Which physical findings are characteristic of Haemophilus influenzae type b (Hib) meningitis?

Updated: Jul 09, 2018
  • Author: Prateek Lohia, MD, MHA; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Answer

Findings on general physical examination of children with Hib meningitis are helpful in arriving at the diagnosis, although they may be subtle or equivocal.

General findings

Temperature higher than 38.5°C is found in at least 94% of individuals with meningitis. The temperature tends to be higher in bacterial meningitis than in viral. Studies wherein most cases of childhood meningitis were due to Hib have shown that approximately 80% of children with meningitis have temperatures higher than 38.8°C on presentation, compared with 40% of children with viral meningitis. The fever may exert protective effects, reducing bacterial replication; hence, aggressive treatment of fever may be counterproductive.

The combination of fever with either change in behavior/mental status or new seizures compels consideration of meningitis in children, especially those younger than 1 year.

Occasionally, children with Hib meningitis are hypothermic. These patients tend to be severely ill at presentation, and the hypothermia portends a worse prognosis. In part, the poorer outcome may be due to enhanced bacterial replication at lower temperatures.

The combination of anorexia or vomiting with fever may cause an infant to appear dehydrated (ie, dry oral mucous membranes, diminishment of the usual glabrous appearance of the skin, altered skin texture to finger stroke). These findings are especially important indicators of meningitis in patients without associated diarrhea.

Skin color may be abnormal; the skin may appear pale, cyanotic, ashen, or pasty. These skin-color changes and associated dehydration are statistically significant indicators of meningitis in children younger than 2 years with fever and no clear alternative diagnosis.

In more severe cases, the infant or child may appear cachectic, with loss of skin turgor or capillary refill. Very ill children may have tachycardia and thready pulse in addition to high fever.

Changes in mental status have been shown to be important indicators of enhanced risk for serious infectious illnesses (ie, meningitis, sepsis, pneumonia, urinary tract infection) in children younger than 2 years. Most children with meningitis show changes in mental status, and at least 40% of patients exhibit other neurologic deficits at or shortly after presentation. Special care must be taken to exclude meningitis in such cases because it is has the greatest potential to produce devastating consequences if it is not recognized and treated swiftly.

An altered level of consciousness ranging from drowsiness to stupor or coma is common. This can have an effect on cry. In young children, consciousness may be assessed with reference to their reaction to parent stimulation/smile/holding or their reaction to brightly colored interesting toys, presentation of their bottle, or an approach from the examiner. The eyes may appear glazed over. Marked changes in their reaction, to which parents can attest, are statistically significant indicators of serious infectious disease in children younger than 2 years.

Irritability is common in meningitis and is often associated with loss of interest in surroundings or various forms of visual or auditory stimulation. Photophobia may also be found.

The combination of abnormalities in cry, skin color, hydration, and mental status as measured by response to parental or social stimulation has 88% specificity and 77% sensitivity for the diagnosis of meningitis in small children. If a suggestive history and examination findings are also found, the sensitivity rises to 92%.


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