fontanelle in young children;
• excessive anxiety, which is especially aggravated by any sharp sound or touch (including in a dream);
• a sharp deterioration in appetite against the background of a preserved drinking regime;
• difficulty breathing, rapid breathing;
• changes in blood pressure indicators, tachycardia;
• the pretentiousness of the postures taken;
• skin rash;
• convulsions (especially typical for children and debilitated patients).

Meningism in children

If a child shows signs of meningism, this does not mean that we are talking about any serious and severe pathology. Symptoms will depend on the underlying cause of the problem and directly on the child's body and its immune defenses. Most often, meningism occurs in children 3-6 years old and goes away on its own without consequences. However, if this happens, the child must be examined by a doctor.

The susceptibility of babies to stress, toxic or infectious agents is several times higher than that of an adult. For example, if an adult can easily tolerate a cold, flu or ARVI "on his feet", having only "erased" symptoms, then in a child the pathology can manifest itself in all possible ways. Since the baby's brain is more sensitive to various irritating factors, the signs of meningism appear more often. [7]

What symptoms can such a violation reveal itself? Usually it is general weakness, apathy, loss of activity, headache, dizziness, chills, fever, muscle pain. Possible diarrhea and vomiting, abdominal pain, skin rashes. In more complex cases, convulsions and delirium appear. To clarify the diagnosis and check the meningeal signs of the child, you need to urgently show the doctor: you should call an ambulance as soon as possible. This is especially important if there is a high fever, severe head pain with no relief from vomiting, neck pain, and inability to tilt the head. In the smallest babies, the reason for an emergency visit to the doctor should be fever, crying without stopping, clear signs of anxiety, pulsation and protrusion of the fontanel. Until the arrival of the medical team, the child must be laid on its side (to prevent inhalation of vomit), put pillows under the body and head, loosen clothes, and provide constant access to fresh air.

Forms

According to the etiological factor, the following types of meningism are distinguished:

• toxic meningism (provoked by intoxication);
• traumatic;
• hypertensive;
• tumor;
• fungal (candidal, cryptococcosis, etc.);
• parasitic, etc.

According to pathogenetic characteristics, there are:

• secondary meningism (arising as a sign or complication of another disease);
• idiopathic meningism (when the cause of the syndrome cannot be identified).

Depending on the stage of the pathological process, meningism is:

• lightning fast;
• sharp;
• subacute.

Meningism can have several degrees of severity:

• easy;
• medium-heavy;
• heavy;
• extremely hard.

Complications and consequences

Meningism usually goes away without a trace, and only occasionally can it cause the development of rather serious complications. The risk of negative consequences is especially high if the patient's treatment is postponed for any reason: the patient may experience seizures and irreversible neurological disorders, for example:

• deterioration of auditory function, up to its complete loss;
• memory impairment and ability to concentrate;
• decreased ability to learn, violations of social adaptation;
• cerebral disorders;
• gait changes (unsteadiness, fuzziness, clumsiness, etc.);
• convulsions.

In more complex cases, it is possible to develop meningitis, renal failure, shock. If proper medical care is not provided, the patient may die. [8]

Diagnostics of the meningism

In the process of collecting anamnesis, special attention is paid to fever, signs of intoxication (general weakness, chills, loss of appetite, feeling of fatigue and drowsiness, etc.).

Find out if there is a sore throat, difficulty breathing through the nose, whether there is a cough, headache (to what extent and where exactly), nausea and vomiting (with or without relief), changes in auditory or visual function, memory impairment, pain in the eyes, rashes on the skin.

External examination includes an assessment of the condition of the skin and mucous tissues of the oral cavity, the presence of hemorrhages, the patient's posture. [9]

It is imperative to pay attention to the level of consciousness, the patient's orientation to the terrain, time and space, to check pathological reflexes, the presence of paresis of the legs, arms and cranial nerves, to assess the quality of pelvic functions.

It is impossible to diagnose meningism, find out the cause of its occurrence and exclude meningitis without examining the cerebrospinal fluid. This fact indicates the unconditional need to admit the patient to a hospital even with minimal suspicion of meningitis. [10]

First of all, the doctor assesses the severity of the patient's condition. Based on this, he makes a decision: to send the patient to the general ward, to the intensive care unit or to the intensive care unit. The need for lumbar puncture with further examination of the cerebrospinal fluid is present in all cases. A contraindication to such a puncture may be a violation of blood clotting: if there are suspicions or confirmation of such violations, the puncture is postponed until control of the condition is established.

