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Adult Meningitis: Rose Hatala, MD, MSc, discusses the clinical examination for adult meningitis.
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Adult Meningitis: Rose Hatala, MD, MSc, discusses the clinical examination for adult meningitis.
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Upload Date:
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News & Perspectives section. Today, I have the pleasure of speaking with Dr. Rose Hatala about adult meningitis, an infection that has a high case fatality rate despite the availability of antimicrobial therapy. Dr. Hatala, why don't you introduce yourself to our listeners? >> Hello. I'm Rose Hatala. I'm a general internist, clinical associate professor with the Division of General Internal Medicine at the University of British Columbia in Canada. >> Dr. Hatala, what do we know about the prevalence of meningitis in adults and are there important demographic characteristics?
>> We know from published data in North America and Europe that the prevalence of bacterial meningitis ranges between three to seven cases per 100,000 patients per year. There are some important demographic characteristics -- patients who are more likely to develop meningitis -- and these include recent upper respiratory tract or ear infections, recent exposure to someone who has meningitis, recent head trauma, injection drug use or alcohol abuse, or recent travel to areas that are endemic to meningococcal disease such as Sub-Saharan Africa.
>> What are the most common symptoms associated with meningitis, and why are these symptoms not particularly useful? >> Some of the common symptoms associated with meningitis include headache, fever, altered mental status, nausea and vomiting, photophobia, or stiff neck. I think it's important, though, to talk about why these findings aren't particularly useful in either ruling in or ruling out the diagnosis of meningitis. First off, meningitis is a serious disease, as mentioned in the introduction, with serious consequences.
And so our role in the clinical examination is likely to be ruling out meningitis in patients for whom we have a low probability that that is the disorder. Anybody for whom we have much of a clinical suspicion, we'll actually go on to lumbar puncture. So in this setting, we're looking for a very powerful negative likelihood ratio, or high sensitivity, in order to rule out the disorder of meningitis. And none of those clinical symptoms that I mentioned have sufficiently high sensitivity or negative likelihood ratios that they are helpful in ruling the disorder.
There are also some problems with the original studies. Most of the literature is retrospective and so, in that setting, specificity or a controlled population is not available. In addition, physical examination findings may have been done with knowledge of the lumbar puncture results and so, again, the accuracy of those findings is somewhat in question. Even in the single large prospective study, it was up to the clinicians to perform their own clinical examination. The clinical examination was not standardized and so, again, we're not entirely sure how frequently each of the items of history were assessed for.
All of this leads to the fact that, then when we look objectively at how useful are the clinical symptoms in helping to rule out meningitis, none of these symptoms are powerful in and of themselves as a single item that they would effectively rule out meningitis. It may turn out down the road with future studies that combinations of symptoms together may be more helpful, but at this point in time we shouldn't rely on single symptoms to rule out the disease. >> Are there physical examination findings that are useful when detecting meningitis in adults?
>> Similar to our discussion about clinical symptoms, there isn't any single physical examination finding that is sufficiently accurate that it would be helpful in ruling out the disease of meningitis. There is a small prospective study with 54 patients in which a test called "jolt accentuation" did look promising, and this test is to actually ask the patient who presents with fever and headache to quickly shake their head horizontally with a frequency of about two or three shakes per second. And if they report that their headache actually worsens with that maneuver, that's considered a positive test.
And so, in a single prospective study, this jolt accentuation test did look like it may be promising for helping to rule out the disorder of meningitis. But further larger studies would be necessary to confirm this finding. And so at this point in time, similar to the presenting symptoms of the patients, there's no single item of physical examination that's sufficiently accurate to help us rule out meningitis. >> What is the reference standard test for meningitis? >> The reference standard test would be microbiologic culture. In many of the studies included -- in particular, those two prospective studies -- included in the update, it was a white blood cell count of greater than five or six cells per millimeter cubed on the CSF fluid.
>> Is there anything else that JAMAevidence users should know about meningitis? >> Well, I think the take home message for JAMAevidence users is really any patient in whom you have a clinical suspicion of meningitis would require a lumbar puncture because there is no single item of clinical history or physical examination that's sufficiently accurate to rule out the disorder. The second issue, which we haven't raised yet, is actually the safety of proceeding to lumbar puncture without CT scan in selected patients. Specifically, if the patient in question is under 60, immuno-competent, has no evidence of central neurologic disease or a recent seizure, and on physical examination has no neurologic abnormalities then, in fact, the likelihood that they have an abnormality on their CT scan is low.
And so in these selected patients presenting with a suspicion of meningitis, it's possible in certain clinical situations to proceed to lumbar puncture without CT head scan. >> Thank you, Dr. Hatala, for this overview of adult meningitis. For more information about this topic, JAMAevidence subscribers can consult Dr. Hatala's updated online chapter on Acute Adult Meningitis in the Rational Clinical Examination. This has been Joan Stephenson of JAMA interviewing Dr. Rose Hatala about adult meningitis for JAMAevidence.
