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Three Part Question

In [children], are [meningeal irritation signs, specifically Kernig's sign, Brudzinski's sign or neck stiffness], reliable signs in helping to [diagnose bacterial meningitis]?

Clinical Scenario

A 3-year-old girl is brought to the emergency department by her parents. She has vomited multiple times and has been feverish and lethargic over the last 24 h. On examination, she is feverish, she has a stiff neck and Kernig's sign is positive. You are concerned about the possibility of meningitis but do not want to put a child through an unnecessary lumbar puncture. You wonder how accurate the above signs of meningeal irritation are in detecting bacterial meningitis in children.

Search Strategy

Medline using the OVID interface 1966—present.
Embase search 1980-present

Medline:((mening$.mp) OR (exp Meningitis, Bacterial)) AND ((neck stiffness.mp) OR (Kernig$.mp) OR (brudzinski$.mp)) Limit to (English language and humans and “all child (0 to 18 years)”.

Embase:((bacterial AND mening$).ti,ab) AND ((neck AND stiffness) OR (nuchal AND rigidity) OR Kernig$ OR brudzinski$).ti,ab).

Limit to: Human and (Human Age Groups Child unspecified age) and English Language.

Search Outcome

One systematic review found. Overall, 118 papers identified (96 with the Medline and 22 with the EMBASE search strategy), of which nine were relevant.

Four relevant papers were already included in the above-mentioned systematic review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Levy et al, 1990, Canada	Chart review of 650 children who underwent lumbar puncture for presumed diagnosis of meningitis	Retrospective cohort study.	Incidence of neck stiffness in children with/without confirmed meningitis	Neck stiffness was present in 44% children with confirmed meningitis and 20% without meningitis (Sn 44%, Sp80%)	Retrospective study Inclusion/exclusion criteria not clearly defined Small patient numbers in subgroup analysis CSF proven bacterial meningitis not described
			Incidence of Brudzinskis sign in chidren with/without meningitis	Brudzinskis sign was present in 68% children with confirmed meningitis and 35% children without meningitis (Sn 68%, Sp 65%)
			Incidence of Kernigs sign in children with/without meningitis	Kernigs sign was present in 15% children with confirmed meningitis and 4% children without meningitis (Sn 15%, Sp 96%)
Rothrock et al, 1992, USA	258 children (0–24 months) hospitalised with bacterial meningitis over a 12-year period. Considered to have bacterial meningitis if: +CSF culture, gram stain, immune electrophoresis/antigen OR +blood culture with raised CSF WBCs	Retrospective cohort study	Incidence of neck stiffness in children with confirmed bacterial meningitis	Neck stiffness was present in 54-59% children with bacterial meningitis	Retrospective study. Absent documentation - only 20% children had Kernigs or Brudzinskis sign documented. Analysed cohort restricted to under 2s
			Incidence of positive Brudzinskis sign in children with confirmed bacterial meningitis	Brudzinskis sign was positive in 10-13% children with bacterial meningitis
			Incidence of positive Kernigs sign in children with confirmed meningitis	Kernigs sign was positive in 9-11% children with bacterial meningitis
Oostenbrink et al, 2001, Netherlands	326 consecutive ED patients (aged 1 month-15 years) with signs of meningeal irritation Bacterial meningitis defined as >5WCC in CSF and positive culture of CSF and/or blood.	Retrospective cohort study	Incidence of bacterial meningitis in children presenting with neck stiffness	Bacterial meningiis was present in 42%(CI: 35-49%) of children with neck stiffness	Retrospective study. Absent documentation - 40% cases Brudzinski's/Kernig's signs not documented. Subgroup analysis based on small patient numbers. LPs(gold standard) not performed on all children. Weak inclusion criteria (some atypical meningitis presentations missed). Frequency of meningeal irritation signs not assessed in children without meningitis.
			Incidence of bacterial meningitis	Bacterial meningitis was present in 30%(CI: 16-49%) of children with positive Kernigs sign
			Incidence of bacterial meningitis in children with positive Brudzinskis sign	Bacterial meningitis was present in 36%(CI: 22-52%) of children with positive Brudzinskis sign
Curtis et al, 2010, Canada	10 studies included CSF analysis as gold standard for diagnosing meningitis 18 symptom descriptors and 48 sign descriptors were extracted for meta-analysis	Systematic review	Sensitivity, specificity, likelihood ratios for: –Neck stiffness, –Kernig’s sign –Brudzinski’s sign	Neck stiffness: Sn51%, Sp89%, +LR 4.0 (95% CI 2.6 to 6.3), −LR 0.56 (95% CI 0.43 to 0.72) Kernig's sign: Sn53%, Sp85%, +LR 3.5 (95% CI 2.1 to 5.7), −LR 0.56 (95% CI 0.41 to 0.75) Brudzinski's sign: Sn66%, Sp74%, +LR 2.5 (95% CI 1.8 to 3.6), −LR 0.46 (95% CI 0.31 to 0.68)	Heterogeneous studies and patient groups br>Results not age defined Imprecise definitions of signs
Amarilyo et al, 2011, Israel	108 children aged 2 months to 16 years with clinically suspected meningitis Meningitis defined as >6WBC/mcl microliter of CSF	Prospective cohort study	Nuchal rigidity	Sensitivity 65% (95% CI 50% to 77%) PPV 0.8	Small sample size 28% of patients lacked documentation about presence or absence of eningeal signs
			Kernig's sign	Sensitivity, 27% (95% CI 15% to 41%) Specificity, 87% (95% CI 68% to 96%) PPV 0.77
			Brudzinski's sign	Sensitivity, 51% (95% CI 36% to 65%) Specificity 80% (95% CI, 63 to 92) PPV 0.81

Comment(s)

Bacterial meningitis can often cause a diagnostic challenge as signs and symptoms are various and non-specific, especially in children. As delay in diagnosis and treatment of meningitis worsens its prognosis, physicians have a low threshold to perform lumbar puncture and commence antibiotics, both of which are not without risk. The evidence of this short-cut review of the literature shows that signs of meningeal irritation have variable sensitivity and specificity and therefore cannot be used alone in diagnosing meningitis.

Clinical Bottom Line

Clinical signs of meningeal irritation such as neck stiffness, Kernig's sign and Brudzinski's sign are not reliable in diagnosing bacterial meningitis particularly in neonates and infants.

References

1. Levy M, Wong E, Fried D. Diseases that mimic meningitis: analysis of 650 lumbar punctures Clinical Paediatrics. 1990; 29(5): 254-261.
2. Rothrock SG, Green SM, Wren J, et al. Pediatric bacterial meningitis: Is prior antibiotic therapy associated with an altered clinical presentation? Ann Emerg Med 1992; 21(2): 146-152.
3. Oostenbrink R, Moons KG, Theunissen CCW et al. Signs of meningeal irritation at the emrgency department: How often bacterial meningitis? Pediatric Emerg Care 2001; 17(3): 161-164,
4. Curtis S, Stobart K, Vandermeer B, et al. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics 2010;126:952–60.
5. Amarilyo G, Alper A, Ben-Tov A, et al. Diagnostic Accuracy of Clinical Symptoms and Signs in Children With Meningitis. Pediatric Emerg Care 2011;27:196–9.