History and exam
Key diagnostic factors
common
rapid onset of illness and rapid deterioration
Meningococcal infections typically evolve rapidly. A febrile illness persisting >24 hours without progression is unlikely to be caused by Neisseria meningitidis.[41]
fever
Sustained fever occurs in most meningococcal infections. However, fever is not always present, especially in neonates.[47]
leg pain
Up to 72% of children and adults with meningococcemia complain of leg pain, an early sign of sepsis.[41]
seizures
neck pain and stiffness
Neck pain and stiffness are caused by meningeal inflammation. Neck stiffness is a common sign of meningitis but is not reliably present in young infants.
paresis
May be caused by meningeal irritation.
headache
An early nonspecific symptom.
photophobia
May be caused by meningeal irritation.
altered mental status
altered consciousness
Common sign of severe infection, including meningitis and sepsis, and is observed in up to 50% of patients with meningococcal infections.[41] One or more neurologic complications (impairment of consciousness, seizures, or focal neurologic abnormalities) are seen in 30% to 40% of patients.[49] Older adult patients with bacterial meningitis are more likely to present with altered consciousness, and less likely to develop headache and neck stiffness, than younger adult patients.[48]
focal neurologic deficit including cranial nerve involvement and abnormal pupils
May be caused by meningeal irritation and raised intracranial pressure, and exudates encasing the nerve roots. One or more neurologic complications (impairment of consciousness, seizures, or focal neurologic abnormalities) are seen in 30% to 40% of patients.[49]
hypotension
Typically occurs late in septic shock and is a risk factor for death in meningococcal infections.[51]
shock
Early manifestation of sepsis.
toxic/moribund state
A sign of serious illness.
pallor or mottled skin
Early sign of meningococcal sepsis.[41]
rash
A hemorrhagic (non-blanching petechial or purpuric) rash is noted in 42% to 83% of patients with meningococcemia.
In a minority of patients, an erythematous, blanching, maculopapular rash may be initially observed, becoming hemorrhagic later in the course of disease.[41] A rash most commonly develops 4-18 hours after the initial symptoms of illness.[41][49] The rash may be less visible in patients with darker skin tones - check soles of feet, palms of hands, and conjunctivae.[47]
cold hands and feet
Early manifestation of sepsis.[41]
hypotonia
May be a sign of severe systemic illness, particularly in young infants.
uncommon
high-pitched cry
Kernig sign
Severe stiffness of the hamstrings causing inability to straighten the leg when the hip is flexed to 90 degrees. Uncommon, but indicates meningeal inflammation and is suggestive of meningitis. Should not be relied on for diagnosis as sensitivity can be low.[48]
It is elicited by having the patient lie supine and flexing the thigh so that it is at a right angle to the trunk, and extending the leg at the knee joint. If the leg cannot be completely extended due to pain, this is considered positive.
Brudzinski sign
Severe neck stiffness causing the patient’s hips and knees to flex when the neck is passively flexed. Uncommon, but indicates meningeal inflammation and is suggestive of meningitis. Should not be relied on for diagnosis as sensitivity can be low.[48]
Other diagnostic factors
common
irritability
An early nonspecific symptom.
lethargy
An early nonspecific symptom.
muscle ache/joint pain
An early nonspecific symptom.
poor appetite or feeding
An early nonspecific symptom.
nausea or vomiting
Vomiting may be a nonspecific indication of illness or a symptom of elevated intracranial pressure.
thirst
Common early symptom of sepsis.
coryza, sore throat, or cough
Recent upper respiratory tract infection is a risk factor for meningococcal infection and is described in up to 50% of patients.
respiratory distress
A sign of serious illness.
tachycardia
A sign of serious illness.
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