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Scott - Bacterial meningitis is alive and well here in LV - we have seen it in a variety of age groups. There is good evidence that there has been an increase in pneumococcal serotypes not covered by the polyvalent vaccines since there widespread use, such that the burden of pneumococcal meningitis (as opposed to H. flu type b) has not decreased nearly as much. 

Brouwer MC, van de Beek D. Epidemiology of community-acquired bacterial meningitis. Curr Opin Infect Dis. 2018;31(1):78-84.

Also, the absence of meningismus in older kids with bacterial meningitis is well described and occurs in a substantial subset. 

Geiseler J, Nelson, K.E. Bacterial meningitis without clinical signs of meningeal irritation. . Southern Med J 1982;75(4):448-450.

Much of the data on the sensitivity of the neck exam is of the retrospective variety. I have only read one really good prospective study on the sensitivity of PE for bacterial meningitis and it was a single center variety as I recall.

Walsh-Kelly C, Nelson DB, Smith DS, et al. Clinical predictors of bacterial versus aseptic meningitis in childhood. Ann Emerg Med. 1992;21(8):910-914.

Tough case.


Jay

Jay D. Fisher MD FAAP FACEP
Medical Director, Pediatric EM
Children's Hospital of Nevada at UMC
Clinical Professor of Emergency Medicine and Pediatrics
UNLV School of Medicine








> On February 14, 2018 at 4:18 PM "Conners, Gregory, P" <[log in to unmask]> wrote:
> 
> 
> I shared this with our ID director (Dr. Mary Anne Jackson), who pointed out that bacterial meningitis appears at this time of year as a complication of influenza:
> "Both pneumococcal and meningococcal meningitis can occur post flu as well as GAS and S aureus invasive disease and TSS."
> 
> She also addressed Jim's question:  "We do know that new serotypes [of pneumococcus] have emerged but this is not waning immunity because the teen only got PCV7".
> 
> 
> Greg Conners
> 
> Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP
> 
> Director, Division of Emergency Medicine
> Associate Chair of Pediatrics
> Professor of Pediatrics and Emergency Medicine
> Children’s Mercy Hospital, Kansas City
> University of Missouri, Kansas City
> [log in to unmask]
> 
> 
> 
> 
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of [log in to unmask]
> Sent: Wednesday, February 14, 2018 2:25 PM
> To: [log in to unmask]
> Subject: Re: Bacterial meningitis
> 
> *** This message was sent to you from an External Source. Please do not open untrusted links or attachments. ***
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> ________________________________
> 
> 
> Could you share with us the clinical findings and history that prompted the LP?
> 
> 
> Shiu-Lin
> 
> 
> 
> 
> Shiu-Lin Tsai, MD
> Division of Pediatric Emergency Medicine
> 
> Department of Emergency Medicine
> Columbia University Medical Center
> 
> 
> 
> -----Original Message-----
> From: Scott Freedman <[log in to unmask]>
> To: PED-EM-L <[log in to unmask]>
> Sent: Wed, Feb 14, 2018 2:44 pm
> Subject: Bacterial meningitis
> 
> ALL:
> Since Jan 1st this year, we have seen 3 cases of culture + bacterial meningitis come through are ED;  2 with *Strep pneumoniae* and 1 with *Neisseria meningiditis*.  All 3 were in older children/ teens who received their Prevnar 13  vaccines as well as the Menactra series in the patient with Neisseria.  Anyone else seeing cases of this sort?  I do not recall 3 cases of bacterial meningitis in older kids in a community setting such as ours in quite a long time.  Is this random bad luck or do  we all need to be more vigilant?  Incidentally, none had neck pain or meningismus as a clinical finding.
> 
> --
> Kind regards,
> 
> Scott
> Scott Freedman, MD
> Medical Director,  Pediatric Emergency Dept Rockville MD
> 
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For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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