If the patient has an increase in intracranial pressure, or there are other disorders in the form of focal neurological insufficiency, edema of the optic nerve, impaired consciousness, convulsions, and also if the patient is HIV-infected, then contrast-enhanced neuroimaging using computed tomography or magnetic resonance imaging is performed before the puncture...

If the skin in the area of the proposed puncture is inflamed, or there is a suspicion of subcutaneous or parameningeal spinal infection, then the puncture procedure is carried out in another area - more often in the region of the cisterna magna or the upper cervical vertebra C2. [11]

Additional tests that are used for diagnosis:

1. Cerebrospinal fluid examination (the only method to help distinguish meningism from inflammatory meningitis).
2. Bacteriological tests:
   • standard bacterial inoculations, as well as inoculation of cerebrospinal fluid on agar (chocolate or blood);
   • inoculation on media for mycobacteria, amoebas and fungal infections (if necessary).
3. General extended blood count with leukocyte count, blood smear examination.
4. Blood biochemistry (creatinine, glucose index, electrolytes).
5. General clinical analysis of urine.
6. Bacteriological analysis of blood, urinary fluid and nasopharyngeal secretions.

Instrumental diagnostics involves performing a chest x-ray, computed tomography or magnetic resonance imaging to determine parameningeal infectious foci. [12]  Instrumental studies are generally selected and assigned depending on the specific situation:

• An electrocardiogram is indicated for patients with hemorrhagic skin rashes, as well as with auscultatory changes in the heart.
• Chest X-ray is prescribed in the presence of catarrhal symptoms, with auscultatory pulmonary changes.
• CT or MRI of the brain is necessarily performed with meningeal and focal neurological symptoms, which makes it possible to exclude organic lesions, acute hydrocephalus, ventriculitis, etc.
• Neurosonography is performed for focal neurological symptoms, seizures, signs of increased intracranial pressure.
• Electroencephalography is performed to exclude intracranial complications of the otorhinogenic plan and organic disorders.

CSF with meningism is characterized by the following differential diagnostic signs:

Indicative values	Liquor is normal	Liquor with meningism
Features of color and transparency	No color shade, transparent.	No color shade, transparent.
Pressure (mm h.st.)	130 to 180.	200 to 250.
The number of drops per minute flowing from the needle during puncture	40 to 60.	60 to 80.
Cytosis indicator (number of cells per 1 μl)	2 to 8.	2 to 12.
Cytosis	0.002-0.008	0.002-0.008
The percentage of lymphocytes on the cytogram	90-95	90-95
Percentage of neutrophils on the cytogram	3-5	3-5
Percentage of protein on the cytogram in mg / liter	From 160 to 330.	From 160 to 450.
Sedimentary reactions	-	-
Dissociation	-	-
Glucose	1.83 to 3.89.	1.83 to 3.89.
Chlorides in mol / liter	120 to 130.	120 to 130.
Fibrin film	Without education.	Without education.
Puncture reaction	When a large volume of fluid is released, there is pain in the head, vomiting.	Puncture causes significant relief, often becoming the turning point of the disease.

Differential diagnosis

Before a laboratory liquorological study, there are significant difficulties in making a diagnosis of meningism. Differential diagnosis is performed after a thorough study of all combinations of clinical, epidemiological and laboratory information, including the results of specific studies. At this stage, in order to fully determine the provoking factor of the disease and select further therapeutic tactics, there is often a need to obtain advice from doctors of narrow specialties - in particular, a neuropathologist, an infectious disease specialist, an ENT specialist, a neurosurgeon, a phthisiatrician, an ophthalmologist, etc. Differential diagnosis is necessary to exclude influenza, food toxicoinfection, subarachnoid hemorrhage, tuberculosis, meningitis , meningococcal infection. A frequent cause of diagnostic errors in these pathologies is an illiterate check and an inadequate assessment of meningism syndrome. With pronounced or doubtful meningeal signs, the patient is urgently placed in the infectious diseases department of the hospital. 

