Fungal meningitis physical examination
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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-not oriented in time, place and person
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.
- Inflammed 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 (CN II), facial muscles weakness (CN VII), decreased hearing acuity (CNV III), diplopia (CN III, IV, V)
- 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.