In the current swine flu pandemic there is a risk that the diagnosis of meningitis may be missed Dr Claire Knight and Linda Glennie provide anupdate on the importance of the vital signs
Claire Knight BSc(Hons) PhD Medical Information OfficerLinda Glennie BSc MSc Head of Research and Medical Information Meningitis Research Foundation Bristol
Meningitis is a disease feared by parents and health professionals alike. The rapid onset and progression of the disease and potentially lethal outcome makes it vital to diagnose the disease early, but this can be difficult. This is particularly the case during the current swine flu pandemic, where concerns have been raised that cases of meningitis may be missed due to a misdiagnosis of swine flu. Early symptoms of meningitis and septicaemia often resemble viral illnesses such as influenza, making the condition difficult to diagnose. Classic symptoms (the ones that many health professionals and lay people most commonly associate with meningitis), such as a nonblanching rash and a stiff neck, are often late symptoms of the disease and neck stiffness is rarer in infants and young children. The presence of ear or upper respiratory tract infections does not necessarily exclude a diagnosis of meningitis. The emphasis should therefore be on regular, close monitoring of an ill child and assessment of the vital signs. Awareness of the recognised "red flag" symptoms of septicaemia - cold hands and feet, limb pain and pale or mottled skin - could also aid earlier diagnosis and hence potentially improve prognosis. Journal of Family Health Care 2010; 20(1): 6-8
_ During the swine flu pandemic and the influenza season it is important not to overlook a possible diagnosis of meningitis and septicaemia
_ Early diagnosis in meningitis is often life-saving. Hours count in this rapidly progressing, potentially life-threatening illness
_ Check the vital signs. Know the red flag symptoms of cold hands and/or feet, limb pain and pale or mottled skin, which are early warning signs of septicaemia
_ Do not think only of the classic symptoms of stiff neck, photophobia and rash, as these often only occur late in the illness and neck stiffness is rarer in infants and young children
_ Do not rule out meningitis just because the child has an upper respiratory tract infection or ear infection - these symptoms can co-exist with meningitis_ Parents of a sick, feverish child must be advised what to do and how to access medical help if the child's condition worsens
_ Prevention of meningitis remains key - ensure children receive their full course of infant immunizations
Meningitis is a rapidly progressing, potentially fatal illness where early and prompt diagnosis can be life-saving. Unfortunately, early symptoms of meningitis and septicaemia often resemble viral illnesses such as influenza and in the current swine flu pandemic there is a risk that a diagnosis of meningitis and septicaemia may be missed. Health professionals therefore need to be vigilant, check the vital signs, be aware that the classic symptoms such as rash, stiff neck and photophobia may not be present especially in the early stages, and ensure that parents know how to access medical help if their child's condition deteriorates. The case study below illustrates the need to keep meningitis in mind when a child has influenza-like symptoms.
Influenza or meningitis?
Two-year-old Georgia Keeling contracted meningococcal septicaemia last summer. Her symptoms started with a fever, before she went on to develop a rash and vomiting. Her parents sought advice from the local Health Centre, where staff suggested they call the pandemic flu line as it could be swine flu. Staff at the pandemic flu helpline suggested the parents call NHS Direct as Georgia only had one symptom of swine flu. NHS Direct advised them to take Georgia to hospital if her temperature reached 40°C, but at this point it had not. Within one hour her condition had deteriorated, with the rash now resembling bruising, and her parents dialled 999. A paramedic arrived, only to tell the family that the ambulance that was on its way would be turned back as she had swine flu. The parents were advised to give Georgia Tamiflu and Calpol. However, within an hour, Georgia's eyes had glazed over and another ambulance was called, but by this time it was too late and Georgia died at hospital.
Despite her parents repeatedly voicing concerns about meningitis, they had been reassured by a number of health professionals that she had swine flu. Georgia's heartbreaking story illustrates how important it is for a sick, feverish child with suspected meningitis or septicaemia to be seen by a doctor to be properly assessed, and how difficult it can be in the early stages to tell the difference between meningitis and other less serious self-limiting conditions such as flu.
What are meningitis and septicaemia?
Meningitis and septicaemia can be caused by a range of bacteria and viruses (and sometimes fungi). While viral meningitis is usually a less severe, self-limiting illness, bacterial meningitis is a serious life-threatening disease that can kill within hours. Bacterial meningitis and septicaemia are the result of bacteria entering the bloodstream by penetrating the mucosa of the nose and throat. In the bloodstream the bacteria multiply rapidly and produce toxins. In meningitis, the bacteria cross the blood-brain barrier causing inflammation of the meninges, whereas septicaemia is the bloodpoisoning form of the disease.
