Meningism

The term "meningism" refers to a syndrome that occurs in some common infectious pathologies under the influence of irritation of the meninges. Meningism is characterized by such symptoms as headache, rigidity of the neck muscles, increased intracranial pressure against the background of unchanged composition of the cerebrospinal fluid.

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

Meningism syndrome

Among many non-specific syndromes, meningism is diagnosed quite often. The pathology usually develops during acute illnesses or during exacerbation of chronic processes. It is characterized by headache, vomiting, increased sensitivity, meningeal symptoms of varying intensity.

The basic clinical symptoms are considered to be rigidity of the occipital muscles, Kernig's and Brudzinski's symptoms.

• Rigidity of the occipital muscles is determined after checking for instability of the cervical vertebrae (for example, this may occur with trauma or rheumatoid arthritis). The patient assumes a horizontal position on his back, the head is at the same level as the body. With one hand, support the patient's chest, and the other hand is placed under the back of the head and an attempt is made 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 the symptom.
• Brudzinski's symptom (upper) consists of bringing the chin to the chest, which causes involuntary bending of the legs in the area of the hip and knee joints. The same bending occurs when pressing on the pubic symphysis (lower symptom).
• Kernig's sign involves bending the patient's leg at the hip joint (90° angle), followed by an attempt to straighten it at the knee joint. With a positive Kernig's sign, such straightening becomes impossible, the patient resists and complains of pain. This symptom is always bilateral (spreads to both limbs).

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

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

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

To differentiate from meningitis, a cerebrospinal fluid test is mandatory. During a lumbar puncture, most patients show elevated intracranial pressure (up to 250 mm Hg). Meningism is characterized by a fairly rapid disappearance of symptoms after a decrease in temperature and a decrease in toxic effects on tissue. [ 1 ]

Epidemiology

Today, it is impossible to clearly state the absolute incidence of meningitis in all countries of the world: such statistical information is not always kept and is practically not published. And there are several reasons for this.

Firstly, meningismus combines a number of symptoms characteristic of different etiopathogenetic and clinical aspects, and most specialists consider meningismus 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 the basis, and not the manifestations of meningism. [ 2 ]

It is known that in underdeveloped countries the incidence rate is approximately 50 times higher than in developed countries. The risk of developing meningism is equally distributed between representatives of both sexes, different races and nationalities, different age categories. However, 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 approximately 1 case per ten thousand. The level of complications against the background of the syndrome is estimated at approximately 15%.

Causes meningismus

The human immune system is capable of protecting 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 disorder are either insufficient or completely futile. As a result, a condition of meningism develops. [ 3 ]

This problem may be due to the following reasons:

• toxic effects, poisoning (especially chemicals);
• hypersensitivity reactions, allergic processes (in particular, drug allergies);
• fungal, viral infections;
• parasitic diseases;
• benign and malignant tumor processes;
• otolaryngological pathologies, diseases of structures located in close proximity to the brain;
• alcohol, drug addiction;
• uncontrolled use of potent medications;
• diabetes, obesity.

Childhood meningism can develop even as a result of hypertension or acute respiratory viral infection.

ARVI and meningism

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

Complications against the background of acute respiratory viral infection develop quite often. This is usually due to untimely therapy or weakened immune defense of the patient. Meningism is said to occur if single or multiple meningeal signs are detected in the absence of laboratory confirmation of inflammatory damage to the soft membranes of the brain.

Risk factors

Risk factors for the development of meningism are:

• Age. Meningism is most often found in preschool-aged children and elderly patients (over 55 years old).
• Wrong lifestyle. Meningism is often diagnosed in people suffering from alcohol and drug addiction, having venereal diseases, helminthiasis, chronic intoxication.
• Professional hazards. Toxic brain damage is possible in people working in hazardous industries, regularly exposing themselves to varying degrees of intoxication.
• Severe weakening of the immune system, immunodeficiency states. The risk of developing meningism increases in people suffering from AIDS, alcoholism, diabetes, 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 cerebrospinal fluid pressure as a result of subarachnoid hemorrhage, acute hypertensive encephalopathy, occlusion syndrome in neoplasms inside the cranial cavity (tumor processes, intrathecal and parenchymatous hematomas, abscesses), meningeal carcinomatosis (melanomatosis, sarcoidosis), pseudotumor syndrome, radiation encephalopathy;
• irritation of the meninges due to a toxic reaction caused by exogenous intoxications (alcohol, hyperhydration, etc.), endogenous intoxications (hypoparathyroidism, malignant processes), infectious pathologies in which the meninges are not affected (flu, salmonellosis, etc.);
• pseudomeningeal syndrome without direct irritation of the meninges (characteristic of mental disorders such as paratonia or vertebrogenic disorders, such as spondylosis).

