Because the presenting symptoms are subtle and overlap with those of less serious infection, a high index of suspicion for meningitis is crucial. Two modes of presentation are seen. The most frequently encountered pattern is an insidious progression of a febrile illness over several days. Less commonly, a fulminant progression to septic shock and meningitis may occur over hours, most commonly caused by N. meningitidis.
Symptoms and signs of bacterial meningitis depend on patient age and duration of illness. No single complaint or physical finding is specific. However, the findings of fever associated with altered mental status constitutes a reasonable basis for suspicion for meningitis. Infants typically present with nonspecific symptoms including decreased responsiveness, poor feeding, and vomiting. Although common, fever is not universally present at the time of diagnosis. Signs of "paradoxical irritability" despite parental comforting attempts; decreased responsiveness to visual, verbal, and painful stimuli; hypotonia; bulging fontanelle; or respiratory distress may be seen. Older children will usually complain of headache, photophobia, nausea, and vomiting. As for infants, signs of lethargy and confusion are primary indicators for suspicion of meningitis, and fever may not be consistently present. Nuchal rigidity and the classic findings of the Kernig sign (neck pain elicited with passive knee extension) and Brudzinski sign (involuntary lower extremity flexion elicited with passive neck flexion) are helpful only if positive. Seizures occur early in the course of 25 percent of patients with bacterial meningitis and are typically initially generalized but may be focal. 38 Focal neurologic findings, focal or prolonged seizures, and presentation with obtundation or coma suggest an adverse outcome. Pretreatment with oral antibiotics is associated with an altered presentation characterized by less consistent findings of fever or altered level of consciousness and longer duration of symptoms before diagnosis. 36
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