Diagnostic accuracy of clinical symptoms and signs in children with meningitis

Pediatric High-Risk Conditions

Meningitis, appendicitis, and testicular torsion are among the most common conditions resulting in malpractice litigation in Pediatric Emergency Medicine. With meningitis, most litigation claims involved patients <2 years old. Notably, 25% of patients had no fever and many lacked classic signs of meningitis. For appendicitis, nearly 3/4 of litigated cases claimed delayed/missed diagnosis. A non-diagnostic ultrasound (eg, no appendix visualized) has a negative predictive value of only 86%. Finally, testicular torsion carries a 34-42% testicular loss rate and 10% of patients with torsion only present with isolated abdominal pain. Atypical presentations must be considered and clear return precautions are imperative.

An Infant With COVID-19 Presenting With a Bulging Fontanel: A Case Report and Literature Review

A bulging fontanel is a sign of elevated intracranial pressure, which can be caused by diseases with intracranial fluid retention or swelling of the cerebral parenchyma. We experienced a case of an infant with a typical course of mild coronavirus disease 2019 (COVID-19) but with a bulging fontanel as a finding at presentation. The patient, a three-month-old boy with no underlying conditions, presented to the emergency clinic with fever, vomiting, and loss of appetite. Due to the absence of crying and the bulging fontanel, he was referred to our hospital with suspected bacterial meningitis. The diameter of the anterior fontanel was 2.5 cm, as measured by the Popich and Smith method. He showed no signs of consciousness impairment and appeared to be as active as usual. Computed tomography revealed a bulging fontanel. Cerebrospinal fluid examination showed no elevated cell counts, and cultures were negative. Accordingly, bacterial meningitis was ruled out. The fever resolved on the day after admission, and the patient was discharged on the third day after admission in good general condition. When an infant diagnosed with COVID-19 presents with a bulging fontanel, it is important to be aware of its low specificity and excessive antibiotic treatment should be reconsidered.

Diagnostic and treatment dilemmas in well children with petechial rash in the emergency department

This article presents a discussion based on a case study of an eight-month-old boy with petechial rash who presented at the emergency department (ED). Blood tests were obtained and intravenous antibiotics were administered. The patient was admitted to the children's ward and was discharged the next day. It was suspected that the rash was caused by a non-specific viral illness. Non-blanching rashes, such as petechial rash, in well children often lead to diagnostic and treatment dilemmas in the ED. Clinicians fear missing the diagnosis of invasive meningococcal disease, which results in blood tests, cannulation and early administration of antibiotics. Non-blanching rashes have many potential causes and extensive tests and antibiotic treatment may not always be necessary and have the potential to cause harm. A tailored approach to investigate, treat and discharge well children with petechial rash from the ED is advocated.

Microbial aspects and potential markers for differentiation between bacterial and viral meningitis among adult patients

OBJECTIVES

Meningitis is a medical emergency with permanent disabilities and high mortality worldwide. We aimed to determine causative microorganisms and potential markers for differentiation between bacterial and viral meningitis.

METHODOLOGY

Adult patients with acute meningitis were subjected to lumber puncture. Cerebrospinal fluid (CSF) microorganisms were identified using Real-time PCR. PCT and CRP levels, peripheral and CSF-leucocyte count, CSF-protein and CSF-glucose levels were assessed.

RESULTS

Out of 80 patients, infectious meningitis was confirmed in 75 cases; 38 cases were bacterial meningitis, 34 cases were viral meningitis and three cases were mixed infection. Higher PCT, peripheral and CSF-leukocytosis, higher CSF-protein and lower CSF-glucose levels were more significant in bacterial than viral meningitis patients. Neisseria meningitides was the most frequent bacteria and varicella-zoster virus was the most common virus. Using ROC analyses, serum PCT and CSF-parameters can discriminate bacterial from viral meningitis. Combined ROC analyses of PCT and CSF-protein significantly improved the effectiveness in predicting bacterial meningitis (AUC of 0.998, 100%sensitivity and 97.1%specificity) than each parameter alone (AUC of 0.951 for PCT and 0.996 for CSF-protein).

