History and exam
Key diagnostic factors
common
headache
Present in 87% of adults with bacterial meningitis.[43]
neck stiffness
A stiff neck with resistance to passive neck flexion (nuchal rigidity) is a classic sign of meningitis.
Present in 30% of children and 83% of adults with bacterial meningitis.[43][59][63]
Absence of a stiff neck does not rule out meningitis.[62]
The classic triad of fever, neck stiffness, and altered mental status occurs in only 41% to 51% of patients. However, in one study, 95% had at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status.[43]
fever
altered mental status
Present in 69% of adults with bacterial meningitis.[43]
In older patients, this may be the only presenting sign of meningitis.[1]
The classic triad of fever, neck stiffness, and altered mental status occurs in only 41% to 51% of patients. However, in one study, 95% had at least two of the four symptoms of headache, fever, neck stiffness, and altered mental status.[43]
confusion
photophobia
Well-recognized symptom of bacterial meningitis.
vomiting
Well-recognized symptom of bacterial meningitis.
seizures
Can occur in children and adults.
Children have seizures more frequently when infected with Streptococcus pneumoniae and Haemophilus influenzae type b than with meningococcal disease.[1]
hypothermia (infants)
In infants the signs and symptoms can be nonspecific and may include hypothermia.[1]
irritability (infants)
In infants the signs and symptoms can be nonspecific and may include irritability.[1]
lethargy (infants)
In infants the signs and symptoms can be nonspecific and may include lethargy.[1]
poor feeding (infants)
In infants the signs and symptoms can be nonspecific and may include poor feeding.[1]
apnea (infants)
In infants the signs and symptoms can be nonspecific and may include apnea.[1]
uncommon
focal neurologic deficit
Focal neurologic deficits, including aphasia, hemiparesis, or cranial nerve palsies, may be present.[60]
May also include dilated nonreactive pupil, abnormalities of ocular motility, abnormal visual fields, gaze palsy, arm or leg drift.
Suggests increased intracranial pressure.
abnormal eye movement
Suggests cranial nerve palsy (III, IV, VI) and increased intracranial pressure.
facial palsy
Cranial nerve VII may be involved and damaged due to increased intracranial pressure and inflammation. This damage may lead to facial palsy.
balance problems/hearing impairment
Cranial nerve VIII may be involved and damaged due to increased intracranial pressure and inflammation. This damage may lead to balance problems and hearing impairment.
bulging fontanel in infants
Indicates raised intracranial pressure.
Other diagnostic factors
common
high-pitched cry (infants)
In infants the signs and symptoms can be nonspecific and may include high-pitched cry.[1]
uncommon
rash
papilledema
On visual field exam, an enlarged blind spot may be elicited.
Indicates raised intracranial pressure.
Kernig sign
With the patient supine and the thigh flexed to a 90° right angle, attempts to straighten or extend the leg are met with resistance.
Present in 53% of children and 11% of adults with bacterial meningitis.[59]
Brudzinski sign
Flexion of the neck causes involuntary flexion of knees and hips.
Alternative sign is passive flexion of the leg on one side causing contralateral flexion of the opposite leg.
Present in 66% of children and 9% of adults with bacterial meningitis.[59]
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