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.