Meningitis - RCE Synopsis


Question: Does this Adult Patient Have Meningitis

Original Citation: Attia J, Hatala R, Cook DJ, Wong JG. Does This Adult Patient Have Acute Meningitis? JAMA. 1999 Jul 14;282(2):175-81.

Bottom Line: The following recommendations are based only on adult patients who are not immunocompromised.

· The absence of all 3 of the classic triad of fever, stiff neck, and altered mental status

can virtually eliminate the diagnosis of acute meningitis (sensitivity of 99-100%)

· Fever is the most sensitive (85%) of the classic triad, occurring in the majority of patients

· A normal mental status helps to exclude meningitis in low risk patients

· Kernig and Brudzinski signs have low sensitivity but high specificity

· In one study of 34 patients the absence of jolt accentuation of headache in a patient

who presents with fever and headache essentially excludes meningitis (sensitivity 97%)

SORT Grade of Recommendation: B, Based on 1 high-quality diagnostic cohort study and 9 lower quality but stringently selected retrospective chart reviews.

Updated Search Findings: An updated search no new relevant

Comments/Hints/Suggestions: There should be a stronger suspicion of meningitis in patients with DM, otitis media, PNA, sinusitis, and alcohol abuse as these conditions are pre-disposing factors.

Prevalence: The annual incidence of bacterial meningitis in the US is approximately 3/100,000 (0.003%) and the incidence of viral meningitis is 10.9/100,000 person-years.

Accuracy of Exam

Symptoms reported in History

Positive LR

Negative LR

Sensitivity (# of pts)

Specificity (calculated from 1 prospective study)

Headache

Unable to calculate

Unable to Calculate

50% (303)

Unable to Calculate

Nausea/Vomiting

Unable to calculate

Unable to calculate

30% (136)

Unable to calculate

Neck Pain

Unable to calculate

Unable to calculate

28% (NA)

Unable to calculate

Signs on Physical Exam

Fever

1.54

Unable to calculate

85% (733)

45%

Stiff neck

Infinite

Unable to calculate

70% (733)

100%

Altered Mental Status

Unable to calculate

Unable to calculate

67% (811)

Unable to calculate

Classic Triad

Unable to calculate

Unable to calculate

46% (426)

Unable to calculate

2 symptoms

Unable to calculate

Unable to calculate

95%

Unable to calculate

1 symptom

Unable to calculate

Unable to calculate

99-100%

Unable to calculate

Focal Neuro Findings

Unable to calculate

Unable to calculate

23% (794)

Unable to calculate

Rash

Unable to calculate

Unable to calculate

22% (446)

Unable to calculate

Kernig’s Sign

Infinite

Unable to calculate

9%

100%

Jolt Accentuation

2.4

Unable to calculate

97%

60%

Description of how symptoms elicited or defined:

Neck Stiffness- assessed by gentle forward flexion of the neck with the pt in a supine position to determine rigidity

Kernig’s Sign- assessed with the pt lying supine with the hip flexed at 90 degrees. A positive sign occurs when extension of the knee results in resistance to extension or pain in the hamstring

Brudzinski’s Sign- assessed with the pt lying supine and passively flexing the neck. A positive sign occurs when the knees and hips also flex in response.

Jolt Accentuation of Headache- assessed by asking the pt to turn their head horizontally at a frequency of 2-3 rotations/second. A positive sign is worsening of the baseline headache.

www.nlm.nih.gov/medlineplus/ency/article/000680.htm provides diagrams of both Kernig

and Brudzinski signs as well as providing a patient friendly handout with relevant information

Precision: Kappa statistics were not given in this article and there were no comments made on the precision of the history or physical exam maneuvers. There was no statement given as to the uniformity of the exams between the studies. There was also no description of how each examiner performed their exam.

Studies description

Inclusion criteria: Original English and French language studies describing the precision and accuracy of the adult physical exam in which the majority of the patients had objectively confirmed bacterial or viral meningitis. Studies were excluded if they enrolled children, immunocompromised adults, mixed patient populations from which adult data could not be extracted, focused on metastatic meningitis, or meningitis caused by a single microbial origin such as Listeria or TB. Tuberculous meningitis was excluded due to the fact that this infection is more common in HIV infection and children. However 2 studies did report data that included tuberculous meningitis, as there was insufficient data to extract those with that particular infection.

Search Date: A MEDLINE search from 1966-1997 yielded 139 abstracts. 10 studies met the inclusion criteria, 9 of which were retrospective chart reviews and 1 prospective cohort study.

Number Found and Reviewed: As above, the search yielded 139 abstracts; 10 of which met the inclusion criteria.

Quality: 9 of the included studies were Level 2 studies as they were retrospective chart reviews. The 1 prospective cohort study fell somewhere between a Level 1 and Level 2 due to the fact that the study only enrolled 34 patients who had standardized physical exams performed prior to LP. There was however, no description of this standardized physical exam.

Limitations: This study is severely limited by the fact that there are no control groups. Due to the fact that the clinical presentation was assessed in 845 patients who all had confirmed meningitis it is impossible to perform appropriate statistical analysis. Without a control population, only sensitivities can be calculated, and the reported sensitivities might be an over-representation as the physical exam documented in the chart may have been performed with knowledge of the LP results.

In the one prospective study, some specificity values were able to be calculated, but these numbers need to be interpreted cautiously due to the small number of patients studied. Also, the prospective study excluded patients presenting with mental status abnormalities and only enrolled those with fever and headache, so they may have excluded patients with the highest likelihood of meningitis. Each patient received a “standardized clinical exam” but there is no description of what this exam entails.

Gold Standards: Meningitis confirmed by LP or autopsy

Updated SearchDate: 6/13/2007

An updated search performed on http://www.sgim.org/clinexam.cfm specifically focusing on 1997-2007 yielded no new relevant articles regarding the importance of the history and physical exam in diagnosing acute meningitis.

Reviewed by: Katherine Tabori, MD, M. Lee Chambliss MD Date: June 2007


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