History and exam
Key diagnostic factors
common
fever
Consider the possibility of bacterial meningitis when assessing any child aged <16 years with acute febrile illness, particularly if they have associated risk factors.[2]
Fever is the most common sign in children (reported in 92% to 93%).[3] It may be associated with chills/shivering.[2]
However, fever is often absent in infants.[2][3] 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.[4] In infants <3 months, the combination of fever and irritability is seen in 41% and temperature instability is seen in 20%.[4]
Practical tip
In children aged ≤5 years, do not routinely use measurements of oral and rectal temperature to determine body temperature.[27] Instead:
In infants aged <4 weeks, use an electronic thermometer in the axilla.[27]
In children aged 4 weeks to 5 years, use of one of the following:[27]
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.[27]
vomiting/nausea
irritable/unsettled
headache
altered mental state
Includes confusion, delirium and drowsiness, and impaired consciousness.[2] Can also be a feature of shock.[2] Present in 13% to 56% of children with bacterial meningitis.[3][34][36][37]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale score <0 or drop of ≥3) can be a sign of raised intracranial pressure.[4][28] [ Glasgow Coma Scale Opens in new window ]
Coma is a feature in 5% of infants <3 months with bacterial meningitis.[4]
neck stiffness
photophobia
May be caused by meningeal irritation.
seizures
Occur in:
9% to 34% of neonates with bacterial meningitis.[3][4] More common with group B streptococci than Escherichia coli.[3]
10% to 56% of children with bacterial meningitis.[3][32][34][36][37] More common with Streptococcus pneumoniae and Haemophilus influenzae type b than Neisseria meningitidis.[5]
focal neurological deficit
rash
Examine the patient's skin very carefully for a rash.[2] In practice, 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.[2]
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.[40]
shock
An early sign of sepsis. Signs of shock in children and young people include:[2]
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 state/decreased conscious level
Poor urine output.
Practical tip
Think 'Could this be sepsis?' based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[39] See Sepsis in children.
raised intracranial pressure
Signs of raised intracranial pressure include:[4][28]
Raised intracranial pressure[4][28]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale score <0 or drop of ≥3) [ Glasgow Coma Scale Opens in new window ]
In children unable to give a verbal response (in practice, those under 2 years), use the Glasgow Coma Scale with modification for children.[2] 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.[2]
bulging fontanelle
Kernig’s sign
With the patient lying flat, flex their thigh so that it is at a right angle to the trunk and extend the leg at the knee joint. If the leg cannot be completely extended due to pain, this is considered positive.
Kernig’s sign is is more common in older children with bacterial meningitis.[41]
Brudzinski’s sign
When the patient’s neck is abruptly flexed passively, meningeal irritation causes involuntary flexion of the hips and knees. Brudzinski’s sign results from inflammation of the lumbosacral nerve. It is more common in older children with bacterial meningitis.[41]
apnoea
Present in 23% of infants <3 months.[4]
presence of risk factors
Risk factors for bacterial meningitis include:
Age <2 years
Incomplete immunisation
Infants who have not had their childhood vaccines are at high risk of contracting Haemophilus influenzae type b, pneumococcal, or meningococcal meningitis.[17]
Immunocompromising conditions
Immunodeficiency, which can be congenital (e.g., hypogammaglobulinaemia, complement deficiency, common variable immunodeficiency, sickle cell disease) or acquired (e.g., asplenia or hyposplenia, use of immunosuppressive medication, HIV infection, cancer) increases the risk of bacterial meningitis.[5][20][21][22]
Cranial structural defects
Congenital or acquired cranial structural defects may increase risk of bacterial meningitis.[5]
Medical Devices
Perinatal period
During the perinatal period, neonates are at increased risk of bacterial meningitis if:[24]
There is premature or prolonged (>18 hours) rupture of membranes
There is maternal colonisation with group B streptococcus
There is maternal chorioamnionitis
They are premature
They have low birth weight.
Exposure to pathogens
Exposure to infection within the household or close contact with another person who has meningitis increases the patient’s risk of bacterial meningitis.[5]
Contiguous infection
Infections such as sinusitis, pneumonia, mastoiditis, and otitis media increase the risk of meningitis.[5]
Crowding
Crowding (e.g., in a household or dormitory) provides an ideal environment for transmission of bacteria.[5]
Other diagnostic factors
common
lethargy
ill appearance
A sign of serious illness.
refusing food/drink
muscle ache/joint pain
An early non-specific symptom.[2]
respiratory symptoms 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.[4]
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