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Bacterial meningitis without clinical signs of meningeal irritation
Abstract:
A clinical diagnosis of meningitis in neonates is difficult because of paucity of physical findings. In older infants and children, nuchal rigidity, Kernig's or Brudzinski's sign, or bulging fontanelles are sought. A review of 1,064 cases of bacterial meningitis beyond the neonatal period revealed that 16 (1.5%) patients had none of those meningeal signs during the entire hospitalization, despite CSF pleocytosis. Eight patients (50%) were 2 years old or older. Lumbar punctures were done because of unexplained fever, changes in behavior or mental status,, seizures, or occurrence of skin petechiae in febrile patients. These patients frequently had moderate pleocytosis and all survived. The meningitis was caused by Neisseria meningitidis in seven patients, Haemophilus influenzae in six, Streptococcus pneumoniae in two, and Salmonella enteritidis in one patient. CSF should be examined in a patient of any age whenever meningitis is a consideration, even if patients lack meningeal signs.
Insights
Meningitis diagnosis can be challenging in children lacking typical signs. Cerebrospinal fluid (CSF) examination is crucial for diagnosis, even without meningeal signs, to ensure timely treatment.
Area of Science:
- Pediatrics
- Infectious Diseases
- Neurology
Background:
- Clinical diagnosis of meningitis in neonates is challenging due to limited physical findings.
- In older children, classic meningeal signs like nuchal rigidity, Kernig's, or Brudzinski's signs are typically sought.
- Bacterial meningitis can present atypically, especially in younger children.
Purpose of the Study:
- To determine the frequency of bacterial meningitis cases presenting without classic meningeal signs in non-neonatal patients.
- To identify patient characteristics and causative pathogens in meningitis cases lacking typical clinical indicators.
- To emphasize the importance of cerebrospinal fluid (CSF) examination in suspected meningitis, irrespective of meningeal signs.
Main Methods:
- Retrospective review of 1,064 cases of bacterial meningitis beyond the neonatal period.
- Analysis of clinical presentation, including the presence or absence of meningeal signs (nuchal rigidity, Kernig's, Brudzinski's).
- Evaluation of cerebrospinal fluid (CSF) findings, particularly pleocytosis, and patient outcomes.
Main Results:
- 16 (1.5%) patients had no meningeal signs during hospitalization despite CSF pleocytosis.
- Half of these patients (8/16) were aged 2 years or older.
- Lumbar punctures were performed due to unexplained fever, altered mental status, seizures, or petechiae; moderate pleocytosis was common, and all patients survived.
Conclusions:
- Bacterial meningitis can occur in children of all ages without presenting meningeal signs.
- Cerebrospinal fluid (CSF) examination is essential for diagnosing meningitis in any patient, even when classic signs are absent.
- Prompt CSF analysis is critical for appropriate management and survival in suspected meningitis cases.