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How to use clinical signs of meningitis
  1. Alexander Tracy1,
  2. Thomas Waterfield2
  1. 1 General Paediatrics, Birmingham Children’s Hospital, Birmingham, UK
  2. 2 School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
  1. Correspondence to Dr Alexander Tracy, General Paediatrics, Birmingham Children’s Hospital, Birmingham B4 6NH, UK; alexander.tracy{at}


Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig’s sign and Brudzinski’s sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.

  • infectious diseases
  • general paediatrics
  • statistics
  • evidence-based medicine
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  • Contributors AT conceived the work and contributed to the interpretation of data, drafting the manuscript and revising for intellectual content. TW contributed to the interpretation of data, drafting the manuscript and revising for intellectual content, and designed the figures.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Parental/guardian consent obtained.

  • Provenance and peer review Commissioned; externally peer reviewed.

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