Varied early symptoms of bacterial meningitis in adults and children highlight diagnostic challenges

In a recent study published in the journal Scientific Reports, researchers investigated the early symptoms, management, and prognosis of community-acquired bacterial meningitis (CABM) to provide additional clarity for this disease’s early diagnosis and treatment.

Study: Pre-hospital symptoms associated with acute bacterial meningitis differs between children and adults. Image Credit: steph photographies / Shutterstofck.com

Background

Fever, neck stiffness, and altered mental state are all symptoms that are characteristic of CABM in over 50% of patients. The non-specific nature of early CABM symptoms can lead to misdiagnoses, which ultimately increases the risk of this condition progressing to severe symptoms. Additional factors that increase the risk for poor outcomes from CABM include advanced age, comorbidities, and male sex.

The current data on the early symptoms of CABM is sparse and based on hospital records or recall. Thus, more comprehensive knowledge of these symptoms in all age groups is needed. 

About the study

In the current retrospective study, researchers recruited CABM patients in Denmark who contacted emergency medical services (EMS) before being hospitalized between January 1, 2016, and December 31, 2020. All patient electronic health records (EHR) were reviewed to confirm CABM diagnoses.

For information on pre-hospitalization symptoms, archived audio files of all patients’ initial phone calls to EMS were used. These files also provided information on pre-hospital administration of antibiotics, patient characteristics, handling by the hospital, and vital status.

The significance level used in the statistical analysis was a two-sided P-value of less than 0.05. Furthermore, Fisher’s Exact test was used to calculate the P-values between groups.

Study findings

Of the 209 CABM patients included in the study, 171 were adults, and 38 were children. The median age of all adult patients was 61 years, 47% of whom were female. No differences regarding sex, year of contracting the disease, or use of pre-hospital antibiotics were observed among the pediatric patients.

A total of 21 different symptoms were identified in the patient’s initial phone calls to EMS. Most patients presented with at least one of the three aforementioned classic meningitis symptoms; however, few presented with all three at the time of their initial phone call.

Children more frequently reported at least two of the three symptoms. Compared to adults, children were more likely to have a meningococcal etiology at 32% compared to 5%. Accordingly, contact with the medical helpline was more frequent for children than adults, at 89% and 51%, respectively.

As compared to children, adults were more commonly severely ill when they made a phone call to EMS. On average, callers reported 3.6 symptoms, with children more likely to present with fever, fatigue, rashes, and neck stiffness. Comparatively, adult patients were more likely to present with altered mental states, headache, and leg pain. 

Only 4% of all patients received pre-hospital antibiotics, which resulted in a 30-day mortality rate of 5% and 12% among children and adults, respectively. All eight patients who received pre-hospital antibiotic treatment had a 0% mortality rate within 30 days, whereas the others had varying mortality rates depending on their initial assessment and treatment. Children and adults were nearly equally under suspicion of CABM pre-hospital or at initial evaluation at 53% and 46%, respectively.

Conclusions

The researchers pursued an evidence-guided line of questioning to identify all CABM cases, even when the classic triad of meningeal symptoms was absent. The study findings indicate that this approach could facilitate clinicians’ ability to distinguish CABM from other time-sensitive medical emergencies, such as stroke.

Based on these observations, all CABM patients, even in febrile or mentally altered states, should be examined for all three meningitis symptoms of fever, altered mental state, or neck stiffness until a doctor establishes another cause of their symptoms. Upon suspicion of CABM, prompt action is imperative to ensure appropriate care, including lumbar puncture and initiation of antibiotic therapy.

Future studies are needed to establish appropriate guidelines for identifying which patients with non-specific symptoms should be suspected of CABM to optimize the early management of this deadly disease.