DIAGNOSING MENINGITIS AT THE EMERGENCY DEPARTMENT – HOW ACCURATE ARE WE?

Abstract

Objectives: Meningitis is associated with a high mortality rate and neurologic sequelae are common among survivors. However, it is a diagnostic challenge and can be under-recognized at the Emergency Department (ED). We aimed to determine the accuracy of the diagnosis of meningitis made in the ED and identify features associated with diagnostic accuracy. Methods: A retrospective review of case records was carried out. Cases presenting to the ED an urban tertiary center from 2013 to 2017 with a diagnosis of meningitis in its records were selected. Information about patient demographics, clinical features and course were collected for analysis. Accuracy was determined by comparing the ED diagnosis with discharge diagnosis on inpatient record. Results: There were 83 cases of meningitis diagnosed in the ED during the study period. The median age was 36 (range 15 to 96) years old and 54 (65.1%) of the patients were male. Fever (n=76, 91.6%), headache (n=50, 60.2%) and altered mental status (n=24, 28.9%) were the most common symptoms and neck stiffness (n=28. 33.7%), Glasgow Coma Score less than 15 (n=16, 19.3%) and Kernig’s sign (n=11, 13.3%) were the most common signs. The accuracy of ED diagnosis of meningitis was 28.9%. Among the cases which were not meningitis, the most common diagnoses were other infections followed by conditions involving the musculoskeletal and central venous systems. Vomiting (OR 3.33, 1.24-9.09, p=0.021) was the only feature associated with diagnostic accuracy. Conclusion: Meningitis is a great mimicker and can be difficult to diagnose in the ED. Given the lack of clinical features which can be used to differentiate meningitis from other conditions, a high index of suspicion is required so that interventions can be promptly initiated to reduce mortality and morbidity.

Keywords

• Diagnosis,Emergency Medicine,Meningitis

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