From the Guidelines
The physical examination for meningitis should focus on identifying signs of meningeal irritation and neurological dysfunction, including nuchal rigidity, altered mental status, fever, and rash, as these are the most critical findings to guide immediate management and improve outcomes in terms of morbidity, mortality, and quality of life. According to the UK Joint Specialist Societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1, the presence or absence of headache, altered mental status, neck stiffness, fever, rash, seizures, and any signs of shock should be documented.
Key Findings
- Nuchal rigidity (neck stiffness when attempting passive flexion) is a critical sign of meningeal irritation.
- Altered mental status, which can range from mild confusion to coma, is a key indicator of neurological dysfunction.
- Fever is a common finding, although its absence does not rule out meningitis.
- Rash, particularly petechial or purpuric, may suggest meningococcal infection.
- Other important elements include assessment of vital signs, mental status evaluation, and cranial nerve examination.
Special Considerations
- In infants, bulging fontanelles, irritability, high-pitched crying, and poor feeding may be present instead of classic meningeal signs.
- The physical exam should be performed promptly but should never delay administration of antibiotics when bacterial meningitis is suspected, as early treatment significantly reduces mortality and neurological sequelae 1.
- Remember that absence of meningeal signs does not rule out meningitis, particularly in immunocompromised patients, the elderly, or very young children, where signs may be subtle or absent despite serious infection.
Diagnostic Approach
- Blood cultures should be taken as soon as possible and within 1 hour of arrival at hospital 1.
- Lumbar puncture (LP) should be performed within 1 hour of arrival at hospital, provided it is safe to do so, and treatment should be commenced immediately after the LP has been performed 1.
- The UK Joint Specialist Societies guideline also recommends documenting the patient's conscious level using the Glasgow coma scale and performing a thorough neurological examination to detect focal deficits that might indicate complications such as cerebral edema or stroke 1.
From the Research
Key Findings on Physical Examination
- Physical examination may not be sufficient to accurately identify patients with meningitis 2
- Clinical signs associated with intracranial conditions that are a contraindication for a lumbar puncture include:
- Severely decreased consciousness
- New onset focal neurological signs
- Epileptic seizures 3
- Patients with suspected community-acquired bacterial meningitis should undergo a targeted quick but profound workup and early initiation of therapy in the Emergency Department 3
Importance of Early Diagnosis and Treatment
- Early antibiotics administration and favorable outcomes have been demonstrated by previous studies 4
- Immediate initiation of effective therapy is crucial to positively influence mortality and neurological outcome 5
- Antibiotics should be administered within 30 min after admission 5
Diagnostic Procedures
- Lumbar puncture (LP) is a critical diagnostic procedure for suspected acute bacterial meningitis 6, 3
- LP should be performed safely without prior imaging if clinical signs that point to contraindications of a lumbar puncture are absent 3
- CSF culture is more likely to be positive if LP is performed within 4 hours after starting antibiotics 6