Many infectious and non-infectious pathologies are accompanied by the phenomena of meningism, which greatly complicates the correct diagnosis. Therefore, the diagnosis should be based on clinical information, taking into account the whole complex of clinical, laboratory and epidemiological data and the results of consultation of doctors of narrow specialties. [13]

Consultations of such specialists are shown:

• ophthalmologist - with the development of cerebral edema;
• otolaryngologist - for diseases of the ENT organs;
• pulmonologist - with the development of pneumonia;
• infectious disease specialist - to exclude an infectious disease;
• resuscitator - to assess the indications for transferring the patient to the intensive care unit;
• phthisiatrician - to differentiate meningism from tuberculous meningitis (if there are indications for that);
• neurosurgeon - to exclude abscesses, epiduritis, brain tumors, as well as to assess occlusive symptoms;
• cardiologist - to assess cardiac activity.

Meningitis and meningism: similarities and differences

Meningitis is an inflammatory process that affects the meninges (pia mater)	Meningism is not an inflammation, but an irritation of the meninges (toxic substances, high blood pressure, etc.)
Meningitis can exist as an independent pathology, or as a complication of another infectious and inflammatory process	Meningism is always one of the symptoms of other diseases, and is never considered as an independent pathology.
With meningitis, there are inflammatory changes in the cerebrospinal fluid	With meningism, there are no inflammatory changes in the cerebrospinal fluid
Meningitis does not go away on its own	Meningism can completely disappear within three days, after eliminating the cause of its appearance

Treatment of the meningism

The choice of a therapeutic regimen for meningism depends on the cause of the disorder, on the clinical symptoms, on the severity of the painful symptoms, on the general condition of the patient and the presence of complications. [14]

Standard treatments may include:

• Bed mode.
• Diet food.
• Drug therapy:
  • etiotropic treatment;
  • symptomatic treatment;
  • intensive therapy and resuscitation (according to indications).
• Non-drug therapy:
  • physical methods of influence;
  • sanitation of foci of infection;
  • processing and ventilation of the room;
  • general hygiene measures.

Changes in the diet of patients with meningism are necessary for quick recovery of strength, reducing irritation. Boiled foods are preferred. Cooking in a double boiler, baking, stewing is also allowed. If you intend to cook meat, then it is better to choose low-fat types of it: veal, chicken fillet, rabbit meat, turkey. Lean fish in the form of cutlets, soufflés, pâtés is considered a good choice. As a side dish, you can serve porridge - for example, buckwheat, barley, wheat. It is better to eat vegetables and fruits not raw, but baked or stewed, in the form of mashed potatoes and casseroles. Dairy products are a must (if tolerated). 

Drug treatment is aimed at normalizing body temperature, eliminating pain and preventing complications.

Medicines

For the treatment of meningism, various drugs can be used, depending on the causes of the pathological condition.