Meningitis and septicaemia can occur separately but in meningococcal infection, the most common cause of bacterial meningitis in the UK, they often occur together. Septicaemia without signs of meningitis is more life-threatening. The charity Meningitis Research Foundation estimates that there are approximately 3,300 cases of bacterial meningitis and septicaemia in the UK each year and that, on average, approximately one person dies from the disease and its complications every day.
Can we spot meningitis and septicaemia earlier?
As Georgia's case demonstrates, it can be difficult to diagnose meningitis and septicaemia in the early stages. Most health professionals typically recognise meningitis and septicaemia when the classic signs and symptoms appear, such as stiff neck, photophobia, decreased level of consciousness and a non-blanching rash (see Figure 1).
Figure 1: The "tumbler test". If a glass tumbler is pressed firmly against a septicaemic rash, the marks will not fade. You will be able to see the marks through the glass. But note: the rash is a late sign and it is important to recognise and act on early signs of septicaemia such as limb pain, cold hands and feet and pale or mottled skin
Box: Results of a recent study into the clinical recognition of meningococcal disease in children and adolescents*
In 2006 The Lancet published a study of 448 children aged 16 years or younger with meningococcal disease.
The main findings were:
• The time-window for clinical diagnosis was narrow. Most children had only non-specific symptoms during the first 4-6 hours of the disease but were close to death by 24 hours
• The classic symptoms of haemorrhagic rash, meningism and impaired consciousness developed late (median onset 13-22 hours)
• The median time of admission to hospital was 19 hours after onset of the disease, yet 72% of the children had early symptoms of septicaemia (leg pains, cold hands and feet and abnormal skin colour) at a median time of 8 hours.
Recognition of early symptoms of sepsis - leg pains, cold hands and feet and abnormal skin colour - could shorten the time to hospital admission for children with meningitis.
These early symptoms should receive greater emphasis so that parents and clinicians, particularly primary care practitioners, are aware of them and understand the urgency of rapid referral to hospital. * Thompson MJ, Ninis N, Perera R et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006; 367(9508): 397-403
"Red flag" symptoms
So if every person displaying flu-like symptoms could be developing meningitis, how do we know who is likely to go on and develop the disease? A large national study, funded by Meningitis Research Foundation (see Box), has shown that there are some symptoms that typically develop 4-8 hours after the very early non-specific ones that are signs of sepsis and early circulatory shutdown2.
These so-called "red flag" symptoms are:
_ Cold hands and/or feet
_ Limb pain
_ Pale or mottled skin.
These symptoms typically appear before the more classic symptom of haemorrhagic rash and symptoms of inflammation of the meninges (meningism), i.e. the triad of neck stiffness (nuchal rigidity), photophobia and impaired mental state.
Figure 2: Symptoms of meningitis and septicaemia. This checklist card is available free of charge from Meningitis Research Foundation (see Resources)
Red flag symptoms do not present in every child, but one or more of them were seen in three-quarters of children within the study, and were present at the first appointment with a primary care physician. Knowing these earlier warning symptoms of septicaemia could bring forward a diagnosis by about five hours.
The importance of measuring vital signs
Opportunities to diagnose cases of meningitis early can also be missed if care is not taken to measure the vital signs of an ill child. Guidance from the National Institute of Clinical Excellence (NICE) on feverish illness in children recommends a systematic assessment of feverish children. This should include routine measurement of vital signs such as heart and respiratory rate, temperature and capillary refill time3.
The "traffic light" system
The NICE guideline has a "traffic light" system based on such signs and symptoms to help identify children at risk of serious illness. Important clues can be picked up during a thorough examination of the child - feel how cold the hands and feet are, undress the child and check for a rash. It is also important to remember that earache and upper respiratory tract infections, supporting an alternative cause of symptoms, do not exclude meningitis. It is important not to rule out meningitis just because other symptoms may be present too.
The "safety net" system for monitoring a sick and feverish child
The NICE feverish illness guideline also recommends implementing a "safety net" in cases where a child is being sent home, or is being looked after at home, but a more serious diagnosis such as meningitis cannot yet be excluded. This should include making sure the parents know how and when to access further medical help and advice if necessary. They should be encouraged to trust their instincts and seek help again if they are concerned symptoms are getting worse. When deciding on how and where to manage the sick child, the practitioner should take into account the patient's access to health care over the coming hours and days, e.g. whether it is a Friday evening and the surgery is closed over the weekend, and whether the family lives in a remote area, and whether they have transport. This is particularly important to bear in mind with the current swine flu pandemic, where people are being encouraged to stay away from GP practices and keep away from other people.
