Meningitis: fever, neck stiffness and altered mental state were common.

Clinical bottom line (level 2a)

  1. Common findings in patients with meningitis included fever, neck stiffness, altered mental state and headache.
  2. Absence of neither fever, neck stiffness or altered mental status, may help to rule out meningitis (99% have one of these signs).
  3. Absence of the full triad of fever, neck stiffness and altered mental status, does not help to rule out meningitis.
Attia et al: Journal of the American Medical Association 1999; 282 (2): 175-181 Expires November 2003

The study

Systematic review of all diagnostic studies of
  • Patients: with suspected meningitis
  • Intervention: clinical signs and symptoms
  • Outcome: meningitis (confirmed on lumbar puncture or autopsy)


    • Articles found in English and French using MEDline, 1966 to 1997 (search terms: available from authors on request ) and searching reference lists of pertinent articles.

    Selection criteria: as above
    Appraisal criteria: reviewed by one of the authors for relevance
    Articles excluded if:
    • no objective confirmation of bacterial or viral meningitis
    • enrolled predominately children or immunocompromised adults, or a mixed population from which adult data could not be extracted
    • focused only on metastatic meningitis or meningitis of a single microbial organism


    10 studies were found involving 824 patients, aged 16 to 95. Nine were retrospective chart reviews.

    The evidence


    diagnostic test sensitivity for
    meningitis
    (95% CI)
    fever 85%
    (78% to 91%)
    neck stiffness 70%
    (58% to 82%)
    altered mental state 67%
    (52% to 82%)
    headache 50%
    (32% to 68%)
    fever, neck stiffness and altered mental state 46%
    (22% to 69%)
    nausea and vomiting 30%
    (22% to 38%)
    focal neurological findings 23%
    (15% to 31%)
    rash 22%
    (1% to 43%)
    total

    • focal neurological findings: bilateral Babinski reflexes, pupillary abnormalities, hemiparesis, cranial nerve abnormalities, nystagmus, convulsion and/or seizure, tremor

    Comments

    1. One study reported signs in patients without meningitis - 13% of acute care patients and 35% of geriatric patients had nuchal rigidity. 1.5% of acute care patients and 12% of geriatric patients had a positive Kernig's sign.
    2. Head jolt requires futher confirmation before widepread use should be adopted.

    Citation

    1. Attia J, Hatala R, Wong JG, et al: does this adult patient have acute meningitis?. Journal of the American Medical Association 1999; 282 (2): 175-181
    Contributor: Chris Ball and Clare Wotton, November 1999
    Reviewer: Daniel Sontheimer

    Clinical Question.
    Patient suspected meningitis
    Intervention or Exposure clinical signs and symptoms
    Outcome meningitis