Symptoms meningismus

Symptoms of meningism may vary, depending on the underlying cause of the pathological condition, the severity and acuteness of the underlying disease. Most often, the following main symptoms can be detected:

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

The patient is often lethargic, and pain sensitivity is dulled.

Neck rigidity is a basic indicator that determines irritation of the meninges. It demonstrates the presence of resistance to voluntary or involuntary flexion movements in the neck area. The occipital form of rigidity does not always appear immediately, sometimes increasing gradually. Specialists use the following clinical tests to determine the disorder:

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

Rigidity of the occipital muscles differs from that in osteoarthritis of the cervical spine or in viral infection accompanied by severe myalgia. In these pathologies, neck movement is impaired 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 in flexion of the neck. It turns out that the patient can turn the neck in any direction, but it is difficult for him to touch the chin to the chest. [ 5 ]

Symptom complex of meningism

The symptom complex, or meningism syndrome, consists of cerebral and directly meningeal symptoms. Cerebral symptoms include intense pain in the head (pressing, bursting, diffuse), nausea (to the point of vomiting, which does not bring relief). A severe form of meningism may be accompanied by psychomotor agitation, delirium and hallucinations, convulsions, and 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 Brudzinski's symptoms (upper, middle and lower).
3. Reactive pain symptoms (pain when pressing on the eyeballs and on the area where the branches of the trigeminal nerve originate, increased pain in the head when tapping the zygomatic arches and cranium).
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 meningism development are associated with the signs of the underlying disease. They are quite easy to recognize:

• feverish condition, chills, which is especially typical for children;
• clouding of consciousness, memory impairment, decreased concentration, hallucinations, and in severe cases, mental disorders;
• nausea, up to its severe manifestations;
• sometimes – photophobia (the patient tries to close his eyes, or covers his head with a blanket, turns away from any light source);
• difficulty or inability to tilt the head with the chin to the chest;
• severe headache, which becomes even more pronounced under the influence of loud sounds, movements, and light stimuli;
• difficulties with movement and flexion of the lower limbs;
• involuntary bending of the legs of a bedridden patient when trying to bring his chin to his chest;
• paleness 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 intensified by any sharp sound or touch (including during sleep);
• a sharp deterioration in appetite while maintaining a drinking regimen;
• difficulty breathing, rapid breathing;
• changes in blood pressure, tachycardia;
• the pretentiousness of the poses taken;
• skin rash;
• convulsions (especially typical for children and weakened patients).

Meningismus in children

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

The susceptibility of children to stress, toxic or infectious agents is several times higher than that of an adult. For example, if an adult easily tolerates a cold, flu or acute respiratory viral infection "on their feet", having only "erased" symptoms, then in a child the pathology can manifest itself in all possible ways. Since the infant's brain is more sensitive to various irritants, the signs of meningism occur more often. [ 7 ]

What symptoms can such a disorder reveal itself? Usually, it is general weakness, apathy, loss of activity, headache, dizziness, chills, fever, muscle pain. Diarrhea and vomiting, abdominal pain, skin rashes are possible. In more severe cases, convulsions and delirium appear. To clarify the diagnosis and check the meningeal signs of the child, you must urgently show the doctor: you should call an ambulance as soon as possible. This is especially important if there is a high temperature, severe headache, vomiting that does not bring relief, pain in the neck and the inability to tilt the head. In the smallest children, the reason for an urgent visit to the doctor should be an elevated temperature, non-stop crying, obvious signs of anxiety, pulsation and protruding fontanelle. Until the arrival of the medical team, the child should be laid on his side (to prevent inhalation of vomit), pillows should be placed under the body and head, clothing should be loosened, and constant access to fresh air should be provided.

