Patients with suspected meningitis

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European Journal of General Practice

ISSN: 1381-4788 (Print) 1751-1402 (Online) Journal homepage: http://www.tandfonline.com/loi/igen20

Patients with suspected meningitis Rinco Koorevaar , Marc A. Bruijnzeels, Johannes C. Van der Wouden, Emiel Van der Does, Koos Van der Velden & Lisette WA Van Suijlekom-Smit To cite this article: Rinco Koorevaar , Marc A. Bruijnzeels, Johannes C. Van der Wouden, Emiel Van der Does, Koos Van der Velden & Lisette WA Van Suijlekom-Smit (1995) Patients with suspected meningitis, European Journal of General Practice, 1:1, 21-24, DOI: 10.3109/13814789509160750 To link to this article: http://dx.doi.org/10.3109/13814789509160750

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ORIGINAL PAPER

Patients with suspected meningitis: a study in general practice Rinco Koorevaar, Marc A Bruijnzeels, Johannes C van der Wouden, Emiel van der Does, Koos van der Velden, Lisette WA van Suijlekom-Smit To assess the management of patients with suspected meningitis by general practitioners, we used data from the Dutch National Survey of Morbidity and Interventions in General Practice. In this study, involving 161 general practitioners with a practice population of 335,000 persons, all patient contacts in general practice and all hospital admissions were registered. Additional information was gathered by interviewing the GPs involved. We selected patients with a provisional diagnosis of meningitis by the GP and/or a hospital diagnosis of meningitis. Of the 17 patients with the provisional diagnosis of meningitis by the GP eight had a final diagnosis of meningitis (predictive value of the provisional diagnosis: 46%). In the majority of patients with another final diagnosis the GP reported meningeal irritability and lowered consciousness, but this was not confirmed in hospital. Of all ten patients with a final diagnosis of meningitis eight had the correct provisional diagnosis of meningitis by the GP (sensitivity of the provisional diagnosis meningitis: 80%). We conclude that it is often difficult to diagnose meningitis in general practice. Inevitably, patients will be referred with a provisional diagnosis of meningitis which cannot be confirmed in hospital. Eur J Gen Practice, 1995; 1: 21-4.

Meningitis is one of the most severe infections, but does not occur frequently in general practice. The incidence of meningitis is highest among children younger than two Rinco Koorevaar, M D . Marc A Bruijnzeels, MA Data-analyst. Johannes C van der Wouden, MA PhD, Research coordinator. Emiel van der Does, M D PhD, Professor o f General Practice. Department o f General Practice, Room Fe319, Erasmus University Rotterdam, PO Box 1738,3000 DR Rotterdam, The Netherlands. Koos van der Velden, MPH, Epidemiologist. Netherlands Institute of Primary Health Care (NIVEL),PO Box I568 ,3500 BN Utrecht, The Netherlands. Lisette WA van Suijlekom-hit, M D PhD, Paediatrician. Department of Paediatrics, Erasmus University and University HospitallSophia Childrens Hospital Rotterdam, PO Box 1738, 3000 RN Rotterdam, The Netherlands. Correspondence to: Dr Johannes C van der Wouden. Submitted: July 14th, 1994; accepted in revised form: November lst, 1994.