CONCLUSION

CSF-protein and serum PCT are considered as potential markers for differentiating bacterial from viral meningitis and their combination improved their predictive accuracy to bacterial meningitis.

Bulging fontanelle in febrile infants as a predictor of bacterial meningitis

It is common practice to perform a lumbar puncture in infants presenting with fever and a bulging fontanelle in order to rule out bacterial meningitis. However, most of these infants have benign, self-limiting diseases. The objective was to determine whether there is an association between bulging fontanelle and bacterial meningitis in febrile infants. This retrospective cohort study included febrile children with a bulging fontanelle who underwent lumbar puncture at Meir Medical Center from 2005 through 2015. A total of 764 children ages 2-18 months underwent lumbar puncture during the study period. Among them, 304 had a bulging fontanelle and fever on evaluation and cerebrospinal fluid pleocytosis was found in 115 (37.8%), including 1 case of bacterial meningitis (0.3%). None of the infants described on admission as appearing well on presentation was found to have bacterial meningitis. Of the 764 children who underwent lumbar puncture, 10 infants were diagnosed with bacterial meningitis, and only one (10%) presented with a bulging fontanelle.Conclusion: The finding of a bulging fontanelle has very low sensitivity and specificity for bacterial meningitis. Most causes of a bulging fontanelle in febrile infants are self-limiting diseases. The routine approach of performing a lumbar puncture in febrile infants with a bulging fontanelle should be reconsidered. What is Known: • It is common to perform a lumbar puncture in febrile infants with a bulging fontanelle, to rule out bacterial meningitis. • However, there are only few researches regarding the relationship between bulging fontanelle and bacterial meningitis. What is New: • The finding of a bulging fontanelle has very low sensitivity and specificity for bacterial meningitis • The need for routine lumbar puncture in these cases should be reconsidered.

The Prevalence of Viruses in the Cerebrospinal Fluid of Children with Aseptic Meningitis in Shiraz, Iran

Objectives: The current study aimed to evaluate the causative agents of viral meningitis through real-time PCR among children with aseptic meningitis. Methods: Children aged 1 month to 16 years with suspected viral meningitis were enrolled in this study (March 2014-February 2015). Cerebrospinal fluid samples were analyzed by real-time PCR for detection of enterovirus, mumps, measles, adenovirus, EBV, CMV, VZV, hhv 6, and rubella viruses. Demographic information, laboratory data, and clinical presentations of patients were also collected. Results: Of 56 patients suspected to viral meningitis, 21 (38.9 %) had a positive PCR result. Enterovirus (42.85%) and mumps (38.1%) were the most prevalent viruses, and VZV and measles were not detected. Three children were coinfected with enterovirus/hhv6, enterovirus/EBV, and mump/adenovirus. Fever, headache, and nausea/vomiting were the most common symptoms in children. The rates of symptoms were not statistically significant among children with positive and negative PCR tests. Conclusions: In the present study Enterovirus and mumps viruses were the most common causes of viral meningitis in children. PCR, as a rapid test for the diagnosis of viral meningitis, can be used to decrease hospitalization length.

How to use clinical signs of meningitis

Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig's sign and Brudzinski's sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.

Bacterial meningitis in Sudanese children; critical evaluation of the clinical decision using clinical prediction rules

BACKGROUND

Sudan falls in the meningitis belt where most global cases of bacterial meningitis are reported. Highly accurate decision support tools have been developed by international specialized societies to guide the diagnosis and limit unnecessary hospital admissions and prolonged antibiotic use that have been frequently reported from countries around the world. The goals of this study are to critically evaluate the clinical decision of bacterial meningitis in children in Sudan using clinical prediction rules and to identify the current bacterial aetiology.

