Context Early clinical recognition of meningitis is imperative to allow clinicians
to efficiently complete further tests and initiate appropriate therapy.
Objective To review the accuracy and precision of the clinical examination in
the diagnosis of adult meningitis.
Data Sources A comprehensive review of English- and French-language literature was
conducted by searching MEDLINE for 1966 to July 1997, using a structured search
strategy. Additional references were identified by reviewing reference lists
of pertinent articles.
Study Selection The search yielded 139 potentially relevant studies, which were reviewed
by the first author. Studies were included if they described the clinical
examination in the diagnosis of objectively confirmed bacterial or viral meningitis.
Studies were excluded if they enrolled predominantly children or immunocompromised
adults or focused only on metastatic meningitis or meningitis of a single
microbial origin. A total of 10 studies met the criteria and were included
in the analysis.
Data Extraction Validity of the studies was assessed by a critical appraisal of several
components of the study design. These components included an assessment of
the reference standard used to diagnose meningitis (lumbar puncture or autopsy),
the completeness of patient ascertainment, and whether the clinical examination
was described in sufficient detail to be reproducible.
Data Synthesis Individual items of the clinical history have low accuracy for the diagnosis
of meningitis in adults (pooled sensitivity for headache, 50% [95% confidence
interval {CI}, 32%-68%]; for nausea/vomiting, 30% [95% CI, 22%-38%]). On physical
examination, the absence of fever, neck stiffness, and altered mental status
effectively eliminates meningitis (sensitivity, 99%-100% for the presence
of 1 of these findings). Of the classic signs of meningeal irritation, only
1 study has assessed Kernig sign; no studies subsequent to the original report
have evaluated Brudzinski sign. Among patients with fever and headache, jolt
accentuation of headache is a useful adjunctive maneuver, with a sensitivity
of 100%, specificity of 54%, positive likelihood ratio of 2.2, and negative
likelihood ratio of 0 for the diagnosis of meningitis.
Conclusions Among adults with a clinical presentation that is low risk for meningitis,
the clinical examination aids in excluding the diagnosis. However, given the
seriousness of this infection, clinicians frequently need to proceed directly
to lumbar puncture in high-risk patients. Many of the signs and symptoms of
meningitis have been inadequately studied, and further prospective research
is needed.