Meningitis

• Meningitis is an inflammation of the soft tissue surrounding the brain, this can be because of a viral or bacterial infection.
• Meningococcal meningitis is caused by a particular bacteria (Neisseria meningitidis), this is the most deadly type as the bacteria can enter the blood and cause sepsis.
• A non-blanching rash is worrying as it may be caused by a meningococcal infection.
• Any child with red flag sepsis signs, such as a high heart rate, high respiratory rate or long capillary refill time requires immediate treatment and transfer to hospital.
• Bacterial meningitis requires antibiotic therapy while viral meningitis is self-limiting and will get better with time.

Meningitis literally means inflammation of the meninges (the soft tissue layer between the brain and the skull) and is often caused by an infection. However, there may be other causes, such as an autoimmune disorder or cancer. Bacterial meningitis can be part of a life-threatening illness in which the blood also becomes infected (septicaemia), leading to a severely unwell child.

Most infections are because of a virus (two-thirds), most commonly an enterovirus (Coxsackie or ECHO) as well as occasionally Epstein-Barr virus or adenovirus. Viral meningitis is more common in spring and summer (Tuppeny, 2013). Bacterial meningitis accounts for about a third of infective meningitides and is most commonly because of Neisseria meningitidis (also known as meningococcal meningitis) or Streptococcus pneumoniae (Agrawal and Nadel, 2011).

Meningococcal meningitis can be deadly as the bacteria can infect the blood causing severe sepsis and shock. Meningococcal infection affects about 1 000 – 2 000 children per year with a death rate of about 10% (Pollard, 2018).

Shock occurs when the body is unable to deliver enough oxygen to the organs to allow them to function. During an infection the space between cells lining the blood vessels increases to allow more inflammatory cells to be delivered to the infected area. This happens greatly in sepsis

Children with meningitis will often have typical non-specific infective symptoms and some specific meningitis symptoms because of the inflammation of their meninges.

Key symptoms include:

• neck stiffness
• headache
• photophobia
• seizures
• changed mental state
• rash.

Inflammation of the meninges leads to neck stiffness and discomfort when the neck is moved. However, it is important to remember that it might not be present at first presentation.

Photophobia and a headache are also classical meningitis symptoms. Patients with meningitis will almost always be lethargic or irritable (Kim, 2010). However, they may have a decreased mental state. 

If the infection is more severe there may be swelling in the brain leading to headaches, nausea or vomiting. Around 30% of people with meningitis will have seizures at presentation, these are mostly generalised seizures and almost never the only symptom that the child has (Arditi et al, 1998).

The characteristic ‘meningitis’ rash is a sign of

It is always important to start with basic observations when examining a child. Furthermore, if an infection is suspected the presence of sepsis should be considered.

A raised heart rate is to be expected in any child who is unwell, the extent to which it is raised can give an indication of how unwell the child is. A raised respiratory rate or low blood pressure are more worrying signs and suggest that the child might have septic shock. A raised temperature is also highly suggestive of an infection (Trautner et al, 2006). However, children compensate very well against serious illness meaning that even if all the observations are normal they could still be seriously unwell (Löllgen and Szabo, 2015).

Capillary refill time is a great marker of how unwell a child is. This is tested by compressing an area of skin on the chest for 5 seconds and seeing how

Management in the community

Undiagnosed meningitis or sepsis represent a possible threat to life and therefore, the child should be urgently referred to hospital. Viral meningitis is not a threat to life. However, it is impossible to rule out a bacterial meningitis without further tests.

The challenge comes in knowing who should be referred urgently and who can wait for further assessment by a GP. The Sepsis Trust has created a flow chart that can be used when assessing the possibility of sepsis in a child in the community, this is freely available on their website (www.sepsistrust.org). Furthermore, they have identified several red flag symptoms for sepsis such as pale skin, low urine output and decreased mental state (Box 1).

Box 1. Red flag symptoms of sepsis

• Objective change in behaviour or mental state
• Does not wake if roused or will not stay awake
• Not doing/interested in anything at all

Differential diagnosis

Each of the above symptoms can be caused by a range of conditions, meningitis is important because it is often the worst possibility. However, when reviewing a child, speaking to concerned parents or reading discharge letters it is useful to know about the other possibilities.