Forms

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

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

According to pathogenetic characteristics, the following are distinguished:

• secondary meningism (occurring as a symptom 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 can be:

• lightning fast;
• sharp;
• subacute.

Meningism can have several degrees of severity:

• light;
• moderate;
• heavy;
• extremely difficult.

Complications and consequences

Meningism usually passes without a trace, and only rarely can cause the development of fairly serious complications. The risk of negative consequences is especially high if the patient's treatment is delayed for some reason: the patient may experience seizures and irreversible neurological disorders, for example:

• deterioration of hearing function, up to and including its complete loss;
• deterioration of memory and ability to concentrate;
• decreased learning ability, impaired social adaptation;
• cerebral disorders;
• changes in gait (unsteadiness, clumsiness, awkwardness, etc.);
• convulsions.

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

Diagnostics meningismus

During the anamnesis collection, special attention is paid to an increase in temperature, signs of intoxication (general weakness, chills, loss of appetite, feeling of fatigue and drowsiness, etc.).

They find out whether there is a sore throat, difficulty breathing through the nose, cough, headache (to what extent and where exactly), nausea and vomiting (with or without relief), changes in hearing or vision, memory loss, pain in the eyes, skin rashes.

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

It is essential to pay attention to the patient’s level of consciousness, orientation in the area, time and space, check for pathological reflexes, the presence of paresis of the legs, arms and cranial nerves, and assess the quality of pelvic functions.

It is impossible to diagnose meningism, determine the cause of its occurrence and exclude meningitis without examining the cerebrospinal fluid. This fact indicates the absolute need to hospitalize the patient even with minimal suspicion of meningitis. [ 9 ]

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 a general ward, to the resuscitation department or the intensive care unit. The need for a lumbar puncture with further examination of the cerebrospinal fluid is present in all cases. A contraindication to such a puncture may be a blood clotting disorder: if there is a suspicion or confirmation of such disorders, the puncture is postponed until the condition is controlled.

If the patient has increased intracranial pressure or other disorders such as focal neurological insufficiency, optic nerve edema, impaired consciousness, seizures, or if the patient is HIV-infected, then neuroimaging with contrast 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 cord infection, then the puncture procedure is performed in another area - most often in the area of the large cistern or the upper cervical vertebra C2. [ 10 ]

Additional tests used for diagnosis:

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

Instrumental diagnostics involves performing chest X-rays, computed tomography or magnetic resonance imaging to determine parameningeal infectious foci. [ 11 ] Instrumental studies are generally selected and prescribed depending on the specific situation:

• An electrocardiogram is indicated for patients with hemorrhagic rashes on the skin, as well as with auscultatory changes in the heart.
• A chest X-ray is prescribed in the presence of catarrhal phenomena and auscultatory pulmonary changes.
• CT or MRI of the brain is mandatory in case of meningeal and focal neurological symptoms, which allows to exclude organic lesions, acute hydrocephalus, ventriculitis, etc.
• Neurosonography is performed in case of focal neurological symptoms, seizures, and signs of increased intracranial pressure.
• Electroencephalography is performed to exclude intracranial complications of an otolaryngogenic nature and organic disorders.

Cerebrospinal fluid in meningism has the following differential diagnostic features:

Indicative values	Cerebrospinal fluid is normal	Liquor with meningism
Features of color and transparency	No color cast, transparent.	No color cast, transparent.
Pressure (mm H2O)	From 130 to 180.	From 200 to 250.
The number of drops per minute flowing from the needle during puncture	From 40 to 60.	From 60 to 80.
Cytosis index (number of cells per 1 µl)	From 2 to 8.	From 2 to 12.
Cytosis	0.002-0.008	0.002-0.008
Percentage of lymphocytes on cytogram	90-95	90-95
Percentage of neutrophils on cytogram	3-5	3-5
Percentage of protein on cytogram in mg/liter	From 160 to 330.	From 160 to 450.
Precipitation reactions	-	-
Dissociation	-	-
Glucose	From 1.83 to 3.89.	From 1.83 to 3.89.
Chlorides in mol/liter	From 120 to 130.	From 120 to 130.
Fibrin film	No education.	No education.
Reaction to puncture	When releasing a large volume of liquid, headache and vomiting are observed.	Puncture causes significant relief and often becomes a turning point in the disease.

