Meningitis Symptoms
Meningitis presents with a combination of fever, headache, neck stiffness, and altered mental status, but the complete "classic triad" occurs in less than 50% of cases, making it essential to maintain high clinical suspicion even when typical features are absent. 1, 2
Core Clinical Features
The cardinal symptoms to assess include:
- Fever - Present in approximately 74% of cases, though may be absent particularly in elderly patients 2, 3
- Headache - Common presenting symptom that should prompt evaluation when severe or accompanied by other features 1, 2
- Neck stiffness - Occurs in 74% of patients but is significantly less common in older adults 2
- Altered mental status - Ranges from confusion to reduced consciousness and indicates severe disease 1, 2
- Photophobia - Part of the meningism syndrome along with headache and neck stiffness 1
Additional Important Symptoms
- Vomiting - Frequently accompanies meningitis and is a more sensitive indicator than some other nonspecific symptoms 1, 4
- Seizures - Occur in approximately 15% of patients and are associated with worse outcomes, more common with pneumococcal disease 1, 2
- Rash - When present (petechial or purpuric), strongly suggests meningococcal disease in 92% of cases, though 37% of meningococcal meningitis patients have no rash 1, 2, 3
Age-Related Presentation Variations
Elderly patients (>65 years) present atypically and are more likely to have altered consciousness rather than classic meningeal signs, with reduced frequency of neck stiffness and fever compared to younger patients. 1, 5, 2
Young adults and adolescents more commonly present with meningococcal disease and may show more classic features but can deteriorate rapidly. 2
Critical Warning Signs of Meningococcal Sepsis
Beyond meningitis symptoms, watch for signs of septic shock:
- Rapidly evolving rash (petechial, purpuric, or maculopapular) indicating high mortality risk 2, 3
- Hypotension and poor capillary refill time 1, 2
- Cold extremities and decreased urine output 1, 2
- Altered mental state with signs of impaired perfusion 1, 2
Patients with meningococcal sepsis can deteriorate rapidly with sudden cardiovascular collapse, requiring immediate recognition even when initial vital signs appear deceptively normal. 1, 2
Important Clinical Pitfalls
Do not rely on Kernig's sign or Brudzinski's sign to rule out meningitis - these have extremely low sensitivity (5-11%) and miss approximately 89-95% of actual cases. 1, 5, 3, 6
The absence of all cardinal features (fever, neck stiffness, altered mental status) effectively rules out meningitis, as at least one feature is present in 99-100% of cases. 5, 2
Clinical features alone cannot distinguish bacterial from viral meningitis, and specific populations may present differently. 1
Essential Historical Elements to Document
- Contact with another person with meningitis or sepsis 1, 2
- Source of infection such as otitis media, sinusitis, or upper respiratory tract infection 1, 2
- Recent travel history 1, 2
- Immunocompromising conditions (HIV, asplenia, immunosuppression) 1, 2
Documentation Requirements
Clinicians must document on presentation:
- Presence or absence of headache, altered mental status, neck stiffness, fever, rash, seizures, and any signs of shock 1, 2
- Glasgow Coma Scale score with serial monitoring 2
- Vital signs including capillary refill time and extremity temperature 2
Urgent hospital referral is mandatory in any adult with suspected meningitis or meningococcal sepsis due to the possibility of rapid deterioration, and concern from either the referring physician or family members should always be taken seriously. 1