Brudzinski’s sign is present when passive neck flexion in a supine patient results in involuntary flexion of the knees and hips. A separate sign — the contralateral reflex — is present if passive flexion of one hip and knee causes flexion of the contralateral leg.
None of the physical examination findings are sensitive, however. In a study of 297 patients with suspected meningitis, the sensitivity of Kernig’s sign, Brudzinski’s sign and nuchal rigidity was 5%, 5 %, and 30%, respectively.4 The specificity was 95% for Kernig’s and Brudzinski’s signs and 68% for nuchal rigidity.4
Jolt accentuation of headache is one of the most sensitive maneuvers used in the diagnosis of meningitis. A positive test consists of the headache worsening when the patient turns the head horizontally at two to three rotations per second. In a study of 34 patients, jolt accentuation had a sensitivity of 97% and a specificity of 60%.5
Meningitis should always be considered in the differential diagnosis of a patient with an unexplained change in mental status. Clinical findings often do not help in establishing the diagnosis. In Mr. B’s case, lumbar puncture was necessary to establish or refute the diagnosis of meningitis, given the findings of fever, headache and rash. Rash is most frequently seen in meningitis caused by Neisseria meningitidis.
It was thought that an inflammatory reaction to Pneumovax caused Mr. B’s fever, headache, left upper-extremity erythema/swelling and lymphocyte-predominant leukocytosis. The adverse drug event resulted in injury and a longer length of stay in the hospital. It is arguable whether the vaccine should have been administered to this patient.
National hospital expenses to treat patients who suffer adverse drug events during hospitalization are estimated to be between $1.56 and $5.6 billion annually.6 The most common adverse experiences reported with Pneumovax were local reaction at injection site, soreness, erythema, warmth, swelling, induration and fever up to 102˚F.
Studies involving the pneumococcal vaccine have not demonstrated effectiveness in preventing community-acquired pneumonia, but most show the vaccine is effective in preventing invasive pneumococcal disease.
Current guidelines recommend the vaccine for those at high risk of pneumococcal pneumonia. However, only 32.8% of U.S. adults aged 18 to 64 years at high risk have received the vaccine as of 2007. Of those aged 65 years and older, only 65.6% have been vaccinated.7
The CDC’s Advisory Committee on Immunization Practices recommends routine vaccination for the following groups:8
- All immunocompetent patients aged 65 years and older
- Individuals aged 2 to 64 years with certain high-risk condition(s)
- Chronic cardiovascular disease (heart failure and cardiomyopathies)
- Chronic pulmonary disease (including chronic obstructive pulmonary disease and emphysema)
- Diabetes mellitus
- Chronic liver disease (including cirrhosis)
- CSF leaks
- Functional or anatomic asplenia (including sickle-cell disease and splenectomy)
- Immunocompromising conditions (including HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephritic syndrome; patients receiving immunosuppressive chemotherapy, including corticosteroids; and patients who have received an organ or bone marrow transplant).
- Adults aged 19 to 64 years who smoke cigarettes or have asthma
- Persons aged 2 to 64 years with cochlear implants
It is important to discuss the benefits and risks of the vaccine with patients before proceeding and to vaccinate as many high-risk patients as possible.
Eugene Wong, MD, is attending physician in internal medicine at New York Presbyterian -The Allen Hospital in New York City. Jonathan Rieber, MD, is attending physician in a private gastroenterology practice in New York City. Gabrielle Flamm is a student at Carleton College in Northfield, Minn.
2. Attia J, Hatala R, Cook DJ, Wong JG. The rational clinical examination. Does this adult patient have acute meningitis? JAMA. 1999;282:175-181.
3. WM Scheld, RJ Whitley, and CM Marra, eds. Infections of the Central Nervous System, 3rd ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2004:393.
5. Uchihara T, Tsukagoshi H. Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991;31:167-171.
6. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277:307-311.
8. Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices.
“Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23).” MMWR Morb Mortal Wkly Rep. 2010;59:1102-1106.
All electronic documents accessed October 3, 2011