Wednesday, January 11, 2006

Sick child with very painful legs - think meningitis

A sick child presents. Do they need:

1. a lumbar puncture?
2. blood cultures and observation?
3. blood cultures and IM antibiotics, f/u 24 hours?
4. treat as benign viral illness ...

BBC summarizes a Lancet article on early signs of meningitis. I'll have to look for more informative synopses of the article, but the 'unable to stand due to leg pain' sounds like it could be possibly distinctive enough to shift one's focus from blood culture only to culture and puncture. The circumoral pallor seems subtle (especially in non-Euros) and the cold hands and pale skin seem pretty nonspecific.

I just wonder how much that one relatively specific finding would really add by itself ...


pidgas said...

Unfortunately, pain so severe that the child refuses to stand is not all that specific. Any time a child presents with leg pain severe enough that they are "unable to stand," (especially in a kid who is previously walking) pediatricians click into "potentially big problem" mode. The first thought would almost certainly be septic arthritis, especially if the child is febrile. So, blood cultures, antibiotics, and possibly a radiologic exam (ultrasound of hip, for example) would probably be started. Also on the differential would be legg-calve-perthes, slipped capito-femoral epiphysis, appendicitis, and perhaps juvenile rheumatoid arthritis or behavioral refusal depending on the age of the child. I'm sure that this list isn't exhaustive, and there are probably obvious diagnoses I'm overlooking. Nevertheless, I cannot say that meningitis is among the first thoughts of this (recently board-certified with MUCH yet to learn) pediatrician. At least not by my training. The way I will use this paper is to seriously consider lumbar puncture in patients with this presentation, but it's almost certainly not specific enough to automatically go full-court press and treat for meningococcal meningitis in any patient who complains of pain and won't walk.

JGF said...

I think the way you'd use this paper is pretty much what I meant. The presumption would be sick, feverish child with symmetric leg pain, unwilling to stand. So bacteremia with bad leg pain. The paper suggests adding an LP to whatever else one might do.

My original comment was kind of sketchy.