Pediatric emergency medicine trisk 2266 2266
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TABLE 94.4
SIGNS AND SYMPTOMS OF MENINGITIS
Signs
Age
Symptoms
Early
Late
0–3 mo
Paradoxical irritability
Lethargy
Bulging fontanelle
Altered sleep pattern
Irritability
Shock
Vomiting
Lethargy
Fever
Hypothermia (<1 mo)
Irritability
Fever
Nuchal rigidity
Altered sleep pattern
Irritability
Coma
4–24 mo
Lethargy
>2 yrs
Shock
Headache
Fever
Coma
Neck pain
Nuchal rigidity
Shock
Lethargy
Irritability
The physical examination in the young infant rarely provides specific corroboration, even when the history
suggests meningitis. Fever may be absent in these children, despite the presence of bacterial infection. Any child
younger than 2 months who is brought to the ED with a documented temperature of ≥100.4°F (38˚C) should be
considered at risk for meningitis. The physical signs are sufficiently elusive that many experts caution that one
should not rely exclusively on the examination to rule out meningeal infection. It is estimated that bacterial
meningitis occurs in 1% to 2% of febrile young infants (Chapter 31 Fever ).
After 2 months of age, increasing, but not absolute, reliance can be placed on the physical findings; fever is
typically noted. Specific evidence of meningeal irritation is often present, including nuchal rigidity and, less often,
Kernig (pain with extension of the leg on a flexed femur) and Brudzinski (involuntary lifting of the legs when the
head is raised while the child is lying supine) signs. When an LP fails to confirm the diagnosis of meningitis,
despite the presence of meningeal signs, other conditions must be pursued that can mimic the findings on physical
examination. Conditions capable of producing the findings typical of meningismus (irritation of the meninges
without pleocytosis in the CSF) include severe pharyngitis, retropharyngeal abscess (RTA), cervical adenitis,
arthritis or osteomyelitis of the cervical spine, upper lobe pneumonia, subarachnoid hemorrhage, pyelonephritis,
and tetanus.
Seizures are a presenting complaint for 20% of children with bacterial meningitis. Many of these are focal,
recurrent, or prolonged seizures. Most clinicians advise that children younger than 6 months with a first-time
febrile seizure should routinely have LP performed to discern the presence of CNS infection, unless there are
specific contraindications or an alternative diagnosis is readily apparent. Febrile seizures are reviewed in Chapter
72 Seizures .
