History and exam
Key diagnostic factors
common
fever
Fever occurs in most meningococcal infections. Be alert to the possibility of bacterial meningitis or meningococcal sepsis when assessing anyone aged under 16 years with acute febrile illness.[9] However, not always present, especially in neonates.[9] Do not be reassured by lack of fever in an unwell baby; around 50% of young infants diagnosed with bacterial meningitis are afebrile on presentation.[52] Take any reported or perception of fever by the parent(s) or carer seriously.
Practical tip
In children aged ≤5 years, do not routinely use measurements of oral and rectal temperature to determine body temperature.[64]
Instead:
In infants aged <4 weeks, use an electronic thermometer in the axilla[64]
In children aged 4 weeks to 5 years, use of one of the following:[64]
Electronic thermometer in the axilla.
Chemical dot thermometer in the axilla. However, use an alternative type of thermometer if multiple temperature measurements are required.
Infra-red tympanic thermometer.
Do not use forehead chemical thermometers because they are unreliable.[64]
vomiting/nausea
Vomiting may be a non-specific symptom of infection or a symptom of raised intracranial pressure. Present in 55% to 67% of children with bacterial meningitis.[53]
irritable/unsettled
An early non-specific symptom.
headache
An early non-specific symptom.[9] Present in 75% of children >5 years with bacterial meningitis.[53][54] However, children younger than 5 years are unlikely to say specifically that they have a headache in practice. Instead, they may be holding their head, saying that their head hurts, or crying.
altered mental state
neck stiffness
Neck pain and stiffness are caused by meningeal inflammation. Classical signs of meningitis (neck stiffness, bulging fontanelle, high pitched cry) are often absent in infants with bacterial meningitis.[9]
photophobia
May be caused by meningeal irritation.
seizures
Occur in 9% to 34% of neonates and 10% to 56% of children with bacterial meningitis.[52][53]
Reported in 5% to 20% of patients with meningococcal meningitis.[46] One or more neurological complications (impairment of consciousness, seizures, or focal neurological abnormalities) are seen in up to 40% of patients with meningococcal meningitis at some point in the clinical course.[55]
focal neurological deficit including cranial nerve involvement and abnormal pupils
May be caused by meningeal irritation and raised intracranial pressure and exudates encasing the nerve rootsroutes. One or more neurological complications (impairment of consciousness, seizures, or focal neurological abnormalities) are seen in 30% to 40% of patients.[55]
rash
Examine the patient’s skin very carefully for a rash.[9] Always document its presence or absence.
In practice, a petechial or purpuric rash is typically associated with meningococcal disease, but it may be present with any type of bacterial meningitis.
In the initial phases there may be only 1 or 2 petechiae.
Be aware that a rash may be less visible in patients with darker skin tones - check soles of feet, palms of hands, and conjunctivae.[9]
Children with petechiae confined to the skin above the nipple line (the distribution of the superior vena cava) may be less likely to have meningococcal disease than those with petechiae below the nipple line.[62]
shock
An early sign of sepsis. Signs of shock in children and young people include:[9][51][52]
Capillary refill time >2 seconds
Abnormal skin colour
Tachycardia and/or hypotension
Respiratory symptoms or breathing difficulty
Cold hands/feet
Toxic/moribund state
Altered mental status/decreased consciousness
Decreased urine output (<1 mL/kg/h)
Hypoxia on arterial blood gas
Base deficit (worse than -5 mmol/L)
Increased lactate (>2 mmol/L)
raised intracranial pressure
Signs of raised intracranial pressure include:[51][52]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale score <9 or drop of ≥3)
In children unable to give a verbal response (in practice, those under 2 years), use the Glasgow Coma Scale with modification for children.[9] Glasgow Coma Scale: modification for children Opens in new window
Relative bradycardia and hypertension
Focal neurological signs
Abnormal posture or posturing
Seizures
Unequal, dilated, or poorly responsive pupils
Papilloedema (late sign)
An enlarged blind spot may be identified when you examine the visual fields.
Abnormal ‘doll’s eye’ movements
back rigidity
A more specific symptom of bacterial meningitis/meningococcal disease.[9]
bulging fontanelle
May be a sign of meningitis; only relevant in children aged under 2 years. Classical signs of meningitis (neck stiffness, bulging fontanelle, high pitched cry) are often absent in infants with bacterial meningitis.[9]
Kernig’s sign
Severe stiffness of the hamstrings causing inability to straighten the leg when the hip is flexed to 90 degrees. Uncommon, but it indicates meningeal inflammation and is suggestive of meningitis. However, it should not be relied on for diagnosis as sensitivity can be low.[48] Kernig’s sign is more common in older children with bacterial meningitis.[63]
Brudzinksi’s sign
Severe neck stiffness causing the patient’s hips and knees to flex when the neck is flexed. Uncommon, it but indicates meningeal inflammation and is suggestive of meningitis. However, it should not be relied on for diagnosis as sensitivity can be low.[48] Brudzinski’s sign is more common in older children with bacterial meningitis.[63]
apnoea
Present in 23% of infants <3 months.[52]
rapid deterioration
Patients with meningococcal disease can deteriorate rapidly.
hypotension
Typically occurs late in septic shock and is a risk factor for death in meningococcal infections.[74]
cold peripheries
Early manifestation of sepsis.[46]
toxic/moribund state
A sign of serious illness.
paresis
May be caused by meningeal irritation.
presence of risk factors
Risk factors for meningococcal infection include:[48]
Younger age
Meningococcal disease has a bimodal distribution in children and young adults with peaks in:
Children aged under 5 years
Adolescents and early adulthood (16-25 years)
Immunocompromise
People with asplenia or hyposlenia are at increased risk from all encapsulated bacteria, including Neisseria meningitidis
Complement deficiency increases risk of meningococcal disease
Patients on immunosuppressants have depressed cell-mediated immunity and are at increased risk for bacterial meningitis
HIV infection, in particular patients with a low CD4 count or high viral load[29][30][31][26]
Recent travel abroad
A source of infection such as otitis media or sinusitis
Recent respiratory illness
Recent neurosurgery/ear, nose, or throat surgery
Contact with another person with meningitis or sepsis
Household crowding
Residence in a dormitory
Other diagnostic factors
common
unusual skin colour
Pallor or mottled skin can be an early sign of meningococcal sepsis.[46]
lethargy
An early non-specific symptom.
ill appearance
A sign of serious illness.
refusing food/drink
An early non-specific symptom. Infants <3 months may present with poor feeding.[52]
muscle ache/joint pain
An early non-specific symptom.
respiratory distress or breathing difficulty
A sign of serious illness. In infants <3 months, 44% may present with respiratory distress (including grunting) and/or need for mechanical ventilation if they are a term baby.[52]
uncommon
chills/shivering
A possible sign of serious illness; typically associated with fever.
diarrhoea, abdominal pain/distension
A non-specific symptom.
sore throat/coryza or other ear, nose, and throat symptoms/signs
Recent upper respiratory tract infection is a risk factor for meningococcal infection and is described in some patients.
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