Pediatric Aseptic Meningitis Clinical Presentation

Updated: Mar 15, 2019
  • Author: Daniel Owens, BM, MRCPCH(UK); Chief Editor: Russell W Steele, MD  more...
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Presentation

History

Headache, neck stiffness, and photophobia are classic symptoms of aseptic meningitis in older children. These symptoms may be absent in younger children, who more commonly present with rash, diarrhea, and cough. Fever may be present. Seizures are more common in aseptic meningitis caused by specific viruses (eg, arboviruses). Other nonspecific symptoms may include arthralgia, myalgia, sore throat, weakness, and lethargy and hypotonia.

Recent travel and potential exposure to ticks or other biting insects are important aspects of the patient’s history. The history varies according to the etiologic agent.

In areas with widespread vaccination of children, enteroviruses are the most common causes of viral meningitis. Onset is usually acute but can be insidious over the week before presentation or can follow an acute febrile illness. Rash, when present, is erythematous, maculopapular, and vesicular, appearing on the soles of the feet, palms, or mucous membranes. Fever may last up to 5 days. Anorexia, nausea, respiratory symptoms and vomiting are common. Sore throat may occur. Rare symptoms include flaccid paralysis, pericarditis, myocarditis, and conjunctivitis.

In areas with low vaccination rates, mumps virus is often the most frequent cause of meningitis. Aseptic meningitis caused by mumps virus occurs 7-10 days after parotitis. Mumps virus, adenovirus, and varicella-zoster virus (VZV) infections tend to be more severe than enterovirus (EV) infections, and often evidence of encephalitis is present. Arbovirus infections frequently are associated with encephalitis and seizures.

In older teenagers and adults, aseptic meningitis may be associated with reactivation of herpes simplex virus (HSV)-2 infections. Reactivation of VZV infections is rare in immunocompetent children.

Aseptic meningitis associated with Mycoplasma pneumonia e infection usually occurs 3-21 days after the respiratory infection. Fungal meningitis occurs in immunocompromised patients and has a variable presentation. Lyme meningitis is characterized by a facial nerve palsy or symptoms headache and neck stiffness often being the sole symptom. [33]

Aseptic meningitis may be caused by drugs, usually nonsteroidal anti-inflammatory drugs (NSAIDs), [41]  chemotherapy agents, [42]  intravenous immunoglobulin (IVIg), [16] antiepileptics [43] or antibiotics. One review found 41 cases of Trimethoprim-sulfamethoxazole induced aseptic meningitis. Symptoms were similar those of viral meningitis. There was a female predominance and an association with autoimmune disease. Symptoms resolved when the drug was withdrawn however patients reacted to Trimethoprim and Sulfamethoxazole when given as single agents. [44]

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Physical Examination

Physical examination findings vary widely, depending on the patient’s age and the organism or condition responsible for the meningitis. The younger the child, the less specific the signs: In a young infant, findings that definitely point to meningitis are rare, but as the child grows older, the physical examination becomes more reliable. Because clinical signs are unreliable, particularly in the younger patient, they should not be the only factors considered when deciding on investigations and lumbar puncture. [45, 20]

The infant may be febrile or hypothermic. Lymphadenopathy may be present. Bulging of the fontanel, diastasis of the sutures, and nuchal rigidity point to meningitis but are usually late findings. Examination should specifically exclude a nonblanching petechial rash, other signs of bacterial meningitis, and features suggestive of a noninfectious etiology.

Neurologic examination includes evaluating for signs of meningism (eg, headache, photophobia, neck stiffness, and positive Kernig or Brudzinski sign) and focal or generalized neurologic signs. Focal neurologic signs may be present in as many as 15% of patients and are associated with a worse prognosis.

A definitive diagnosis of meningitis requires examination of CSF via lumbar puncture. Lumbar puncture should not be carried out in the presence of any contraindications (listed below). The presence or absence of classic meningeal signs and symptoms should not be used as the sole criterion for referring patients for further diagnostic testing. [45, 46]

Contraindications to lumbar puncture, per the National Institute for Health and Care Excellence (UK), are as follows [47] :

  • Signs suggesting raised intracranial pressure:

    • reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 or more)

    • relative bradycardia and hypertension

    • focal neurological signs

    • abnormal posture or posturing unequal,

    • dilated or poorly responsive pupils

    • papilloedema

    • abnormal 'doll's eye' movements

  • shock

  • extensive or spreading purpura

  • after convulsions until stabilized

  • coagulation abnormalities:

    • coagulation results (if obtained) outside the normal range

    • platelet count below 100 x 109 /litre

    • receiving anticoagulant therapy

  • local superficial infection at the lumbar puncture site

  • respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency).

Perform delayed lumbar puncture in children with suspected meningitis when contraindications are no longer present.

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Complications

Serious complications are uncommon but can include unilateral deafness after mumps meningitis, chronic enteroviral meningitis (especially in patients with agammaglobulinemia), and hydrocephalus after lymphocytic choriomeningitis virus infection. Rhombencephalitis has been reported as a complication of EV 71 infection. [40]  A case of fatal leukoencephalitis has been reported due to echovirus 18 infection. [48]  HSV and arbovirus infections, as well as viral infections in AIDS patients, can result in severe neurologic disease.

Seizure disorders, behavioral problems, and speech delay (unrelated to hearing loss) have been reported. In a Korean study, 0.7% of children had neurologic problems such as seizures, amnesia, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), and hydrocephalus, though none were permanent. [38]

Recurrence is possible (known as Mollaret, or benign recurrent meningitis). There is one case report with a familial association. [49]

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