Differential diagnosis

Before conducting a laboratory cerebrospinal fluid study, there are significant difficulties in diagnosing meningism. Differential diagnostics are 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 choose further therapeutic tactics, there is often a need to consult with doctors of narrow specialties - in particular, a neurologist, infectious disease specialist, ENT specialist, neurosurgeon, phthisiatrician, ophthalmologist, etc. Differential diagnostics are necessary to exclude influenza, food poisoning, subarachnoid hemorrhage, tuberculosis, meningitis, meningococcal infection. A frequent cause of diagnostic error in these pathologies is an illiterate check and inadequate assessment of the meningism syndrome. If meningeal signs are pronounced or questionable, the patient is immediately placed in the infectious diseases department of the hospital.

Many infectious and non-infectious pathologies are accompanied by meningism, which significantly complicates the establishment of a correct diagnosis. Therefore, diagnostics should be based on clinical information, taking into account the entire complex of clinical, laboratory and epidemiological data and the results of consultations with doctors of narrow specialties. [ 12 ]

Consultations with the following specialists are shown:

• ophthalmologist - in case of development of cerebral edema;
• otolaryngologist - for diseases of the ENT organs;
• pulmonologist - in case of development of pneumonia;
• infectious disease specialist – to rule out 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);
• neurosurgeon – to exclude abscesses, epiduritis, brain tumors, and also to assess occlusive symptoms;
• cardiologist – to assess cardiac activity.

Meningitis and meningism: similarities and differences

Meningitis is an inflammatory process affecting 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.
Meningitis involves inflammatory changes in the cerebrospinal fluid.	In meningism there are no inflammatory changes in the cerebrospinal fluid
Meningitis does not go away on its own	Meningismus may disappear completely within three days after the cause of its appearance has been eliminated.

Treatment meningismus

The choice of treatment regimen for meningitis depends on the cause of the disorder, clinical symptoms, the severity of painful symptoms, the general condition of the patient and the presence of complications. [ 13 ]

Standard treatment may include:

• Bed rest.
• Diet food.
• Drug therapy:
  • etiotropic treatment;
  • symptomatic treatment;
  • intensive care and resuscitation (as indicated).
• Non-drug therapy:
  • physical methods of influence;
  • sanitation of infection foci;
  • processing and ventilation of the premises;
  • general hygiene measures.

Changes in the diet of patients with meningitis are necessary for rapid recovery and reduction of irritating effects. Preference is given to boiled products. Steaming, baking, and stewing are also allowed. If you plan to cook meat, it is better to choose low-fat types: veal, chicken fillet, rabbit, turkey. Lean fish in the form of cutlets, soufflés, and pates is considered a good choice. Porridges can be served as a side dish - for example, buckwheat, barley, and wheat. Vegetables and fruits are best eaten baked or stewed, in the form of mashed potatoes and casseroles, rather than raw. Dairy products are a must (if well tolerated).

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

Medicines

Different medications can be used to treat meningism, depending on the causes of the pathological condition.

