What are the symptoms of meningitis?

Symptoms of Meningitis

The most common symptoms of meningitis are fever, headache, neck stiffness, and altered mental status, though these classic symptoms may be absent in many cases, necessitating a high index of suspicion and prompt evaluation even when the presentation is atypical. 1

Adult Presentation

• Fever occurs in 77-97% of adult cases 1, 2
• Headache is reported in 58-87% of adult patients 1, 2
• Neck stiffness is present in 65-83% of adult cases 1, 2
• Altered mental status is reported in 30-69% of adult cases 1
• Nausea/vomiting occurs in 45-74% of cases 1
• The classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of adult cases 1, 2
• Rash (particularly petechial or purpuric) is identified in 20-52% of adult patients and is indicative of meningococcal infection in over 90% of cases 1, 2
• Focal neurologic deficits occur in 15-34% of cases 1
• Seizures may occur in adult patients, more commonly with pneumococcal meningitis 1

Pediatric Presentation

• In children beyond neonatal age, fever is the most common symptom (92-93% of cases) 1, 2
• Headache is reported in 2-9% of children up to 1 year of age and 75% of children older than 5 years 1, 2
• Vomiting occurs in 55-67% of pediatric cases 1, 2
• Neck stiffness is present in 40-82% of pediatric cases 1, 2
• Altered mental status is reported in 13-56% of pediatric cases 1, 2
• Seizures have been reported in 10-56% of children at hospital admission 1, 2

Neonatal Presentation

• Neonates present with nonspecific symptoms such as irritability, poor feeding, respiratory distress, pale or marble skin, and hyper- or hypotonia 1, 2
• Fever is present in only a minority (6-39%) of neonatal cases 2
• Seizures occur in 9-34% of neonatal cases, more commonly with Group B streptococcal meningitis 2

Important Clinical Considerations

• The reliability of classic meningeal signs is poor: sensitivity of neck stiffness is only 51% in children and 31% in adults 1, 2
• Kernig's sign has a sensitivity of 53% in children and only 11% in adults 1, 2
• Brudzinski's sign has a sensitivity of 66% in children and only 9% in adults 1, 2
• Absence of classic symptoms cannot be used to rule out bacterial meningitis 1
• The younger the patient, the more subtle and atypical the symptoms 1, 2
• Elderly patients are more likely to have an altered conscious level and less likely to have neck stiffness or fever 1
• Petechial and purpuric rash is usually associated with meningococcal disease (61% of cases) but can also occur in pneumococcal meningitis (9% of cases) 1, 2

Diagnostic Pitfalls

• Relying solely on the presence of the classic triad (fever, neck stiffness, altered mental status) will miss approximately 50% of cases 1
• Kernig's and Brudzinski's signs should not be relied upon for diagnosis due to their poor sensitivity 1
• Clinical features alone cannot distinguish between viral and bacterial meningitis 1
• In patients with suspected meningitis, cerebrospinal fluid examination is essential for diagnosis, unless contraindications for lumbar puncture are present 1
• Meningococcal sepsis can present with hypotension, altered mental state and rash (typically purpuric or petechial) and patients can deteriorate rapidly 1

High-Risk Presentations Requiring Urgent Attention

• Any combination of headache, fever, neck stiffness, or altered mental status 1
• Presence of petechial or purpuric rash with fever 1
• Signs of shock (hypotension, poor capillary refill time) 1
• Seizures in the context of fever or headache 1
• Concern from either the referring doctor or a relative should always be taken seriously 1