Diagnostic Considerations

Rashes are much more commonly associated with such differential considerations as Neisseria meningitidis meningitis, Rocky Mountain spotted fever, subacute bacterial endocarditis, and viral (eg, echovirus 9) meningoencephalitis than with Haemophilus influenzae type b (Hib) meningitis. In these diseases, the rash is typically erythematous and macular or maculopapular at onset and may quickly progress to petechia and purpura. Note that rashes of this sort are occasionally observed in Hib encephalitis.

Hemiconvulsive seizures at presentation with low-grade fever may necessitate the exclusion of Hashimoto encephalopathy. Focal or hemiconvulsive seizures in children may suggest such alternative diagnoses as herpes I, LaCrosse, Japanese B, or other forms of encephalitis, depending on time of year, region of the world, and historical exposures.

Most children younger than 18 months who present with a history of fever and seizures but who have normal findings on examination (including reliable exclusion of meningismus) do not have meningitis. One study showed that the risk for meningitis in such infants is approximately 1.2%. Of the 4 children in that study who did have meningitis, 3 had viral and 1 had Hib meningitis. Children older than 18 months who present with a history of fever and a seizure but who have normal examination findings are even less likely to have meningitis.

Seasonal variation in incidence of Hib meningitis

Time of year is an important factor in differentiating Haemophilus influenzae type b (Hib) meningitis from cases due to the other 2 major causes of human meningitis, N meningitidis and Streptococcus pneumoniae. Hib meningitis has a bimodal distribution, with the first peak in June and the second in September to October. In contrast, the incidence of meningococcal and pneumococcal meningitis is greatest in the winter months.

The increased Hib prevalence in summertime corresponds somewhat, but not exactly, to the period of highest prevalence of arboviral encephalitis, aseptic meningitis, enteric encephalitides such as poliomyelitis or coxsackie encephalitis, and tick-borne encephalitides such as Lyme disease or Rocky Mountain spotted fever. Many of these differential considerations have their highest prevalence in July to August.

Differential Diagnoses

Acute Disseminated Encephalomyelitis
Aseptic Meningitis
Cerebral Venous Thrombosis
HIV-1 Associated CNS Conditions: Meningitis
Meningococcal Meningitis
Neurological Sequelae of Infectious Endocarditis
Status Epilepticus
Tuberculous Meningitis
Viral Encephalitis
Viral Meningitis

Workup

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Author

Prateek Lohia, MD, MHA Assistant Professor, Division of General Internal Medicine, Wayne State University School of Medicine

Prateek Lohia, MD, MHA is a member of the following medical societies: American College of Physicians, Society of General Internal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Cavaliere, MD Assistant Professor of Neurology, Neurosurgery and Medicine, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University in St Louis School of Medicine; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM Adjunct Associate Professor of Neurology, University of Missouri-Columbia School of Medicine; Medical Director of St Mary's Stroke Program, SSM Neurosciences Institute, SSM Health

Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society

Disclosure: Nothing to disclose.

Additional Contributors

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert Stanley Rust, Jr, MD, MA Former Thomas E Worrell Jr Professor of Epileptology and Neurology, Co-Director of FE Dreifuss Child Neurology and Epilepsy Clinics, Director, Child Neurology, University of Virginia School of Medicine; Chair-Elect, Child Neurology Section, American Academy of Neurology

Robert Stanley Rust, Jr, MD, MA is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, American Neurological Association, Child Neurology Society, International Child Neurology Association, Society for Pediatric Research

Disclosure: Nothing to disclose.

Subramanian Swaminathan, DNB, MD Fellow, Department of Infectious Diseases, Detroit Medical Center, Wayne State University School of Medicine

Subramanian Swaminathan, DNB, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, International AIDS Society, HIV Medicine Association

Disclosure: Nothing to disclose.

Haemophilus Meningitis Differential Diagnoses

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