Bacterial meningitis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]


Physical examination of bacterial meningitis may vary in adults and infants. In adults, physical examination findings may include bradycardia, disorientation, papilledema, neck stiffness, positive brudzinski's and kernig's sign. Physical examination findings in infants may include petechial rash, bulging fontanelle, neck stiffness, jaundice and convulsions.

Physical examination

Physical examination of bacterial meningitis may vary in adults and in infants. Patient may present with the classic triad of illness such as fever, neck stiffness and altered mental status. This classic triad is an emergency situation and may prompt management stratgey. Complications of bacterial meningitis may change the clinical presentation and patient may present with hypotension, and other signs of shock. Following signs may suggest bacterial meningitis:[1][2][3][4][5]


The physical examination findings in adults may include the following:

General appearance

  • Patient may look distressed
  • Altered mental status-not oriented in time, place and person

Vital signs

  • Bradycardia may indicate increased intracranial pressure
  • Increased or decreased temperature


  • Signs of infection indicating sinusitis, mastoiditis, and otitis media may help identify the source of infection and give a clue about diagnosis.
  • Papilledema may indicate increased intracranial pressure.
  • Neck stiffness is strongly suggestive of meningitis.


  • Decreased heart rate indicates increased intracranial pressure


  • Signs of neurological deficit may or may not be present.
  • Presence of cranial nerve palsy may suggest complications-present in 10-20% of patients
  • III, IV, VI cranial nerve palsies are common
  • Cranial nerve palsies may present due to increased ICP
  • Motor or sensory deficit may result from vascular inflammation or thrombosis[6]
  • Generalized tonic clonic seizures may occur within 48 hours of admission-20-30% of patients[7]
  • Focal seizures may indicate cerebral injury[7]


Special tests

Following are the special tests for meningitis. Positive tests provide a strong suspicion for meningeal irritation:[8]

  • Postive kernig's sign indicate meningitis.
  • Positive brudzinski's sign may suggest meningitis
  • Jolt accentualtion:[9]
  • Exacerbation of headache by moving head in horizontal direction two to three times indicate positive test.



  1. Attia J, Hatala R, Cook DJ, Wong JG (1999). "The rational clinical examination. Does this adult patient have acute meningitis?". JAMA. 282 (2): 175–81. PMID 10411200.
  2. Accessed on Jan 9th, 2017
  3. Brouwer MC, Tunkel AR, van de Beek D (2010). "Epidemiology, diagnosis, and antimicrobial treatment of acute bacterial meningitis". Clin Microbiol Rev. 23 (3): 467–92. doi:10.1128/CMR.00070-09. PMC 2901656. PMID 20610819.
  4. Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS; et al. (1993). "Acute bacterial meningitis in adults. A review of 493 episodes". N Engl J Med. 328 (1): 21–8. doi:10.1056/NEJM199301073280104. PMID 8416268.
  5. van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M (2004). "Clinical features and prognostic factors in adults with bacterial meningitis". N Engl J Med. 351 (18): 1849–59. doi:10.1056/NEJMoa040845. PMID 15509818.
  6. Pomeroy SL, Holmes SJ, Dodge PR, Feigin RD (1990). "Seizures and other neurologic sequelae of bacterial meningitis in children". N Engl J Med. 323 (24): 1651–7. doi:10.1056/NEJM199012133232402. PMID 2233962.
  7. 7.0 7.1 Arditi M, Mason EO, Bradley JS, Tan TQ, Barson WJ, Schutze GE; et al. (1998). "Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use". Pediatrics. 102 (5): 1087–97. PMID 9794939.
  8. Thomas KE, Hasbun R, Jekel J, Quagliarello VJ (2002). "The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis". Clin Infect Dis. 35 (1): 46–52. doi:10.1086/340979. PMID 12060874.
  9. Uchihara T, Tsukagoshi H (1991). "Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis". Headache. 31 (3): 167–71. PMID 2071396.

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