Fungal meningitis physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
As in the case of any disease, a complete physical exam must be done on the patient looking for positive and negative symptoms. The clinical presentation of [[fungal meningitis]] is usually obscure as are the findings on physical exam. The pertinent findings are low grade [[fever]] and possible neurological signs like focal [[weakness]], loss of sensation and [[cranial nerves]] involvement. | As in the case of any disease, a complete physical exam must be done on the patient looking for positive and negative symptoms. The clinical presentation of [[fungal meningitis]] is usually obscure as are the findings on physical exam. The pertinent findings are low grade [[fever]] and possible neurological signs like focal [[weakness]], loss of sensation and [[cranial nerves]] involvement. | ||
Physical exam findings, including presence of rashes, [[lymphadenopathy]], [[hepatomegaly]], pulmonary disease, ocular pathology (eg, [[endophthalmitis]], vitritis, [[chorioretinitis]], [[uveitis]], optic nerve involvement), and cranial nerve (CN) palsies, may narrow the differential. [[Papilledema]] and [[Abducens nerve palsy|abducens nerve pals]]<nowiki/>y suggest the presence of [[increased intracranial pressure]] (ICP). [[Kernig's sign]] and [[brudzinski's sign]] are not typically present in [[fungal meningitis]]. | Physical exam findings, including presence of [[rashes]], [[lymphadenopathy]], [[hepatomegaly]], [[pulmonary]] disease, ocular pathology (eg, [[endophthalmitis]], vitritis, [[chorioretinitis]], [[uveitis]], [[optic nerve]] involvement), and [[Cranial nerves|cranial nerve]] (CN) palsies, may narrow the differential. [[Papilledema]] and [[Abducens nerve palsy|abducens nerve pals]]<nowiki/>y suggest the presence of [[increased intracranial pressure]] (ICP). [[Kernig's sign]] and [[brudzinski's sign]] are not typically present in [[fungal meningitis]]. | ||
==Physical Examination== | ==Physical Examination== | ||
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====General appearance of patient==== | ====General appearance of patient==== | ||
*Patient may look distressed | *Patient may look distressed | ||
*Altered mental status | *[[Altered mental status]] | ||
====Vitals==== | ====Vitals==== | ||
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*[[Nystagmus]] may be present. | *[[Nystagmus]] may be present. | ||
*Extra-ocular movements may be abnormal | *Extra-ocular movements may be abnormal | ||
*Ophthalmoscopic exam may be abnormal with signs consistent with papilledema and may indicate increased intracranial pressure. | *Ophthalmoscopic exam may be abnormal with signs consistent with [[papilledema]] and may indicate [[increased intracranial pressure]]. | ||
* | *[[Inflamed]] sinuses with [[facial]] [[tenderness]] in some cases. | ||
*Signs of infection indicating [[sinusitis]], mastoiditis, and [[otitis media]] may help identify the source of infection and give a clue about diagnosis. | *Signs of infection indicating [[sinusitis]], [[mastoiditis]], and [[otitis media]] may help identify the source of infection and give a clue about diagnosis. | ||
====Neck==== | ====Neck==== | ||
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*Muscular strength is usually intact, but focal deficits might be present | *Muscular strength is usually intact, but focal deficits might be present | ||
*Sensation is usually intact, but focal deficits might be present | *Sensation is usually intact, but focal deficits might be present | ||
*Hyperactive reflexes may be present | *Hyperactive [[reflexes]] may be present | ||
*Deficits in cranial nerves might be present: decreased vision acuity | *Deficits in cranial nerves might be present: decreased vision acuity, [[facial]] muscles [[Muscle weakness|weakness]], decreased hearing ([[CN VIII]]), and [[diplopia]] | ||
*Gait might be altered | *[[Gait]] might be altered | ||
=====Special tests===== | =====Special tests===== | ||
Following are the special tests for meningitis. Positive tests provide a strong suspicion for meningeal irritation:<ref name="pmid12060874">{{cite journal| author=Thomas KE, Hasbun R, Jekel J, Quagliarello VJ| title=The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. | journal=Clin Infect Dis | year= 2002 | volume= 35 | issue= 1 | pages= 46-52 | pmid=12060874 | doi=10.1086/340979 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12060874 }} </ref> | Following are the special tests for meningitis. Positive tests provide a strong suspicion for meningeal irritation:<ref name="pmid12060874">{{cite journal| author=Thomas KE, Hasbun R, Jekel J, Quagliarello VJ| title=The diagnostic accuracy of Kernig's sign, Brudzinski's sign, and nuchal rigidity in adults with suspected meningitis. | journal=Clin Infect Dis | year= 2002 | volume= 35 | issue= 1 | pages= 46-52 | pmid=12060874 | doi=10.1086/340979 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12060874 }} </ref> | ||