METHODS

This cross-sectional hospital-based study was conducted in October to July of 2010 in a major referral pediatric hospital in Khartoum, Sudan. Febrile children age 1 day to 15 years who were provisionally diagnosed as having meningitis on admission were included (n = 503). Cerebrospinal fluid (CSF) specimens were obtained from all patients while clinical and demographic data were available for only 404. Conventional laboratory investigations were performed. The clinical decision was evaluated by the International Classification of Diseases-Clinical Modification code 320.9 and the Bacterial Meningitis Score. Ethical clearance and permissions were obtained.

RESULTS

Out of 503 provisionally diagnosed bacterial meningitis patients, the final clinical confirmation was assigned to 55.9%. When codes were applied; 5.7% (23/404) with CSF pleocytosis were re-classified as High Risk for bacterial meningitis and 1.5% (6/404) with confirmed bacterial aetiology as Proven Bacterial Meningitis. Neisseria meningitidis was identified in 0.7% (3/404) and Streptococcus pneumoniae in another 0.7%. Typical laboratory findings (i.e. CSF pleocytosis and/or low glucose and high protein concentrations, Gram positive or Gram negative diplococcic, positive bacterial culture) were seen in 5 (83%). Clinically, patients showed fever, seizures, chills, headache, vomiting, stiff neck and bulging fontanelle. All confirmed cases were less than 5 years old and were admitted in summer. All patients were prescribed with antibiotics; they were all recovered and discharged.

CONCLUSIONS

Bacterial meningitis is over-diagnosed in hospitals in Khartoum therefore clinical prediction rules must be adopted and applied to guide the clinical decision. The sole bacterial aetiology in this selected group of Sudanese children remain N. meningitidis and S. pneumoniae, but with significant decrease in prevalence. Some cases showed atypical clinical and laboratory findings.

Viral (aseptic) meningitis: A review

Viral meningitis is an inflammation of the meninges associated with acute onset of meningeal symptoms and fever, pleocytosis of the cerebrospinal fluid, and no growth on routine bacterial culture. It is sometimes associated with viral encephalitis and meningoencephalitis. Viruses reach the central nervous system (CNS) hematogenously or in a retrograde manner from nerve endings. The viral etiology varies according to age and country. Molecular diagnostics technology has helped improve the rate of pathogen detection reducing unnecessary antibiotic use and length of hospitalization. Most of the viral infections detailed in this article have no specific treatment other than supportive care. Many of the viruses discussed are preventable by vaccination and proper skin protection against transmitting vectors.

Diagnosis and Treatment of Central Nervous System Infections in the Emergency Department

Central nervous system (CNS) infections, including meningitis, encephalitis, and brain abscess, are rare but time-sensitive emergency department (ED) diagnoses. Patients with CNS infection can present to the ED with nonspecific signs and symptoms, including headache, fever, altered mental status, and behavioral changes. Neuroimaging and CSF fluid analysis can appear benign early in the course of disease. Delaying therapy negatively impacts outcomes, particularly with bacterial meningitis and herpes simplex virus encephalitis. Therefore, diagnosis of CNS infection requires vigilance and a high index of suspicion based on the history and physical examination, which must be confirmed with appropriate imaging and laboratory evaluation.

The History and Current Relevance of the Eponymous Signs of Meningitis

During the past several decades, researchers have shown that the eponymous signs of meningitis have reduced sensitivity and specificity compared with when they were originally described. This may be because of the changing epidemiology of meningitis and its treatment or it may be because of variations in performance of the maneuvers. For example, in the original descriptions, the Kernig sign (resistance of leg extension) is best elicited with the patient sitting and the Brudzinski nape of the neck sign involves holding down the patient's chest as the neck is flexed. These and other lesser-known signs of meningitis by Amoss, Bikeles and Edelmann all relate to the mechanics of stretching inflamed meninges, and this review will allow the clinician to understand how the history related to these maneuvers is still germane to clinical practice today.

