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 any child or young person with acute febrile illness. However, do not be reassured by lack of fever in an unwell baby; more than 50% of neonates 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.[80]
Instead:
In infants aged <4 weeks, use an electronic thermometer in the axilla[80]
In children aged 4 weeks to 5 years, use of one of the following:[80]
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.[80]
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.[52]
irritable/unsettled
A non-specific symptom. Irritability and lethargy are common in babies and young children. Older children and adults may be agitated, aggressive or subdued.[48]
headache
altered mental state
neck stiffness
Neck pain and stiffness are caused by meningeal inflammation. Headache and neck stiffness are harder to identify in babies and young children.[48]
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]
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.[93]
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.[93]
rash
Examine the patient’s skin very carefully for rash and document its presence or absence.[49]
In the initial phases there may be only 1 or 2 petechiae.
Rash in meningococcal sepsis is typically purpuric or petechial (non-blanching) but may take other forms, including a maculopapular rash.[49][82]
Rash may be atypical or absent in some cases.
Rashes can be hard to detect on brown, black or tanned skin (look for petechiae in the conjunctiva).[48]
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.[76]
shock
An early sign of sepsis. Around 10% to 20% of patients may have evidence of shock or fulminant sepsis with or without meningitis.[49]
Signs of shock in children include:[77][78][79]
Prolonged capillary refill time (e.g., more than 2-3 seconds)
Cold hands/feet
Weak, fast pulse
Pale/mottled/ashen/blue skin, lips or tongue
Other indicators of critical illness in children include decreased level of consciousness, decreased urine output, hypoxia (as demonstrated by measurement of arterial blood gas or oxygen saturations), and elevated lactate levels.[74][80]
raised intracranial pressure
Signs of raised intracranial pressure include:[48]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale of <9 or less or a progressive and sustained or rapid fall in level of consciousness) [ 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, or assess using focal neurological signs. Glasgow Coma Scale: modification for children Opens in new window
New focal neurological signs, including seizures or posturing
Abnormal pupillary reactions or papilloedema
bulging fontanelle
May be a sign of meningitis; only relevant in children with an open fontanelle (typically aged under 2 years).
apnoea
Non-specific sign in babies.[48]
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.[94]
cold peripheries
Early manifestation of sepsis.[46]
paresis
May be caused by meningeal irritation.
presence of risk factors
Risk factors for meningococcal infection include:[49]
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[26][29][30][31]
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.[48]
reduced feeding
An early non-specific symptom for serious illness in infants.[48]
unexplained body pain, including limb, back or abdominal pain
An early non-specific symptom.
respiratory distress or breathing difficulty
Tachypnoea, apnoea, and grunting are non-specific signs of serious illness in babies.[48]
uncommon
chills/shivering
A possible sign of serious illness; typically associated with fever.
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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