What questions should I ask a patient suspected of meningitis?

Questions to Ask a Patient with Suspected Meningitis

When evaluating a patient for suspected meningitis, systematically inquire about cardinal symptoms (headache, fever, altered mental status, neck stiffness, rash, seizures), age-related risk factors, immunocompromise status, recent infections, trauma history, and relevant travel exposures to identify the likely pathogen and guide urgent management. 1

Core Symptom Assessment

Classic Meningitis Symptoms

• Headache severity and onset: Document presence and characteristics, as headache is a common presenting feature 1, 2
• Fever: Ask about duration and pattern, though note that elderly patients may not mount a fever 1
• Altered mental status: Assess level of consciousness changes, confusion, or drowsiness 1
• Neck stiffness: Inquire about neck pain or difficulty moving the neck, though this may be absent in up to 50% of cases 1
• Vomiting and nausea: Document presence as part of the clinical picture 1
• Seizures: Ask about any seizure activity, which is more common with pneumococcal disease 1

Important caveat: The classic triad of fever, neck stiffness, and altered consciousness is present in less than 50% of bacterial meningitis cases, so absence of these features does not exclude the diagnosis 1

Rash Assessment

• Any rash present: Specifically ask about new skin changes 1
• Rash characteristics: When a rash is present with meningitis, meningococcal disease is the cause in 92% of cases (petechial in 89%) 1
• Note: 37% of meningococcal meningitis patients do not have a rash 1

Age-Specific Risk Stratification

Young Adults (Late Teens to 40s)

• Age 18-25: Second peak of meningococcal disease occurs in this group 1
• Women aged 20s-40s: Viral meningitis is more common in this demographic 1

Older Adults (>50 years)

• Age >50: Pneumococcal disease becomes more common 1
• Age >60: Listeria meningitis risk increases, though remains rare 1
• Atypical presentation: Elderly patients are more likely to have altered consciousness and less likely to have neck stiffness or fever 1

Immunocompromise and Medical History

HIV Status and Risk Factors

• Known HIV status: All patients with meningitis should be asked about HIV status and offered testing 1
• CD4 count if known: Cryptococcal meningitis is most common with CD4 <100 but should be considered with CD4 <200 1
• TB meningitis risk: Important consideration at all CD4 counts in HIV-positive patients 1
• HIV seroconversion symptoms: Ask about recent lymphadenopathy, oral candidiasis, or rash suggesting acute HIV infection 1

Other Immunocompromising Conditions

• Asplenia or splenic dysfunction: Increases risk from encapsulated bacteria (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae) 1
• Complement deficiency: Increases meningococcal disease risk 1
• Alcohol dependency: Risk factor for Listeria meningitis 1
• Diabetes mellitus: Associated with increased Listeria risk 1
• Malignancy: Predisposes to Listeria and other opportunistic infections 1
• Immunosuppressive medications: Including biologics or chemotherapy 1

Recent Infections and Associated Conditions

Upper Respiratory Tract Infections

• Otitis media: Pneumococcal meningitis is often associated with ear infections 1
• Sinusitis: Ask about recent sinus infections, which commonly precede pneumococcal meningitis 1
• Recent respiratory illness: Document any preceding upper respiratory symptoms 1

Trauma and Neurosurgical History

CSF Leak Risk Factors

• Head trauma history: Skull fractures increase pneumococcal meningitis risk and predispose to recurrent meningitis 1
• Recent neurosurgery: Any recent brain or spinal procedures 1
• Rhinorrhea (clear nasal drainage): May indicate CSF leak 1
• Otorrhea (clear ear drainage): May indicate CSF leak 1

Previous Meningitis Episodes

• Prior meningitis: Ask about any previous episodes 1
• Recurrent lymphocytic meningitis: HSV-2 is the most common cause 1
• Family history: Ask about family members with meningococcal disease, which warrants immunological investigation 1

Travel History

Geographic Exposures

• Mediterranean travel: Toscana virus risk 1
• Central/Eastern Europe: Tick-borne encephalitis virus 1
• African meningitis belt: Other meningococcal strains 1
• United States: West Nile virus exposure 1
• Europe or USA with tick exposure: Lyme disease risk 1
• Warm freshwater/brackish water exposure: Parasitic meningitis (Naegleria fowleri) 1
• South America or Africa: Trypanosomiasis risk 1

Vaccination History

• Pneumococcal vaccination status: Particularly important in adults >50 years 1
• Meningococcal vaccination: Especially relevant for young adults 1
• H. influenzae type b (Hib) vaccination: Less common cause in vaccinated populations 1

Clinical Examination Caveats

Do not rely on Kernig's and Brudzinski's signs: These have high specificity (up to 95%) but very low sensitivity (as low as 5%), making them unreliable for excluding meningitis 1