European Journal of General Practice, Volume 1, March 1995

years of age.' The case fatality rate of bacterial meningitis varies between 3 to 30% and long-term neurological sequelae develop in as many as one third of all survivors.' An early and correct diagnosis of meningitis is important for the early admittance of the patient to hospital and the immediate initiation of antibiotic treatment.'.' Diagnostic delay is likely to result in an unfavourable outcome.'" The diagnosis can be difficult in infants and in the elderly, and in the early stage of the disease.# None of the symptoms found in patients with meningitis are pathognomonic for meningitis. Fear of missing the diagnosis exists in general practice. From a quality assurance point of view it will be helpful to see what happens in the diagnostic trajectory. We studied the presentation, management and outcome of patients presenting with meningitis or suspected meningitis in general practice by using data of a large, nation-wide morbidity study. Patients and methods Between April lst, 1987, and March 31st, 1988, the Dutch national survey of morbidity and interventions in general practice was carried out by the Netherlands institute of primary health care (NIVEL).' For this survey 103 general practices (161 general practitioners), divided into four groups, .recorded all contacts with patients during one of the four successivethree months registration periods (contact registration). The practices were a stratified random sample across the whole of The Netherlands. The general practice study population consisted of 335,000 persons and was representative of the population of The Netherlands. Data were recorded for each consultation, including type of contact, reasons for consultation, working hypothesis and differential diagnosis, certainty of the working hypothesis, diagnostic procedures, treatment, referral and follow-up appointment. If a patient was admitted to hospital during the registration period (and was discharged not longer than one month after the registration period ended) the general practitioner filled in a registration form including the discharge diagnosis. If a patient went directly to a hospital without seeing a GP, a hospital registration form was also filled in. The data on the registration forms were coded by a researcher using the International classification of Primary Care (ICPC)."'In order to trace all patients with meningitis we searched whether ICPC-code N71 was considered as a diagnosis by the general practitioner on the contact re21

ORIGINAL PAPER

gistration form or as a discharge diagnosis on the hospital registration form. We checked the original forms to exclude other possible diagnoses belonging to the same ICPC-category. Patients with septicaemia as part of meningococcal meningitis were also included. Episodes of meningitis were only studied if they started within the registration period. In order to complete the medical history we visited the general practitioners of the patients involved. We checked the patient’s record held by the GP and the hospital discharge letters and interviewed the general practitioner about the patient contacts using a structured questionnaire. In the patients with a hospital discharge diagnosis we considered the discharge diagnosis to be the final diagnosis. If the patient was not referred w e decided upon a final diagnosis after analysing all data, including the course of the disease. Results In the contact registration 17 patients were given a provisional diagnosis of meningitis by the general practitioner; in the hospital registration two more patients with a hospital diagnosis of meningitis were found, who had been sent to hospital by their GP with another provisional diagnosis. No patients with meningitis went directly to a hospital without consulting a GP. Table 1 shows the reported meningitis symptoms and diagnoses in general practice and in hospital of patients with a working hypothesis of meningitis by the GP but with another final diagnosis. Table 2 gives the clinical parameters of the patients with a final diagnosis of meningitis. Information by the general practitioners, data from the patient charts and the hospital discharge letters were obtained for all patients except one (patient F).

Of the 17 patients with a working hypothesis of meningitis four were not referred to hospital. Two of them had a provisional diagnosis of mumps-meningitis and neck rigidity was found in both patients; one also had a headache

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and a transient delirium. These patients received a final diagnosis of mumps-meningitis. Another patient received the provisional diagnosis of viral meningitis but an X-ray of the maxillary sinus showed signs of sinusitis. Retrospective analysis of the disease course of another patient made the diagnosis of meningitis most unlikely. In this patient we made the final diagnosis: infection of unknown origin. None of these four unreferred patients developed sequelae. Thirteen patients (76%)were referred to hospital. Only one of these patients was not admitted. After examination in the outpatient department, the final diagnosis was hypertonia of the neck musculature. All 12 admitted patients suffered from infections: six had meningitis, six an infection of another type. Special attention was given to the reported meningitis symptoms of the referred patients with a final diagnosis other than meningitis. In the majority of this group of patients the GP reported meningeal irritability and a change in the level of consciousness but these symptoms were not confirmed in hospital. Two patients were traced in the hospital registration with a discharge diagnosis of meningitis who were admitted with another provisional diagnosis by the GP. One patient with a provisional diagnosis of mumps was referred because he vomited and refused to drink; mumps-meningitis and -pancreatitis was diagnosed. The other patient with a provisional diagnosis of fever of unknown origin was referred because he was apathic and hypotonic. Analysis of the presentation to the GP of these two patients made it clear that symptoms pointing to meningitis were present. A classical presentation of meningitis (two or more of the following symptoms present: meningeal irritability, disturbed consciousness, headache, petechiae) was found by the general practitioners in six of the ten meningitis patients. None of the patients in this study was treated with antibiotics before referral to hospital. Three of the patients (0,Q, S), all referred and with a final diagnosis of men-