Immunoglobulin human normal	It is indicated in the acute course of a severe viral or microbial infection, as well as for its prevention. The drug is administered only intramuscularly, according to an individual scheme (usually 3-6 ml once a day, but another treatment regimen is also possible). There are usually no reactions to the administration of immunoglobulin.
Ibuprofen (a propionic acid derivative)	It is indicated at elevated temperature (above 38.0 °) and pain. Take 200 mg of the drug up to 4 times a day, after meals. The duration of treatment is determined by the doctor (preferably no more than five days in a row). Possible side effects: abdominal pain, heartburn, hearing impairment, dry eyes, tachycardia.
Paracetamol (anilide group)	It is prescribed for fever and headaches, 250-500 mg 4 times a day, for several days. Taking the drug is rarely accompanied by dyspepsia, allergic reactions. Most patients take Paracetamol without any particular disorders.
Chloramphenicol (antibiotic of the amphenicol group)	Recommended for moderate and severe infectious processes, hemorrhagic exanthema, allergies to other antibacterial agents. The dosage regimen is set individually. Average oral dose for an adult patient: 0.5 g 3-4 times a day. The duration of treatment is about one week. Possible side effects: dysbiosis, dyspepsia, psychomotor disorders, allergic reactions.
Bicillin-1, Retarpen, benzathine benzylpenicillin (beta-lactam antibiotic-penicillin)	Shown in the same cases as Chloramphenicol. The drug is administered intramuscularly, in an amount from 300 thousand units to 2.4 million units, depending on the doctor's prescription. A likely side effect is the development of anemia, allergic urticaria, and superinfection.
Cefotaxime (3rd generation cephalosporin antibiotic)	It is prescribed in the absence of effect from the use of antibiotics of other groups. The drug is administered intravenously (drip or jet) and intramuscularly, in an individually indicated dosage. Side effects: dyspepsia, dizziness, hemolytic anemia, pain at the injection site.
Dexamethasone (glucocorticoid drug)	It is used in the acute course of the disease, with signs of ONGM, drug allergies, neurological complications. The dosage regimen is individual and depends on the indications, the patient's well-being and his response to treatment. Usually the medication is injected intravenously slowly by injection or drip, or intramuscularly. Most often, the drug is well accepted by the body due to its low mineralocorticoid activity. In pediatric practice, Dexamethasone is used only in the presence of absolute indications.
Quartasol, Trisol (solutions to restore water-electrolyte balance)	They are used for detoxification, intravenously (drip or jet) in volumes necessary to restore fluid balance in the body and remove toxic substances. When using such solutions, the likelihood of developing hyperkalemia must be taken into account.
Sodium chloride, potassium chloride (electrolyte solutions)	Prescribed to replenish electrolyte disturbance, intravenous drip. Possible side effects: acidosis, overhydration. Solutions are administered with caution in case of decompensation of cardiac activity, arterial hypertension, chronic renal failure.
Actovegin (blood product)	Helps improve metabolic processes in case of cerebrovascular accident. Applied intravenously (including infusion) and intramuscularly. Allergic reactions to drug administration are rare. Myalgia is possible.
Plasma preparations, blood substitutes	Indicated for detoxification in severe pathology, as well as sources of immunoglobulins. The dosage and route of administration depend on the specific medication and are determined individually. Side effects: lowering blood pressure, thrombosis and phlebitis in the infusion area.
Thioctic acid	It is used as an antioxidant to regulate fat and carbohydrate metabolism. When taken internally, a single dose is 600 mg. Intravenous can be administered from 300 to 600 mg per day. Treatment may be accompanied by dyspeptic disorders, allergies.
Diazepam (a benzodiazepine derivative)	Recommended for elimination of seizures in severe meningism and the development of acute cerebrovascular accident. Assign orally, intravenously, intramuscularly. The daily amount of the drug varies from 500 μg to 60 mg. Possible side effects: drowsiness, dizziness, fatigue, tremors, muscle weakness.
Furosemide (loop diuretic)	It is prescribed to remove excess fluid to stabilize intracranial pressure. The tablets are taken on an empty stomach, without chewing, with a sufficient amount of water. Use the lowest possible dosage required for effective treatment. Possible side effects: lowering blood pressure, collapse, arrhythmia, thrombosis, headache and drowsiness, tinnitus, thirst, oliguria.
Glycine	It is used as a neuroprotective agent. Used sublingually, 100 mg 3 times a day for 2-4 weeks. In the overwhelming majority of cases, the drug is perceived well, allergic reactions are extremely rare.
Semax (methionyl-glutamyl-histidyl-phenylalanine-prolyl-glycyl-proline)	It is indicated for acute cerebral failure, for optimizing the function of nerve cells, antihypoxic and antioxidant action, as well as for a membrane stabilizing effect. Applied intranasally, in individual dosages. Long-term treatment may be accompanied by mild irritation of the nasal mucosa.
Mexidol (ethylmethylhydroxypyridine succinate)	Shown as an antioxidant, antihypoxic, membrane-protective drug for hypoxic, ischemic conditions, intoxication, impaired cerebral circulation, as well as for optimizing the microcirculatory and rheological properties of blood, reducing platelet aggregation. It is taken orally at 125-250 mg three times a day, for 14-45 days. Reception is completed with a gradual decrease in dosage over several days. Individual hypersensitivity reactions are possible.
Vitamin B 1  (Thiamine Chloride)	Recommended as a supportive agent in acute cerebral insufficiency, as well as for antioxidant and membrane stabilizing effects. The drug is injected intramuscularly deeply, one ampoule daily for 10-30 days. Treatment may be accompanied by increased sweating, increased heart rate.
Vitamin B 6  (Pyridoxine)	It is used to optimize the energy state of nerve cells, to reduce the degree of hypoxia. Adult patients take the drug by mouth at 80 mg 4 times a day, or injected intramuscularly at a daily dosage of 50-150 mg. The duration of therapy is determined by the treating doctor. In some cases, the development of allergic reactions is possible.
Vitamin C	It is indicated for intoxication and hemorrhagic syndrome, signs of ACMH. It is taken orally after meals, 0.05-0.1 g up to five times a day. Long-term use may be accompanied by irritation of the mucous membrane of the digestive system, stomach cramps, thrombocytosis.

