I read with interest the comments by Rogers1 in the Archives. It has been my experience as well that the smiling child does not usually have a serious infectious illness. However, there are instances in which meningitis could be present in a smiling child.
Patient Report. An 11-month-old male infant was seen at the office with a 12-hour history of low-grade fever, irritability, and intermittent crying. On physical examination he was alert, playful, and smiling. The pharynx was inflamed. The left tympanic membrane was inflamed and bulging. The anterior fontanelle was flat. There were no other physical findings. Five hours later he was brought back to the office with increasing lethargy, a bulging fontanelle, and a temperature of 39.9°C. The cerebrospinal fluid (CSF) was cloudy with a leukocyte count of 8.2× 109/L. The CSF glucose level was 2.5 mmol/L (45 mg/dL), protein level was 1.6 g/L, and
Baptist EC. Meningitis in the Child With a Smile. Arch Pediatr Adolesc Med. 1995;149(10):1179. doi:10.1001/archpedi.1995.02170230133029