European Journal of General Practice, Volume 1 , March 1995

ORIGINAL PAPER

ingitis, developed sequelae (chronic headaches, hemiparesis, disturbance of equilibrium). In all of these cases the patient was referred by the GP on the day the problem was presented to him. N o death due to meningitis was found. Discussion

A survey of the literature did not reveal any study about patients suspected of meningitis in general practice. We found four Danish studies that reported on the provisional diagnosis of the GP in patients with a hospital diagnosis of meningitis. ',"J'.'~ These studies used hospital data and are therefore not comparable to our study. They reported a correct diagnosis by the GP in 50-95% of the referred patients with meningitis. In our study, in two of the ten patients with confirmed meningitis, the GP had another working hypothesis, but these patients were referred because the GP considered further evaluation necessary. In the Danish studies the predictive value of the provisional diagnosis of meningitis by the GP in the referred patients was 9% and 40%, in our study 6/13 = 46%. These studies also indicate that it is difficult to diagnose meningitis correctly in general practice. The data of the National Survey provides a unique opportunity to look at cases of meningitis in general practice. The large study population makes it possible to study a disease that is quite rare in general practice. The study design enabled us to trace the patients with meningitis or suspected meningitis both referred to hospital and not referred.

In three patients with mumps clinical signs of meningitis were found; one of them had also signs of pancreatitis. Because of the usually benign character of mumps-meningitis admittance to hospital is not mandatory." The two paEuropean Journal of General Practice, Volume 1, March 1995

tients in this study who showed the typical signs of a mumps-meningitis were not referred by their general practitioners and recovered completely without sequelae. In 53%, 9 of the 17 patients with a provisional diagnosis meningitis by the general practitioner, the final diagnosis turned out to be different. In the majority of these patients the GP reported meningeal irritability and/or disturbed consciousness but this was not confirmed in hospital. Variation of symptoms in time could explain this difference. Another explanation could be the interdoctor variation in examining ill patients, especially for the presence of meningeal irritability. We can conclude that it is difficult to diagnose meningitis correctly in general practice. Hence, it is inevitable that patients will be referred with a provisional diagnosis meningitis which is not confirmed in hospital. Acknowledgement The authors thank Dr Arthur M Bohnen for his helpful comments. References 1 Klein JO, Feigin RD, M c Cracken J r GH. Report of the task force on diagnosis and management of meningitis. Pediatrics 1986; 78 (SUPPI):959-82. 2 Saez-Llorens X, Ramilo 0, Mustafa MM, Mertsola J, McCracken Jr GH. Molecular pathophysiology of bacterial meninb''itis: . current concepts and therapeutic implications. J Pediatrics 1990; 116: 671-84. 3 Mathiassen B, Thomsen H, Landsfeldt U. An evaluation of the accuracy of clinical diagnosis at admission in a population with epidemic meningococcal disease. J rnt Med 1989; 226: 113-6. 4 Sell SH. Long term sequelae of bacterial meningitis in children. Pediatr Infect Dis 1983; 2: 90-3. 5 Swartz MN, Dodge PR. Bacterial meningitis- a review of selected aspects. N Eng J Med 1965; 272: 725-31,779-87,954-63, 1003-9. (References continued on page 24)

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PENSEES

One of the great pleasures of medicine is its links with so many other areas of life and human activity. It is commonplace to describe medicine as an art and a science, but its connections with, particularly, the humanities and the arts are both stimulating and valuable. Any journal worth its salt, as well as reflecting this, will also encourage its readers to contribute, not only on scientific subjects, but also on the wider boundaries relating to medicine. This page, entitled ‘PensCes’, is an invitation to all readers of the Journal to contribute their own ideas, musings, thoughts, on any topic. Contributions should be in English and not exceed 750 words. They should be submitted to the Editor in accordance with details set out elsewhere in the Journal.

ANTON PAVLOVICH Not far from the Kremlin, in a bend of the Moskva river, lies the Novodevichy Convent, founded in 1524. Within its walls a cemetery contains the graves of, amongst others, Prokofiev, Stanislavsky, Eisenstein, Khrushchev and Anton Pavlovich Chekhov.

