What are the meningeal signs of Haemophilus influenzae type b (Hib) infection?

Updated: Jul 09, 2018
  • Author: Prateek Lohia, MD, MHA; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Meningeal signs that may be found in children include nuchal rigidity to passive flexion and the signs of Kernig or Brudzinski. Sometimes the presence of these signs may be difficult to judge in irritable infants. Although resistance to passive neck flexion is found in most cases of childhood meningitis at presentation, Kernig and Brudzinski signs are found in approximately half.

In order to test for Kernig sign, the hip of a recumbent patient is passively flexed to 90 degrees, permitting the knee to be fully flexed. The attempt is then made to passively extend the knee joint. If significant pain or involuntary resistance to the knee extension is encountered, the Kernig sign is present.

Three Brudzinski signs exist: the nape of the neck sign, the identical contralateral hip sign, and the reciprocal contralateral hip sign. All are elicited in the recumbent patient.

The nape of the neck sign is elicited by passive neck flexion, and a positive result is indicated if the hips and knees flex in response. The identical contralateral hip sign is elicited by passive flexion of the hip and knee on one side, and a positive result is indicated if the other leg responds by assuming flexion of the hip and knee. The reciprocal contralateral sign is found if a patient who has manifested an identical contralateral hip sign immediately follows it by a small kick due to sudden partial extension at the knee.

Meningeal signs are found in 77-98% of children older than 12 months presenting with meningitis, in as many as 98% of those aged 12-18 months, and in nearly all of those older than 18 months when properly examined by an experienced individual. Kernig and Brudzinski signs may be difficult to judge in irritable infants.

Meningismus may be universal in fulminant cases or once a child has entered a moderate-to-severe stage of illness. The absence of meningismus does not exclude the diagnosis of meningitis, however, especially in children younger than 8 months. Absence of meningismus at the onset of meningitis is reported in rare instances in children who are older than 2 years. In all such cases of bacterial meningitis, other indicators are present, such as fever, mental status changes, seizures, or elevation of the circulating white blood cell count to greater than 10,000/µL.

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