Procalcitonin as a Serum Biomarker for Differentiation of Bacterial Meningitis From Viral Meningitis in Children: Evidence From a Meta-Analysis

Several studies have explored the use of serum procalcitonin (PCT) in differentiating between bacterial and viral etiologies in children with suspected meningitis. We pooled these studies into a meta-analysis to determine the PCT diagnostic accuracy. All major databases were searched through March 2015. No date or language restrictions were applied. Eight studies (n = 616 pediatric patients) were included. Serum PCT assay was found to be very accurate for differentiating the etiology of pediatric meningitis with pooled sensitivity and specificity of 0.96 (95% CI = 0.92-0.98) and 0.89 (95% CI = 0.86-0.92), respectively. The pooled positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and area under the curve (AUC) for PCT were 7.5 (95% CI = 5.6-10.1), 0.08(95% CI = 0.04-0.14), 142.3 (95% CI = 59.5-340.4), and 0.97 (SE = 0.01), respectively. In 6 studies, PCT was found to be superior than CRP, whose DOR was only 16.7 (95%CI = 8.8-31.7). Our meta-analysis demonstrates that serum PCT assay is a highly accurate and powerful test for rapidly differentiating between bacterial and viral meningitis in children.

Epidemiological, clinical and prognostic profile of childhood acute bacterial meningitis in a resource poor setting

Background:

Childhood bacterial meningitis is a neurologic emergency that continues to kill and maims children particularly in developing countries with poor immunization coverage.

Objective:

This study set out to assess the hospital incidence, pattern of presentation, etiologic agents, outcome and determinants of mortality among the children admitted with bacterial meningitis at the Wesley Guild Hospital (WGH), Ilesa.

Patients and Methods:

We carried out a retrospective review of admitted cases of bacterial meningitis in children aged one month to 15 years at the WGH, Ilesa over a three year period by looking at the hospital records. Factors in the history and examinations were compared among survivors and those that died to determine factors significantly associated with mortality in these children.

Results:

Eighty-one (5.5%) of the 1470 childhood admissions during the study period had bacterial meningitis. Male preponderance was observed and two-thirds of the children were infants. More cases were admitted during the wet rainy season than during the dry harmattan season. Haemophilus influenzae type B and Streptococcus pneumoniae were the leading etiologic agents and ciprofloxacin and ceftriaxone adequately cover for these organisms. Twenty-two (27.2%) of the 81 children died, while 34 (42.0%) survived with neurologic deficits. Children with multiple seizures, coma, neck retraction, hyponatremia, hypoglycorrhachia, turbid CSF as well as Gram positive meningitis at presentation were found to more likely to die (P < 0.05). None of these factors however independently predict mortality.

Conclusion:

Childhood bacterial meningitis often results in death and neurologic deficit among infants and young children admitted at the WGH, Ilesa. Children diagnosed with meningitis who in addition had multiple seizures, neck retraction and coma at presentation are at increased risk of dying.

Role of Clinical Presentations and Routine CSF Analysis in the Rapid Diagnosis of Acute Bacterial Meningitis in Cases of Negative Gram Stained Smears

Background and Aim. Bacterial meningitis is a lethal, disabling endemic disease needing prompt antibiotic management. Gram stained smears is rapid accurate method for diagnosis of bacterial meningitis. In cases of negative gram stained smears diagnosis is delayed till culture results. We aim to assess the role of clinical presentations and routine CSF analysis in the cost-effective rapid diagnosis of negative gram stained smears bacterial meningitis. Methods. Cross sectional study including 623 acute meningitis patients divided into two groups: bacterial meningitis and nonbacterial meningitis groups. The clinical presentations, systemic inflammatory parameters, and CSF analysis were evaluated and compared in both groups. Results. Altered conscious level, localizing neurological signs, Kernig's and Brudzinski's signs together with peripheral leucocytosis (>10.000/mm(3)), high CRP (>6) together with high CSF protein (>50 gl/dL), CSF neutrophilic count (≥50% of total CSF leucocytic count), and low CSF glucose level (<45 gm/dL) and CSF/serum glucose ≤0.6 were significantly diagnostic in bacterial meningitis patients. From the significant CSF analysis variables CSF protein carried the higher accuracy of diagnosis 78% with sensitivity 88% and specificity 72%. Conclusions. High CSF protein (>50 mg/dL) together with plasma inflammatory markers and CSF cytochemical parameters can diagnose bacterial meningitis in gram stain negative smear till culture results.