I visited the cemetery on a cold, wet, November afternoon some years ago and was surprised to see parties of schoolchildren conducted around the memorials. It was difficult to find Chekhov’s grave, but having a copy of his letters, with his photograph on the front cover, and showing this to one of the school party leaders, I was quickly directed to the grave. Chekhov’s reputation in Britain probably rests more on his four great plays than anything else, but his brilliance as a writer of short stories is more notable. He described medicine as his wife, literature - his mistress, when he tired of one he spent the night with the other, he added that as long as it did not become a regular habit, it was not humdrum and neither of them suffered from his infidelity. Many of his stories are informed by, and relate to, his work and understanding as a doctor, mainly as a general practitioner, particularly during his time at his country estate, Melikhovo. Ronald Hingley, the most significant of

his English biographers, suggests that Chekhov had gone to the country expressly to practice medicine. The sick of

the district arrived from miles around, treatment and medicine were free. Chekhov went on his rounds by horse and trap. On one occasion a peasant found lying on a nearby road, his body pierced by a pitchfork, was dumped at Chekhov’s house, the only place where help was available. His understanding of the nature of illness and its effect on both patients and doctors is well illustrated in two of his stories. One entitled ‘Sleep, sleep’, is a tragic tale of a young 13 year old peasant nursemaid, driven to such lengths by her deprivation that she eventually, appallingly, kills the child she is meant to be looking after. In another story, ‘The Enemies’, he describes the conflict of conscience and personal loss, where an overworked doctor, whose son has just: died, has to respond to a patient’s unreasonable demands. In a much less serious vein his understanding of the pressures on doctors is revealed in ‘Uncle Vanya’, when Dr Astrov, visiting Vanya’s family, is relaxing in the warm garden after an enjoyable lunch. A dutiful servant comes in and calls him, ‘Dr Astrov’. The doctor looks up and the servant says ‘there’s a call for you’. We can all recognise the moment. Some consider Chekhov slow and boring but 90 years after his death his short stories are still read, his plays are considered classics and regularly staged. I am sure part of their attraction is their understatement. Other aspects of his greatness are his portrayal of ambiguity, his humour, his tolerance and his lack of moralising. Instead he presents the details of a situation and allows the reader, or observer, to draw conclusions. Chekhov resisted easy, simple labels for both himself and his work. His independence, the range of his interests, his plays and stories are some of the reasons for his continuing value to us today. Edmund Rhys, General Practitioner, United Kingdom.

ORIGINAL PAPER

(Patients with suspected meningitis: a study in general practice, continuation of page 23) 6 Gary N, Powers N, Todd JK. Clinical identification and comparative prognosis of high-risk patients with Haemophilus influenzae meningitis. Am J Dis Child 1989; 143: 307-11. 7 Kaplan SI, Smith EO, Wills C, Feigin RD. Association between preadmission oral antibiotic therapy and cerebrospinal fluid findings and sequelae caused by Haemophilus influenzae type b meningitis. Pediatr Infect Dis 1986; 5: 626-32. 8 Romer FK. Difficulties in the diagnosis of bacterial meningitis. Lancet 1977; 2: 345-7.

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9 Bensing JM, Foets M, Velden J van der, Zee J van der. De nationale studie van ziekten en verrichtingen in de huisartspraktijk. Huisarts Wet 1991; 34: 51-61. 10 Lamberts H, Wood M, editors. ICPC. International classification of primary care. Oxford: Oxford University Press, 1987. 11 Nielsen B, Sorensen HT, Nielsen JO. Children admitted for observation for suspected meningitis. Problems in diagnosis in general practice. Scand J Prim Health Care 1988; 6: 229-32. 12 Sorensen HT, Moller-Petersen J, Krarup HB, Pedersen H, Hansen H, Hamburger H. Diagnostic problems with meningococcal disease in general practice. J CIin Epidemiol1992; 45: 1289-93. 13 Ratzan KR. Viral meningitis. Med Clin North Am 1985;69: 399-413.

European Journal of General Practice, Volume 1, March 1995