Can This Be Meningitis?
Yes, meningitis remains a serious diagnostic consideration in this 3-year-old child with recurrent fever, leukocytosis, and elevated CRP despite oral cephalosporin treatment, and lumbar puncture should be strongly considered to definitively rule out this diagnosis.
Why Meningitis Must Be Considered
The clinical presentation does not exclude meningitis because:
Classic signs are frequently absent in young children. In children aged 3-36 months, the classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of bacterial meningitis cases 1. Neck stiffness has a sensitivity of only 31%, Kernig sign 11%, and Brudzinski sign 9% for detecting meningitis 1.
No single clinical sign rules out meningitis. The absence of meningeal signs has a likelihood ratio of only 0.41, meaning their absence does NOT exclude the diagnosis 2. Even the absence of fever does not rule out meningitis (LR 0.70) 2.
Fever with leukocytosis raises concern. Among children aged 3-36 months with fever ≥39°C and WBC count ≥15,000/mm³, approximately 10% have occult bacteremia 3, and 5-20% of those with bacteremia develop serious sequelae including meningitis 3.
Critical Red Flags in This Case
Treatment failure with cefpodoxime is particularly concerning because:
Persistent fever despite appropriate antibiotic therapy suggests either resistant organisms, inadequate CNS penetration, or a diagnosis requiring different management 4.
Oral third-generation cephalosporins may have insufficient CSF penetration compared to parenteral formulations, potentially masking or partially treating meningitis 4.
Partially treated meningitis is a dangerous pitfall that can delay diagnosis while allowing progression of CNS infection 3.
Specific Clinical Features to Assess
Look for these findings that increase likelihood of meningitis 2:
- History: Bulging fontanel (LR 8.0), neck stiffness reported by parents (LR 7.7), seizures (LR 4.4), or reduced feeding (LR 2.0)
- Examination: Toxic or moribund appearance (LR 5.8), meningeal signs (LR 4.5), neck stiffness (LR 4.0), bulging fontanel (LR 3.5), abnormal tone (LR 3.2), or fever >40°C (LR 2.9)
- Behavioral changes: Altered mental status, irritability, or lethargy 3
Laboratory Interpretation
The elevated CRP supports but does not confirm bacterial meningitis:
In children under 6 years, CRP >20 mg/L suggests bacterial over viral meningitis, while CRP >50 mg/L is highly suggestive in all ages 5.
However, 12% of bacterial meningitis cases have CRP <50 mg/L, particularly in children under 6 years with symptoms <12 hours 5.
Leukocytosis increases concern, as temperature >38.4°C with WBC >6,100/mm³ significantly raises risk of CNS infection 3.
Definitive Diagnostic Approach
CSF examination is the only way to definitively rule out meningitis 1:
CSF analysis remains the cornerstone of diagnosis regardless of presence or absence of classic symptoms 1.
CSF white blood cell count is the best diagnostic parameter for differentiating bacterial meningitis (AUC 0.95) 1.
Clinical characteristics alone cannot rule out bacterial meningitis 3, 1.
Recurrent Meningitis Consideration
Given the recurrent nature of fever, consider underlying anatomical defects 6, 7:
Streptococcus pneumoniae (the most common pathogen in this age group) suggests possible cranial dural defects 6.
Recurrent bacterial meningitis may indicate congenital malformations, skull fractures, or dermal sinus tracts 7.
Delay in diagnosis of underlying causes averages 6 months to 2.5 years after first episode 7.
Immediate Management Recommendation
Perform lumbar puncture unless contraindicated 3:
The ESCMID strongly recommends CSF examination in all children with suspected bacterial meningitis 1.
If lumbar puncture is performed, initiate empiric parenteral antibiotics immediately: cefotaxime (300 mg/kg/day) or ceftriaxone (100 mg/kg/day) plus vancomycin (60 mg/kg/day) until pneumococcal meningitis is ruled out 4.
Do not delay lumbar puncture based on absence of classic signs in a 3-year-old with persistent fever and inflammatory markers despite antibiotic treatment 3, 1.
Common Pitfall to Avoid
Never assume that response or lack of response to oral antibiotics rules in or out serious bacterial infection 8. The persistence of fever despite cefpodoxime treatment is a warning sign, not reassurance, and mandates further investigation including CSF analysis to exclude meningitis 3, 1.