Physiotherapy treatment

Physiotherapy procedures are prescribed at the stage of recovery of the body after the relief of the acute period of meningism. Such treatment includes classical massage sessions with the possible use of hardware techniques.

Vitamin and drug electrophoresis helps to relax or stimulate various muscle groups, depending on the indication. If there are coordination and cognitive disorders, electrosleep, magnetotherapy, magnetic laser treatment are prescribed to restore the functional ability of the central nervous system. Other methods are also involved, which are selected by a physiotherapist in tandem with the attending physician, taking into account the condition of a particular patient.

At the stage of rehabilitation, exercise therapy classes are necessarily prescribed: special exercises accelerate the recovery of motor skills, and the additional use of special simulators and apparatus helps to prevent the possible development of complications.

If necessary, occupational therapy and psychotherapy are included. [15]

Herbal treatment

Alternative healers' recipes often have a stimulating effect in the treatment of meningism. First of all, you should follow all the recommendations of the attending physician: in no case should you abandon traditional treatment in favor of alternative methods. It is better to consult a doctor about the possibility of supplementing conservative treatment with herbal medicine.

A patient with meningism must adhere to bed rest: lie down, allowing the body to rest as much as possible. The room in which the patient is located must be clean and ventilated. Wet cleaning should be done regularly.

Nettle can be used to stabilize the temperature. An infusion is prepared on the basis of the leaves: 250 ml of boiling water is poured into 25 g of raw materials and insisted until it cools. They drink instead of tea. A similar remedy can also be prepared from chamomile flowers, linden, raspberry leaves. Raspberries are especially recommended for meningism, as they perfectly remove the products of intoxication from the body.

Echinacea is used to enhance and strengthen the immune defense. The easiest way is to buy echinacea tincture at the pharmacy and take it 25 drops three times a day, between meals. The duration of treatment is from several weeks to 2 months.

A very useful healing remedy based on ginger root. For its preparation, 4 medium lemons (whole, with skin) and 0.4 kg of fresh ginger are passed through a meat grinder. Mix with 250 ml of honey, cover tightly. It is kept for 10 days in the refrigerator, but to speed up the process, you can simply hold it for 2 days at room temperature, in a dark place. Take a full tablespoon in the morning on an empty stomach (about half an hour before breakfast).

Another great remedy for meningism is aloe juice. For the preparation of the medicine, it is allowed to use a plant that is at least 2 years old. It is better to squeeze the juice from the lower or middle leaves. Fresh remedy is taken in 1 tbsp. L. 2-3 times a day with water (with honey) between meals.

Before starting the treatment of meningism with herbs, it must be borne in mind that any herbal component can cause an allergic reaction. You should first consult your doctor.

Surgery

Lumbar puncture is the main minimally invasive surgical procedure that is performed for meningism for diagnostic and therapeutic purposes. So, puncture allows you to exclude infectious and autoimmune damage to the central nervous system, cerebrospinal meningitis, leukodystrophy, some neuropathies, subarachnoid hemorrhages.

The procedure has some contraindications, for example:

• a strong increase in intracranial pressure due to edema or brain tumor, especially in the posterior region of the skull (in a similar situation, CT is performed first);
• blood clotting disorders, defects of the spine and spinal cord.

Before performing a cerebrospinal puncture, the patient must be sure to determine the quality of blood coagulation. In case of unfavorable results, the procedure is not carried out, but a drug correction of deviations is prescribed. In addition, the fundus of the eye is necessarily examined or computed tomography is done to exclude increased intracranial pressure.

