Meningitis - Acute, Bacterial Initial Assessment

The classic triad of acute bacterial meningitis includes fever, neck stiffness and an altered level of consciousness or cognition (including confusion or delirium). Meningitis may also present with severe headache (especially in children) or any of the symptoms such as petechial or purpuric rash that may be non-blanching and rapidly progressive, which may be suggestive of meningococcal disease when combined with the classic triad and focal neurologic symptoms such as cranial nerve palsies, ataxia, dilated/unequal and poorly reacting pupils (late sign). Chills, myalgia, photophobia, nausea, vomiting and seizures (late sign) may also be present.

Other Signs and Symptoms  

Some patients, such as alcoholics, immunocompromised patients and those who had meningitis after neurosurgery, may not present with the classic signs of meningitis.  

Elderly  

Some elderly may present with lethargy or obtundation, no fever, and variable signs of meningeal inflammation. They may also suffer antecedent or concurrent respiratory infections.

Perform a complete neurologic exam, including a mental status exam. 

Neck Stiffness  

Examine the neck for rigidity by gentle forward flexion with the patient in the supine position.  

Kernig Sign  

The position of the patient is supine with the hip flexed at 90°. This is positive when the extension of the knee from this position elicits resistance or pain in the lower back or posterior thigh.  

Brudzinski Sign  

The position of the patient is supine. This is positive when passive neck flexion results in spontaneous flexion of the knees and hips.  

Contralateral Reflex  

The position of the patient is supine. This is positive when passive flexion of one hip and knee causes flexion of the contralateral leg.  

Signs of Increased Intracranial Pressure (ICP)  

The signs of increased intracranial pressure are altered level of consciousness (eg Glasgow Coma Scale score ≤9, a progressive, sustained or rapid decline in consciousness, stupor or coma), seizures or decerebrate posturing, dilated, poorly reactive, or non-reactive pupils, ocular movement disorders (eg abducens nerve palsy), Cushing reflex (bradycardia, hypertension and irregular breathing), papilledema on fundoscopic exam and projectile vomiting.  

Perform neuroimaging (please see Head Computed Tomography [CT] scan) if present.