Bacterial Meningitis: Signs/Symptoms in Newborns & Younger Children

00:02 So, let's look at the clinical features of bacterial meningitis.

00:08 Newborns are a challenge for physicians because they do not have the classic findings that are talked about in meningitis.

00:18 For example, newborns don't have generally a stiff neck.

00:25 They may have fever, but they may have no fever or they may have a low temperature, so they have temperature instability.

00:37 Newborns with meningitis are generally listless.

00:41 They are not responsive to their surrounding.

00:45 They may have an unusual kind of high-pitched cry, which suggests a process going on in the brain.

00:53 They, as expected, would be fretful, they’re lethargic, they may not feed well, they may not feed at all, and the mothers may notice that they have a very weak suck.

01:07 So, they're generally irritable.

01:09 And, of course, all newborns are jaundiced, but newborns with meningitis may have unusually severe jaundice.

01:18 They may vomit, they may have diarrhea and respiratory distress.

01:23 So, a pediatrician evaluating a newborn has to worry about meningitis in a baby with these kind of findings, any of them.

01:32 And there's an indication to do a spinal tap and examine the cerebrospinal fluid if there's any suggestion of meningitis.

01:46 Children from age one to four are a little easier to evaluate.

01:52 More than 90% of them are going to have fever.

01:55 Eighty-plus percent will be vomiting.

01:59 And stiff neck starts to present itself after about the year of one.

02:07 So, those are the main findings in children one to four.

02:13 Older children and adults are easier to diagnose.

02:17 Virtually 100% will have fever.

02:21 Most of them have headache.

02:24 Almost all of them will have meningismus, which is the syndrome of having a stiff neck.

02:31 And this is an important point.

02:35 Patients with viral meningitis, they may complain of headache, they may have fever, they may even have a stiff neck, but they're not out of it.

02:45 Most patients with bacterial meningitis on the other hand have cerebral dysfunction.

02:50 When they are brought to a physician, and they are usually brought to the physician, they have confusion, their head doesn't work.

03:02 And the classic findings are the findings of Kernig’s and Brudzinski sign.

03:07 Now, Kernig's sign, it's often hard to remember.

03:12 It was for me when I was a student.

03:15 But the way I remember it now is K for kerning, K for doing something with the knee.

03:24 So, the patient is supine and you take the patient's leg and flex the leg like that and then extend the knee.

03:34 Now, in a patient who’s awake, extending the knee puts traction on the meninges and that causes pain going up and down the spine.

03:45 That would be a positive Kernig's sign.

03:48 Now, in a comatose patient, they can't tell you whether they have pain, but doing this maneuver and feeling resistance when you try to extend the knee is a positive Kernig's sign in a comatose patient.

04:04 Brudzinski's sign is where you have the patient lying supine and you flex the patient's neck.

04:15 And if the patient's hips involuntarily flex, they have a positive Brudzinski sign.

04:25 Cranial nerve palsies are not as frequent.

04:29 They occur in a minority of patients with bacterial meningitis, but they are an ominous sign because it usually means that there is involvement of the brainstem.

04:45 In every patient with meningitis, they need to be searched carefully, their extremities, legs, arms for a petechial rash because a petechial rash occurs primarily in meningococcal meningitis, the meningitis due to Neisseria meningitidis.

05:04 But it can occur also in other forms of meningitis, particularly pneumococcal meningitis in the presence of a splenectomy.

05:16 Seizures are, obviously, a bad sign and indicate that the meningitis is pretty far advanced as is hemiparesis.