Clinical features of meningitis

The clinical features of meningitis include:

• neonates
  • often presents with non specific symptoms such as
  • irritability - babies are often irritable with a high-pitched cry
  • poor feeding
  • respiratory distress
  • pale or marble skin
  • hyper or hypotonia
  • fever – seen in a minority 6%-39%
  • seizures – 9%-34%
    • more common in group B streptococcal (GBS) infections compared to E.coli
  • in GBS meningitis within 24 hours of birth, predominant initial symptoms were – respiratory (72%), cardiovascular (69%) and neurologic (63%)
  • septic shock – in about 25% of neonates with meningitis
• in children beyond neonatal age
  • classical features of fever, altered mental status and neck stiffness are less frequent in younger infants compared to older children and adults
  • symptoms include:
    • fever
      • most common symptom in childhood bacterial meningitis – seen in 92-93%
    • chills
    • vomiting
      • seen in 55-67% of chidren
    • neck stiffness
    • photophobia
    • severe headache - reported in
      • 2-9% of children up to 1 year of age
      • 75% of children older than 5 years
    • rash
      • petechial and purpuric rash usually indicate meningococcal disease (rash has also been reported in pneumococcal meningitis)
    • seizures
      • has been reported at hospital admission in 10-56% of children
    • altered mental status – was reported in 13-56% of children
• adults
  • the classic triad of symptoms - fever, neck stiffness and altered mental status is seen in around 41%-51%
  • stiff neck is absent in septicaemia (3)
  • altered mental state includes confusion, delirium, drowsiness, and impaired consciousness
  • petechial rash – identified in 20-52% of patients
    • keep in mind that the rash may be less visible in people with darker skin tones, in these patients check the soles of the feet, palms of the hand and conjunctivae
  • headache
  • nausea/vomiting
  • focal neurological deficit, including cranial nerve involvement and abnormal pupils (1,2,3)

Note:

• Kernig’s and Brudzinski’s signs should not be relied upon for diagnosis of meningitis (4)

Reference:

• (1) van de Beek D et al. ESCMID guideline: diagnosis and treatment of acute bacterial meningitis. Clin Microbiol Infect. 2016;22 Suppl 3:S37-62.
• (2) NICE (June 2010). Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management. Available at https://www.nice.org.uk/guidance/cg102 (Accessed on June 2023)
• (3) Meningitis Research Foundation 2018. Meningococcal Meningitis and Sepsis. Guidance notes. Diagnosis and treatment in general practice
• (4) McGill F et al. The UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults. J Infect. 2016;72(4):405-38.