What are the signs and symptoms of meningitis in different age groups?

Signs and Symptoms of Meningitis by Age Group

Meningitis presents with highly variable clinical features that differ dramatically by age, and the absence of classic signs should never be used to rule out the diagnosis—particularly in neonates and elderly patients where atypical presentations are the norm.

Neonatal Meningitis (0-28 days)

Neonates present with predominantly nonspecific symptoms, making clinical diagnosis extremely challenging. 1

Key Clinical Features:

• Nonspecific symptoms predominate: irritability, poor feeding, respiratory distress, pale or mottled skin, hyper- or hypotonia 1
• Fever is notably absent in the majority (61-94%) of neonatal cases 1
• Respiratory distress or failure is frequently the initial presenting symptom (72% in GBS meningitis) 1
• Seizures occur in 9-34% of cases, more commonly with Group B Streptococcal than E. coli meningitis 1
• Septic shock may be present in approximately 25% of cases 1

Critical Pitfall: The diagnosis cannot be ruled out by clinical examination alone—maintain a very low threshold for lumbar puncture in any neonate with suspected infection. 1

Infants and Young Children (1 month - 5 years)

The younger the child, the more subtle and atypical the presentation, with classic meningeal signs frequently absent. 1

Age-Specific Symptom Patterns:

1-5 months:

• Irritability (85%) 2
• Fever remains most common overall (92-93%) 1

6-11 months:

• Impaired consciousness (79%) 2
• Headache reported in only 2-9% at this age 1

12 months and older:

• Vomiting (55-67%) 1
• Neck stiffness (60-82%) begins to appear more reliably 1
• Headache increases to 75% in children >5 years 1

Common Presenting Features:

• Fever: 92-93% of cases 1
• Vomiting: 55-67% 1
• Altered mental status: 13-56% 1
• Seizures: 10-56% at hospital admission 1
• Neck stiffness: Only 40-82% depending on age 1

Pathogen-Specific Signs:

• Petechial/purpuric rash: Indicates meningococcal disease in 61% of confirmed cases (though also seen in 9% of pneumococcal meningitis) 1

Critical Pitfall: Absence of neck rigidity is associated with age <12 months and short symptom duration—it does NOT exclude meningitis. 2 Neck stiffness has only 51% sensitivity, and Kernig's/Brudzinski's signs have extremely poor sensitivity (5-11%). 1

Older Children and Adolescents (6+ years)

This age group begins to present more like adults with classic features, though important differences remain. 3

Key Clinical Features:

• Nuchal rigidity: Present in 100% in one series 3
• Altered consciousness: 84% 3
• Fever paradoxically absent in 44% on presentation 3
• Headache: 75-78% 1
• Vomiting: Common presenting symptom 1

Critical Pitfall: Older children commonly present without fever and tend to have rapid fever resolution after antibiotic therapy—absence of fever should not delay diagnosis. 3

Adults (18-64 years)

The classic triad of fever, neck stiffness, and altered mental status is present in less than 50% of adult cases. 1

Common Presenting Features:

• Headache: 84% 4
• Fever: 74-77% 1, 4
• Neck stiffness: 74% 4
• Altered mental status: Median Glasgow Coma Scale 11 (IQR 9-14) 4
• Nausea: 62% 4
• Petechial rash: 20-52% of cases (indicative of meningococcal infection in >90% when present) 1, 5

Additional Features:

• Seizures: 19-25% 5
• Focal neurological deficits: 11-34% 5

Critical Pitfall: Neck stiffness has only 31% sensitivity in adults. 1, 5 Kernig's and Brudzinski's signs have extremely low sensitivity (5-11%) and high specificity (up to 95%), making them useful only when positive, never for ruling out disease. 1, 5

Elderly Patients (≥60 years)

Elderly patients present with significantly more atypical features and higher mortality rates. 1, 6

Age-Related Presentation Differences:

• More likely to have altered consciousness than younger adults 1
• Less likely to have neck stiffness 1
• Less likely to have fever 1
• More variable presentations with symptoms confused with other underlying diseases 6
• Broader spectrum of causative organisms (increased Listeria and pneumococcal disease) 1

Critical Pitfall: The absence of classic signs is particularly common in elderly patients due to immunosenescence and comorbidities—maintain high clinical suspicion despite atypical presentations. 1, 6

Universal Clinical Decision Rules

All patients with suspected meningitis require immediate hospital admission via emergency ambulance, ideally arriving within one hour. 1, 5

Mandatory Documentation:

Document presence or absence of: 1

• Headache
• Altered mental status
• Neck stiffness
• Fever
• Rash (any description)
• Seizures
• Signs of shock (hypotension, poor capillary refill)

When to Suspect Meningitis:

Any combination of fever, rash, altered mental status, headache, severe pain, or signs of shock mandates urgent evaluation. 5 Individual symptoms are poor discriminators—combinations are more useful. 1

Never delay antibiotic therapy while awaiting diagnostic confirmation, as mortality remains high (approximately 20% overall, up to 30% for pneumococcal, up to 54% in low-income settings). 1, 5, 4