Meningitis: lack of jolt accentuation helped rule out pleocytosis

Clinical bottom line (level 2b)

Two-thirds of patients with a recent-onset fever and a headache had CSF pleocytosis
No jolt accentuation made CSF pleocytosis much less likely.
Neck stiffness made CSF pleocytosis more likely.

Uchihara and Tsukagoshi: Headache 1991; 31: 167-171

Expires November 2003

The study

Setting: acute hospital, Japan

54 patients (aged range 15 to 71 years; mean 39, 52% female) with recent-onset headache (within 2 weeks)

Excluded if

not conscious enough to answer questions satisfactorily

focal neurological abnormality

chronic recurrent headache (migraine or muscle contraction headache)

Independent ?blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:

Diagnostic test: jolt accentuation: headache worsened on rotating head horizontally 2 or 3 times

The evidence

pre-test probability of CSF pleocytosis: 63%, (95% CI: 51% to 76%)

diagnostic test	CSF pleocytosis	no pleocytosis	LR+ (95% CI)	post-test probability	LR- (95% CI)	post-test probability
jolt accentuation	33	8	2.4 (1.4 to 4.2)	80%	0.049 (0.0069 to 0.35)	8%
neck stiffness	5	0	inf (1.1 to infinity)	100%	0.85 (0.74 to 0.98)	59%
positive Kernig's sign	3	0	inf (0.63 to infinity)	100%	0.91 (0.82 to 1.0)	61%
total	34	20

Comments

No other clinical features usefully predicted pleocytosis.
Poor characterisation of the population studied makes generalising these results difficult.

Citation

Uchihara T, and Tsukagoshi H: jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache 1991; 31: 167-171

Contributor: Chris Ball and Clare Wotton, November 1999
Reviewer: Luis Ruiz Del Fresno

_{Clinical Question.}