Adults and children mostly have only one of the classical 'triad' of meningitis symptoms, research shows

Prompt recognition of symptoms and treatment is vital for good outcomes in cases of meningitis. However, new research to be presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID 2023, Copenhagen, 15-18 April) shows both adults and children mostly have only one of the classical 'triad' of commonly related symptoms (fever, altered mental state and neck stiffness), and rarely have all three, with a substantial proportion (one in seven) having none.

The study, by Dr Nichlas Hovmand (Center for Research & Disruption of Infectious Diseases [CREDID], Copenhagen University Hospital, Denmark) and colleagues, was a retrospective observational study of pre-hospital and hospital data in patients with community-acquired bacterial meningitis (CABM) between January 2016 and December 2021 admitted to a hospital in the Capital Region of Denmark (population approx. 1.8 million). Reported symptoms were extracted from archived audio files of the initial phone call to the emergency medical services.

Of the 209 patients, 171 (82%) were adults and 38 (18%) were children. The most frequent symptoms were altered mental state (58% of total patients/ 61% of adults / 42% of children) and fever (57% of all patients / 50% adults / 92% children), while neck stiffness was less common (9% all patients / 6% adults / 18% children) (see Figure 1 of full abstract).

Children versus adults more often presented with fever (92% v 50%), fatigue (71% v 49%), rashes (16% v 1%), and neck stiffness (18% v 6%), while adults more often presented with altered mental state (61% v 42%), headache (36% v 21%), and leg pain (15% v 3%).

Most patients (85%) had at least one of the three symptoms in the classical triad of meningitis, but very few (3%) had all three (see below). A significant proportion (15% overall, 16% adults, 8% children) had none of these symptoms (see Figure 2 of full abstract).

The median time from initial contact to hospitalization was 1.2 hours (children 1.8 hours and adults 1.2 hours). Children were more likely to be asked to stay home (34% vs. 11%) and less likely to have an ambulance sent to them compared to adults (21% vs. 69%). A single child (3%) and 7 adults (4%) received antibiotics pre-admission (Figure 3). Dr Hovmand says: "Patients with bacterial meningitis presented to emergency medical services with a variety of symptoms that differed significantly in children and adults. The classical triad of symptoms was rare for both children and adults. Very few patients received antibiotics pre-admission. We suggest that questioning of additional relevant symptoms should be done in all cases of patients with fever or an altered mental state."

On few antibiotics being prescribed pre-hospital, he says: "This is a very complex subject, and low rates of antibiotics prescriptions pre-hospital is probably related to unspecific symptoms making early diagnosing very difficult. It is a critical issue to ensure early antibiotic treatment and this is unfortunately an ongoing common problem causing disease and mortality from meningitis even though effective treatment is available. Getting rid of treatment delay for this disease remains a topic of enormous importance if we aim to improve outcomes for the patients and it is something we are currently looking into in our study group."

On questioning of symptoms, he adds: "Which symptoms are relevant will vary from case to case as sometimes a few symptoms could be enough to confirm the suspicion of meningitis and thus, further questioning would not change the strategy from there on. If for instance all three symptoms of the triad is present, it is unlikely any other symptoms would eliminate the suspicion of meningitis. In cases of doubt, further questioning could help to differentiate between meningitis and other suspected diagnoses, which would most often be other infections or stroke. Thus, knowledge about which symptoms that patients with meningitis present with is an important tool to help find the patients as early as possible, but it is difficult because the symptoms often are unspecific in the early stages of the disease.

"We suggest that all patients with fever and/or an altered mentally state should be asked for specifically related symptoms such as neck stiffness, leg pain, headache and rashes. However, it is very important to keep in mind that most patients with bacterial meningitis will not present with all the specific symptoms – especially in the early stages of the disease. The potential symptoms are many, and as well as those already mentioned can include tremors and/or seizures, back pain, diarrhea, cold-like symptoms, shortness of breath and vomiting."