Amarilyo Gil, Alper Arik, Ben-Tov Amir, Grisaru-Soen Galia
Department of Pediatrics, Dana Children's Hospital, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
Pediatr Emerg Care. 2011 Mar;27(3):196-9. doi: 10.1097/PEC.0b013e31820d6543.
The diagnostic accuracy of the classic symptoms and signs of meningitis in infants and children has not been established.
All children aged 2 months to 16 years with clinically suspected meningitis were eligible for this prospective cohort study at 2 large medical centers between February 2006 and October 2007. Exclusion criteria were severe chronic disease, severe immune deficiency, or idiopathic intracranial hypertension. The emergency department physician obtained information on clinical symptoms and signs and cerebrospinal fluid analysis. Meningitis was defined as white blood cell count of 6 or higher per microliter of cerebrospinal fluid.
A total of 108 patients with suspected meningitis were enrolled. Meningitis was diagnosed in 58 patients (53.7%; 6 bacterial and 52 aseptic). Sensitivity and specificity were 76% and 53% for headache (among the verbal patients) and 71% and 62% for vomiting, respectively. Photophobia was highly specific (88%) but had low sensitivity (28%). Clinical examination revealed nuchal rigidity (in patients without open fontanel) in 32 (65%) of the patients with meningitis and in 10 (33%) of the patients without meningitis. Brudzinski and Kernig signs were present in 51% and 27% of the patients with meningitis, respectively, and had relatively high positive predictive values (81% and 77%, respectively). Bulging fontanel in patients with open fontanel was present in 50% of the patients with meningitis but had a positive predictive value of only 38%.
Classic clinical diagnostic signs have limited value in establishing the diagnosis of meningitis in children and should not be the sole determinants for referral to further diagnostic testing and lumbar puncture.
婴幼儿和儿童脑膜炎经典症状和体征的诊断准确性尚未得到证实。
2006年2月至2007年10月期间，在2家大型医疗中心，所有年龄在2个月至16岁、临床上疑似脑膜炎的儿童均符合这项前瞻性队列研究的条件。排除标准为严重慢性病、严重免疫缺陷或特发性颅内高压。急诊科医生获取了临床症状和体征以及脑脊液分析的信息。脑膜炎的定义为每微升脑脊液白细胞计数为6或更高。
共纳入108例疑似脑膜炎患者。58例患者（53.7%；6例细菌性和52例无菌性）被诊断为脑膜炎。头痛（在能表达的患者中）的敏感性和特异性分别为76%和53%，呕吐的敏感性和特异性分别为71%和62%。畏光具有高度特异性（88%）但敏感性较低（28%）。临床检查发现，脑膜炎患者中有32例（65%）（囟门未闭者除外）出现颈项强直，无脑膜炎患者中有10例（33%）出现颈项强直。布鲁津斯基征和克尼格征在脑膜炎患者中的出现率分别为51%和27%，且阳性预测值相对较高（分别为81%和77%）。囟门未闭患者中，50%的脑膜炎患者出现囟门隆起，但其阳性预测值仅为38%。
经典的临床诊断体征在儿童脑膜炎诊断中的价值有限，不应作为转诊进行进一步诊断检查和腰椎穿刺的唯一决定因素。