The patient is placed in a supine position on his side, closer to the edge of the manipulation table, with his back to the surgeon. The patient bends his legs at the knee and hip joints, the knees lead to the abdomen, the head leads to the utmost in the direction of the knees. In this case, the vertebral column should be on the same plane, without excessive bends. [16]

The puncture is performed in the intervertebral space, optimally in the area of the spinous processes L4, L5, L3 and L4.

The surgeon processes the operating field, performs infiltrative anesthesia. For the procedure, she uses a sterile one-time special needle with a mandrel and equipment for measuring the pressure of the cerebrospinal fluid. Slowly inserts the needle towards the navel, cranially at an angle, beveled upward. After passing through the dense shell, a "failure" is felt, after which the doctor removes the mandrel: if everything is done correctly, cerebrospinal fluid begins to drip from the needle. Further, using a special apparatus, the pressure of the cerebrospinal fluid is measured, after which the surgeon collects fluid into previously prepared sterile test tubes. Upon completion of the procedure, he inserts the mandrel back into the needle, removes it and applies a sterile bandage.

After the intervention, the patient must remain in the supine position for at least 60 minutes (preferably 2-4 hours).

Lumbar puncture is rarely accompanied by complications, but the patient should be informed about them:

• headache appears 1-2 days after the procedure, decreases when lying down, goes away on its own within 1-10 days;
• back pain in the area of the puncture;
• pain in the lower extremities (the so-called radicular pain);
• numbness of the lower extremities, subarachnoid or epidural hemorrhage, abscess (very rare).

Other types of surgical intervention are performed only with the development of otogenic meningitis, abscesses, neoplasms of the brain, etc.

Prevention

Preventive measures include maintaining a healthy lifestyle, preventing the development of intoxications and infectious diseases, and supporting immunity.

• Get enough sleep. Perhaps this advice sounds trite, but a full 7-9-hour sleep - sound and deep - favors an adequate immune defense of the body. A good night's rest not only determines the quality of a person's recovery after heavy exertion, but also creates the necessary basis for maintaining a sufficient level of immunity, which will allow the body to resist both various infectious diseases and the development of meningism.
• Avoid stress. Regular meditation practice, the same healthy sleep, an active life position, a positive outlook will help in this. Stress is an invisible but powerful factor in weakening the immune system, and the right fight against it leads to a significant improvement in health.
• Avoid large crowds and communication with strangers during periods of "surge" of infectious diseases. Remember: it is easy to get infected, and sometimes it is very difficult to cure an infectious pathology. In addition, you need to wash your hands thoroughly, not only after visiting the restroom and before eating, but also immediately upon coming home.
• Exercising too intense can weaken the body; it is better to replace it with less intense workouts.
• Adequate intake of clean water throughout the day helps to cleanse the body of harmful substances and potential toxins, and also maintains the necessary water balance.
• Review your diet. It is important that the body receives the required amount of basic nutrients (proteins, fats and carbohydrates), as well as vitamins and minerals.

Forecast

Most cases of meningism pass within a few days after the elimination of the underlying disease. Some patients may develop asthenic syndrome, which is expressed in unreasonable malaise, general weakness, and depressive mood. This syndrome disappears on its own within a few weeks or months. The development of severe disorders is possible if the pathology that caused meningism turned out to be serious. In a similar situation, patients are found to have intellectual disorders, paralysis or paresis, disorders of the organs of vision or hearing, convulsions, and less often ischemic stroke. [17]

All persons with detected occipital rigidity, regardless of the severity of the disease, should be hospitalized in the neurological or infectious diseases department, ENT department or clinic of maxillofacial surgery, which depends on the localization of the primary focus of the disease. Children are hospitalized in the children's departments of the hospital, either in the intensive care unit or in the intensive care unit. Monitoring of the patient's condition is performed at first every 3 hours, then every 6 hours.

It is rather difficult to predict the course and consequences of such a pathological condition as meningism in advance, although in most cases the outcome is considered favorable. A preliminary thorough diagnosis and treatment of the underlying disease is required. In further patients who have been diagnosed with meningism, observation by a neurologist for 2 years is recommended.