Immunoglobulin human normal	It is indicated for acute severe viral or microbial infections, as well as for their prevention. The drug is administered only intramuscularly, according to an individual regimen (usually a single dose of 3-6 ml, but another treatment regimen is also possible). Reactions to the administration of immunoglobulin are usually absent.
Ibuprofen (propionic acid derivative)	It is indicated for 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 loss, dry eyes, tachycardia.
Paracetamol (anilide group)	Prescribed for fever and headaches, 250-500 mg 4 times a day for several days. Taking the drug is rarely accompanied by dyspepsia or allergic reactions. Most patients perceive Paracetamol without any particular disorders.
Chloramphenicol (an 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. The average dose for oral administration by an adult patient: 0.5 g 3-4 times a day. Duration of treatment is about one week. Possible side effects: dysbacteriosis, dyspepsia, psychomotor disorders, allergic reactions.
Bicillin-1, Retarpen, benzathine benzylpenicillin (beta-lactam antibiotic penicillin)	It is indicated in the same cases as Chloramphenicol. The drug is administered intramuscularly, in quantities from 300 thousand U to 2.4 million U, depending on the doctor's prescription. The probable side effect is the development of anemia, allergic urticaria, superinfection.
Cefotaxime (third generation cephalosporin antibiotic)	It is prescribed when there is no effect from the use of antibiotics of other groups. The drug is administered intravenously (drip or jet) and intramuscularly, in an individually designated dosage. Side effects: dyspepsia, dizziness, hemolytic anemia, pain at the injection site.
Dexamethasone (glucocorticoid drug)	It is used in acute cases of the disease, with signs of acute myocardial infarction, drug allergies, neurological complications. The dosage regimen is individual and depends on the indications, the patient's well-being and their response to treatment. Usually, the medication is administered 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 if there are absolute indications.
Kvartasol, Trisol (solutions for restoring 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 hyperkalemia must be taken into account.
Sodium chloride, potassium chloride (electrolyte solutions)	Prescribed to replenish electrolyte imbalance, intravenously by drip. Possible side effects: acidosis, hyperhydration. Solutions are administered with caution in case of cardiac decompensation, arterial hypertension, chronic renal failure.
Actovegin (blood product)	Helps improve metabolic processes in cerebrovascular disorders. It is administered intravenously (including by infusion) and intramuscularly. Rarely, allergic reactions to the drug are observed. Myalgia is possible.
Plasma preparations, blood substitutes	They are indicated for detoxification in severe forms of pathology, as well as sources of immunoglobulins. The dosage and route of administration depend on the specific medication and are determined individually. Side effects: decreased 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. Intravenously, 300 to 600 mg per day can be administered. Treatment may be accompanied by dyspeptic disorders, allergies.
Diazepam (benzodiazepine derivative)	Recommended for the elimination of seizures in severe meningism and the development of acute cerebral circulatory failure. It is prescribed orally, intravenously, intramuscularly. The daily dose of the drug varies from 500 mcg to 60 mg. Possible side effects: drowsiness, dizziness, fatigue, tremor, muscle weakness.
Furosemide (loop diuretic)	Prescribed to remove excess fluid to stabilize intracranial pressure. Tablets are taken on an empty stomach, without chewing, with a sufficient amount of water. Use the minimum possible dosage required for effective treatment. Possible side effects: decreased blood pressure, collapse, arrhythmia, thrombosis, headache and drowsiness, tinnitus, thirst, oliguria.
Glycine	It is used as a neuroprotective agent. It is used sublingually at 100 mg 3 times a day for 2-4 weeks. In the vast majority of cases, the drug is well received, allergic reactions occur extremely rarely.
Semax (methionyl-glutamyl-histidyl-phenylalanine-prolyl-glycyl-proline)	It is indicated for acute cerebral insufficiency, for optimizing the function of nerve cells, antihypoxic and antioxidant action, and for membrane-stabilizing effect. It is used intranasally, in individual dosages. Long-term treatment may be accompanied by mild irritation of the nasal mucosa.
Mexidol (ethylmethylhydroxypyridine succinate)	It is indicated 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 the blood, reducing platelet aggregation. Taken orally, 125-250 mg three times a day for 14-45 days. The intake is completed by gradually reducing the 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 action. The drug is administered intramuscularly deep, 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 orally at 80 mg 4 times a day, or intramuscularly at a daily dosage of 50-150 mg. The duration of therapy is determined by the attending physician. In some cases, allergic reactions may develop.
Ascorbic acid	It is indicated for intoxication and hemorrhagic syndrome, signs of ONMG. 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

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

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

At the rehabilitation stage, exercise therapy sessions are mandatory: special exercises accelerate the restoration of motor skills, and the additional use of special exercise machines and devices helps prevent the possible development of complications.

If necessary, occupational therapy and psychotherapy are included. [ 14 ]

Herbal treatment

Traditional healers' recipes often have a stimulating effect in the treatment of meningism. First of all, you should follow all the recommendations of your doctor: you should never abandon traditional treatment in favor of traditional methods. It is better to consult with your 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 must be carried out regularly.