Prevention is key
As early diagnosis can be so difficult, and the disease can progress so rapidly, prevention is key. While there is no universal vaccine against meningitis and septicaemia, every injection in the routine infant immunisation schedule up to and including the immunisation at around 13 months, protects against a form of meningitis and septicaemia. It is important to emphasise to parents that their child is not fully protected if they have not received their 12 and 13 month booster vaccinations. Uptake of boosters tends to be lower than for the primary doses, and parents may not understand that without boosters, protection is short-lived. Vaccines have been hugely successful in reducing the burden of meningitis. The introduction of MenC vaccine alone has reduced cases of group C meningococcal disease by over 95%4. New vaccines protecting against more types of pneumococcal disease have been developed, and it is hoped that a vaccine against group B meningococcal disease, the current biggest single cause of meningitis in the UK, is on the horizon. However, even with these exciting developments in the fight against meningitis, forms of the disease will remain for which there is no vaccine, so the importance of early recognition cannot be overstated.
Although 90% of people survive meningitis, and most survivors make a full recovery without permanent after effects, approximately one in four survivors is left with some form of after effect. These after effects can range from serious disabling complications such as amputations or cerebral palsy, to more subtle cognitive and coordination problems that have a significant impact on the survivor's quality of life5. It is important to ensure that patients are followed up carefully after discharge from hospital. A hearing test should be performed within four weeks of being well enough to be tested6. It is important that this is done as soon as possible as bone growth in the inner ear is wellknown after meningitis and can limit the chances of successful cochlear implantation if this is needed. It may be necessary to repeat hearing tests, which is especially important in young children who are learning language skills. Some children and young people develop mental or emotional problems following meningitis.
Some children develop visual and verbal memory difficulties after severe meningitis or septicaemia, an aspect currently being researched at Imperial College School of Medicine at St Mary's Hospital, London with a grant from Meningitis Research Foundation. Psychological follow-up is important and consideration should be given to whether referral to child and adolescent mental health services is required. A joined-up approach involving educational and social services may be necessary.
In some cases, problems may not be evident until years after the illness, when routine followup has long ceased, and families may then have problems in accessing specialist care. For example, learning difficulties may only surface when the child starts school, or distortions of bone growth may develop years after septicaemia. It is therefore important to be mindful of these possibilities and consider whether appropriate support is in place.
The introduction of vaccines against some forms of meningitis and septicaemia has led to a dramatic decrease in cases caused by vaccinepreventable bacteria. Preventing cases through vaccination not only saves lives but also reduces the burden on health, educational and social services. However, there are still forms of the disease for which there are no vaccines and it is important to be aware of the symptoms. While very early symptoms are common to many selflimiting illnesses such as swine flu or seasonal influenza, awareness of the "red flag" symptoms and assessment of a child's vital signs can help detect cases of meningitis and septicaemia earlier, thereby increasing the chance of survival.
1. Bourke TW, Shields MD. A/H1N1 pandemic: misdiagnosis in the time of meningitis. (Letter.) British Medical Journal (Clinical Research Edn.) 2009; 339: b3423 2. Thompson MJ, Ninis N, Perera R et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006; 367(9508): 397-403
3. National Institute for Health and Clinical Excellence [NICE]. Feverish illness in children: assessment and initial management in children younger than 5 years. London. Clinical Guideline 47. NICE, 2007. www.nice.org.uk
4. Ramsay ME, Andrews N, Kaczmarski EB, Miller E. Efficacy of meningococcal serogroup C conjugate vaccine in teenagers and toddlers in England. Lancet 2001; 357(9251): 195-196
5. Grimwood K, Anderson VA, Bond L et al. Adverse outcomes of bacterial meningitis in school-age survivors. Pediatrics 1995; 95(5): 646-656
6. National Deaf Children's Society [NDCS]. Quality Standards in Paediatric Audiology. Vol. IV. Guidelines for the Early Identification and the Audiological Management of Children with Hearing Loss. London: NDCS, 2000
Meningitis Research Foundation
This registered charity produces a range of resources for health professionals and the public, including the recently updated booklet for primary care practitioners in the UK entitled Vital signs, Vital issues: Recognition and prevention of meningitis and septicaemia. All Meningitis Research Foundation's materials are available free of charge by telephoning 01454 281811 or via the charity's website www.meningitis.org Meningitis Research Foundation also runs a Freefone 24-hour helpline on 080 8800 3344
Childhood Immunisation Schedule NHS Immunisation Information http://www.immunisation.nhs.uk