*[[Kernig's sign]] | *[[Kernig's sign]] | ||
:*Postive kernig's sign indicate meningitis. | :*Postive [[Kernig's sign|kernig's]] sign indicate meningitis. | ||
*[[Brudzinski's sign]] | *[[Brudzinski's sign]] | ||
:*Positive brudzinski's sign may suggest meningitis | :*Positive [[Brudzinski's Sign|brudzinski's]] sign may suggest meningitis | ||
*It should be noted that [[Kernig's sign]] and [[brudzinski's sign]] are not typically present in fungal meningitis. | *It should be noted that [[Kernig's sign]] and [[brudzinski's sign]] are not typically present in fungal meningitis. | ||
*Jolt accentualtion:<ref name="pmid2071396">{{cite journal| author=Uchihara T, Tsukagoshi H| title=Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. | journal=Headache | year= 1991 | volume= 31 | issue= 3 | pages= 167-71 | pmid=2071396 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2071396 }} </ref> | *Jolt accentualtion:<ref name="pmid2071396">{{cite journal| author=Uchihara T, Tsukagoshi H| title=Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. | journal=Headache | year= 1991 | volume= 31 | issue= 3 | pages= 167-71 | pmid=2071396 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2071396 }} </ref> | ||
:*Exacerbation of headache by moving head in horizontal direction two to three times indicate positive test. | :*Exacerbation of [[headache]] by moving head in horizontal direction two to three times indicate positive test. | ||
====Heart==== | ====Heart==== | ||
*Decreased heart rate indicates increased intracranial pressure | *Decreased heart rate indicates [[increased intracranial pressure]] | ||
===Infants=== | ===Infants=== | ||
*Neck stiffenss or [[hypotonia]] | *Neck stiffenss or [[hypotonia]] | ||
*Altered mental status | *[[Altered mental status]] | ||
*Bulging fontanelle | *Bulging [[fontanelle]] | ||
*[[Convulsions]] | *[[Convulsions]] | ||
*[[Petechial rash]] | *[[Petechial rash]] | ||
Revision as of 21:48, 8 March 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby; Prince Tano Djan, BSc, MBChB [2]
Overview
As in the case of any disease, a complete physical exam must be done on the patient looking for positive and negative symptoms. The clinical presentation of fungal meningitis is usually obscure as are the findings on physical exam. The pertinent findings are low grade fever and possible neurological signs like focal weakness, loss of sensation and cranial nerves involvement. Physical exam findings, including presence of rashes, lymphadenopathy, hepatomegaly, pulmonary disease, ocular pathology (eg, endophthalmitis, vitritis, chorioretinitis, uveitis, optic nerve involvement), and cranial nerve (CN) palsies, may narrow the differential. Papilledema and abducens nerve palsy suggest the presence of increased intracranial pressure (ICP). Kernig's sign and brudzinski's sign are not typically present in fungal meningitis.
Physical Examination
Adults
General appearance of patient
- Patient may look distressed
- Altered mental status
Vitals
Temperature
- A low grade fever is often present
HEENT
- Nystagmus may be present.
- Extra-ocular movements may be abnormal
- Ophthalmoscopic exam may be abnormal with signs consistent with papilledema and may indicate increased intracranial pressure.
- Inflamed sinuses with facial tenderness in some cases.
- Signs of infection indicating sinusitis, mastoiditis, and otitis media may help identify the source of infection and give a clue about diagnosis.
Neck
- Neck stiffness is strongly suggestive of meningitis.
Neuromuscular
- The mental status is usually intact
- Muscular strength is usually intact, but focal deficits might be present
- Sensation is usually intact, but focal deficits might be present
- Hyperactive reflexes may be present
- Deficits in cranial nerves might be present: decreased vision acuity, facial muscles weakness, decreased hearing (CN VIII), and diplopia
- Gait might be altered
Special tests
Following are the special tests for meningitis. Positive tests provide a strong suspicion for meningeal irritation:[1]
- Postive kernig's sign indicate meningitis.
- Positive brudzinski's sign may suggest meningitis
- It should be noted that Kernig's sign and brudzinski's sign are not typically present in fungal meningitis.
- Jolt accentualtion:[2]
- Exacerbation of headache by moving head in horizontal direction two to three times indicate positive test.
Heart
- Decreased heart rate indicates increased intracranial pressure
Infants
- Neck stiffenss or hypotonia
- Altered mental status
- Bulging fontanelle
- Convulsions
- Petechial rash
References
- ↑ 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.
- ↑ Uchihara T, Tsukagoshi H (1991). "Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis". Headache. 31 (3): 167–71. PMID 2071396.