Nettle can be used to stabilize the temperature. An infusion is prepared from the leaves: 25 g of raw material is poured with 250 ml of boiling water and infused until cool. Drink instead of tea. A similar remedy can also be prepared from chamomile flowers, linden, raspberry leaves. Raspberry is especially recommended for meningitis, as it perfectly removes intoxication products from the body.

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

A very useful remedy based on ginger root. To prepare it, mince 4 medium lemons (whole, with the peel) and 0.4 kg of fresh ginger. Mix with 250 ml of honey, cover tightly with a lid. Keep in the refrigerator for 10 days, but to speed up the process, you can simply keep 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 excellent remedy for meningitis is aloe juice. To prepare 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 1 tbsp. 2-3 times a day, washed down with water (possibly with honey), between meals.

Before starting to treat meningism with herbs, it is necessary to take into account that any plant component can cause an allergic reaction. It is necessary to consult with the attending physician beforehand.

Surgical treatment

Lumbar puncture is the main minimally invasive surgical procedure performed for meningism for diagnostic and therapeutic purposes. Thus, the puncture allows 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 swelling of the brain, especially in the posterior region of the skull (in such a situation, CT is performed first);
• blood clotting disorders, defects of the spine and spinal cord.

Before performing a cerebrospinal puncture, the patient's blood clotting quality is determined. If the results are unfavorable, the procedure is not performed, and medication correction of deviations is prescribed. In addition, the fundus of the eye is examined or a CT scan is performed 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 knees and hip joints, brings his knees to his stomach, and brings his head as far as possible towards his knees. The spinal column should remain on one plane, without excessive bends. [ 15 ]

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

The surgeon processes the surgical field and performs infiltrative anesthesia. For the procedure, he uses a sterile disposable special needle with a stylet and equipment for measuring the cerebrospinal fluid pressure. He slowly inserts the needle towards the navel, cranially at an angle, with the cut beveled upwards. After passing through the dense membrane, a "failure" is felt, after which the doctor removes the stylet: if everything is done correctly, cerebrospinal fluid begins to drip from the needle. Then, using a special device, the cerebrospinal fluid pressure is measured, after which the surgeon draws the fluid into pre-prepared sterile test tubes. Upon completion of the procedure, he inserts the stylet back into the needle, removes it and applies a sterile bandage.

After the intervention, the patient must remain in a lying 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 limbs (so-called radicular pain);
• numbness of the lower extremities, subarachnoid or epidural hemorrhage, abscess (very rare).

Other types of surgical intervention are performed only in the case of otogenic meningitis, abscesses, brain tumors, etc.

Prevention

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

• Get enough sleep. This advice may sound trivial, but a full 7-9 hours of sleep – deep and strong – promotes adequate immune protection of the body. A good night's rest not only determines the quality of a person's recovery after heavy loads, but also creates the necessary basis for maintaining a sufficient level of immunity, which will allow the body to resist various infectious diseases and the development of meningitis.
• Do not allow stress to influence you. Regular meditation practice, healthy sleep, an active life position, and a positive outlook will help with this. Stress is an invisible but powerful factor in weakening the immune system, and the correct fight against it leads to a significant improvement in health.
• Avoid large crowds and contact 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 thoroughly wash your hands not only after visiting the toilet and before eating, but also immediately upon returning home.
• Too intense training can weaken the body: it is better to replace it with training of lower intensity.
• Drinking enough clean water throughout the day helps cleanse the body of harmful substances and possible toxins, and also maintains the necessary water balance.
• Review your diet. It is important that the body receives the necessary amount of basic nutrients (proteins, fats and carbohydrates), as well as vitamins and minerals.

Forecast

Most cases of meningism resolve within a few days after the underlying disease has been eliminated. Some patients may develop asthenic syndrome, which is expressed in causeless malaise, general weakness, and low 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 is serious. In such a situation, patients are found to have intellectual disabilities, paralysis or paresis, visual or auditory disorders, seizures, and, less commonly, ischemic stroke. [ 16 ]

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

It is quite 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. Preliminary thorough diagnostics and treatment of the underlying disease are necessary. In the future, patients diagnosed with meningism are recommended to be monitored by a neurologist for 2 years.