TABLE 94.4 SIGNS AND SYMPTOMS OF MENINGITIS Signs Age Symptoms Early Late 0–3 mo Paradoxical irritability Lethargy Bulging fontanelle Altered sleep pattern Irritability Shock Vomiting Lethargy Fever Hypothermia (2 yrs Shock Headache Fever Coma Neck pain Nuchal rigidity Shock Lethargy Irritability The physical examination in the young infant rarely provides specific corroboration, even when the history suggests meningitis Fever may be absent in these children, despite the presence of bacterial infection Any child younger than months who is brought to the ED with a documented temperature of ≥100.4°F (38˚C) should be considered at risk for meningitis The physical signs are sufficiently elusive that many experts caution that one should not rely exclusively on the examination to rule out meningeal infection It is estimated that bacterial meningitis occurs in 1% to 2% of febrile young infants (Chapter 31 Fever ) After months of age, increasing, but not absolute, reliance can be placed on the physical findings; fever is typically noted Specific evidence of meningeal irritation is often present, including nuchal rigidity and, less often, Kernig (pain with extension of the leg on a flexed femur) and Brudzinski (involuntary lifting of the legs when the head is raised while the child is lying supine) signs When an LP fails to confirm the diagnosis of meningitis, despite the presence of meningeal signs, other conditions must be pursued that can mimic the findings on physical examination Conditions capable of producing the findings typical of meningismus (irritation of the meninges without pleocytosis in the CSF) include severe pharyngitis, retropharyngeal abscess (RTA), cervical adenitis, arthritis or osteomyelitis of the cervical spine, upper lobe pneumonia, subarachnoid hemorrhage, pyelonephritis, and tetanus Seizures are a presenting complaint for 20% of children with bacterial meningitis Many of these are focal, recurrent, or prolonged seizures Most clinicians advise that children younger than months with a first-time febrile seizure should routinely have LP performed to discern the presence of CNS infection, unless there are specific contraindications or an alternative diagnosis is readily apparent Febrile seizures are reviewed in Chapter 72 Seizures