What are the clinical presentation and treatment of meningitis in a pediatric patient, particularly an infant or young child with a history of seizures?

Clinical Presentation of Meningitis in Pediatric Patients

Bacterial meningitis in children frequently presents with nonspecific symptoms, and classic signs may be absent—therefore, a high index of suspicion and low threshold for cerebrospinal fluid examination is essential, as clinical examination alone cannot rule out meningitis. 1

Age-Specific Clinical Presentations

Neonates (≤28 days)

Neonates present predominantly with nonspecific symptoms rather than classic meningeal signs: 1, 2

• Nonspecific symptoms include irritability, poor feeding, respiratory distress, pale or marble skin, and hyper- or hypotonia 1, 2
• Fever is present in only 6-39% of neonatal cases, making its absence unreliable for ruling out meningitis 1, 2
• Seizures occur in 9-34% of cases, more commonly with Group B streptococcal meningitis than E. coli meningitis 1, 2
• Respiratory distress or failure is frequently an initial symptom, with 72% showing respiratory symptoms, 69% cardiovascular symptoms, and 63% neurologic symptoms in early-onset GBS meningitis 1
• Septic shock may be present in approximately 25% of neonatal meningitis cases 1, 2

Infants and Children Beyond Neonatal Age

The younger the child, the more subtle and atypical the symptoms—classic signs become more apparent with increasing age: 1

Most Common Presentations:

• Fever is the most consistent finding, present in 92-93% of pediatric bacterial meningitis cases 1, 2
• Vomiting occurs in 55-67% of cases 1, 2
• Neck stiffness is present in 40-82% of cases, but sensitivity is only 51% 1, 2
• Altered mental status is reported in 13-56% of cases 1, 2
• Headache shows marked age variation: only 2-9% in children <1 year versus 75% in children >5 years 1, 2

Seizures in the Context of Meningitis:

Seizures occur at hospital admission in 10-56% of children with bacterial meningitis, making them a significant presenting feature: 1

• Seizures outside the typical febrile convulsion age range are an independent indicator of meningitis (likelihood ratio 4.40) 3
• Partial seizures are particularly concerning and independently indicate meningitis 4
• However, bacterial meningitis presenting solely as a simple febrile seizure is extremely rare or nonexistent 5, 6
• Children with seizures and meningitis are typically obtunded or comatose at presentation, not neurologically normal 5

Pathogen-Specific Signs:

• Petechial and purpuric rash strongly suggests meningococcal disease (present in 61% of meningococcal cases vs. 9% of pneumococcal cases) 1
• Rash occurs in 4-51% of pediatric cases overall 1

Critical Diagnostic Indicators

The following clinical features independently raise the likelihood of meningitis and warrant immediate lumbar puncture: 4, 3

• Bulging fontanel (likelihood ratio 3.50-8.00) 4, 3
• Neck stiffness (likelihood ratio 4.00-7.70) 4, 3
• Cyanosis 4
• Impaired consciousness (likelihood ratio 5.80 when toxic/moribund) 4, 3
• Partial seizures 4
• Seizures outside febrile convulsion age range (likelihood ratio 4.40) 4, 3

Poor Diagnostic Accuracy of Classic Signs

Clinical signs alone have poor sensitivity and cannot exclude bacterial meningitis: 1, 3

• Neck stiffness: sensitivity only 51% in children 1, 3
• Kernig sign: sensitivity 53% in children 1, 3
• Brudzinski sign: sensitivity 66% in children 1, 3
• The classic triad of fever, neck stiffness, and altered mental status is absent in many cases 2
• Absence of fever does not rule out meningitis (likelihood ratio 0.70) 3

Critical Management Pitfalls

Do not rely on the absence of classic meningeal signs to rule out bacterial meningitis—characteristic clinical signs may be completely absent, particularly in younger children: 1, 2

• Cerebrospinal fluid examination is essential when bacterial meningitis is suspected, unless contraindications exist 1, 2
• Maintain a low threshold for lumbar puncture in neonates, as clinical examination alone cannot rule out meningitis 1
• In children with seizures and suspected meningitis, base the decision for lumbar puncture on post-ictal mental status and presence of other concerning features (apathy, altered consciousness, meningeal signs) rather than the seizure alone 5, 6
• The presence of ≥1 of the following mandates lumbar puncture and/or presumptive treatment: bulging fontanel, neck stiffness, cyanosis, impaired consciousness, partial seizures, or seizures outside febrile convulsion age range 4