[Examination and clinical signs in infancy]

The first 2 years of life are essential to visual development. The ophthalmological examination of a baby is different from that of an adult, in terms of both methodology and clinical signs. The specifics of examination at this age require a rigorous history taking as a first step: personal and family medical history, first sign of the disease and its progression. Cycloplegic refraction and fundus exam are both critical regardless of the reason for consultation. In addition, fundus exam must be performed at the first visit in cases of strabismus, nystagmus, or abnormal visual function, in order to rule out underlying retinoblastoma. Gross inspection of the patient can offer much information: malformations, visual behavior, oculomotor abnormalities. Quantification of vision and refraction is age-specific. It cannot be based solely on visual behavior, it cannot be just an approximation, and it often needs to be repeated. Lastly, examination of the anterior and posterior segments may require specialized equipment, special techniques, and may reveal pathology specific to the infant. Throughout the examination, patience and gentleness help greatly to insure a reliable diagnosis.

Management of a child with vomiting

Vomiting is a protective reflex that results in forceful ejection of stomach contents up to and out of the mouth. It is a common complaint and may be the presenting symptom of several life-threatening conditions. It can be caused by a variety of organic and nonorganic disorders; gastrointestinal (GI) or outside of GI. Acute gastritis and gastroenteritis (AGE) are the leading cause of acute vomiting in children. Important life threatening causes in infancy include congenital intestinal obstruction, atresia, malrotation with volvulus, necrotizing enterocolitis, pyloric stenosis, intussusception, shaken baby syndrome, hydrocephalus, inborn errors of metabolism, congenital adrenal hypoplasia, obstructive uropathy, sepsis, meningitis and encephalitis, and severe gastroenteritis, and in older children appendicitis, intracranial mass lesion, diabetic ketoacidosis, Reye's syndrome, toxic ingestions, uremia, and meningitis. Initial evaluation is directed at assessment of airway, breathing and circulation, assessment of hydration status and red flag signs (bilious or bloody vomiting, altered sensorium, toxic/septic/apprehensive look, inconsolable cry or excessive irritability, severe dehydration, concern for symptomatic hypoglycemia, severe wasting, Bent-over posture). The history and physical examination guides the approach in an individual patient. The diverse nature of causes of vomiting makes a "routine" laboratory or radiologic screen impossible. Investigations (Serum electrolytes and blood gases,renal and liver functions and radiological studies) are required in any child with dehydration or red flag signs, to diagnose surgical causes. Management priorities include treatment of dehydration, stoppage of oral fluids/feeds and decompression of the stomach with nasogastric tube in patients with bilious vomiting. Antiemetic ondansetron(0.2 mg/kg oral; parenteral 0.15 mg/kg; maximum 4 mg) is indicated in children unable to take orally due to persistent vomiting, post-operative vomiting, chemotherapy induced vomiting, cyclic vomiting syndrome and acute mountain sickness.

Diagnosis and management of bacterial meningitis in the paediatric population: a review

Paediatric bacterial meningitis is a neurological emergency which, despite advances in medical management, still has a significant morbidity and mortality. Over recent decades new vaccines have led to a change in epidemiology of the disease; however, it remains a condition that requires a high index of suspicion, prompt diagnosis, and early management in the emergency department. New laboratory techniques and clinical tools are aiding the diagnosis of bacterial meningitis, yet some controversies still exist in its management. This paper outlines the changing epidemiology of the disease, current diagnostic techniques as well as controversies and advances in the management of bacterial meningitis in the paediatric population.