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Three Part Question

In [children presenting to hospital with febrile convulsions] does [routine lumbar puncture] [detect unsuspected cases of meningitis]

Clinical Scenario

An 11 month old child presented to the emergency department after just having a febrile convulsion. The child does not like to look at the lights in the department but otherwise appears well. You wonder whether this child should be investigated for meningitis, and whether a lumbar puncture is necessary.

Search Strategy

OVID Medline <1966-June week 3 2006>
EMBASE < 1980 to 2006 week 26>
CINAHL <1982 to June week 5 2006>
Paediatric filter applied
([lumbar puncture.mp. OR exp. Lumbar Puncture/ OR spinal puncture.mp. OR spinal tap.mp. OR dural puncture.mp. OR dural tap .mp.]) AND (febrile convulsion.mp. OR exp Febrile convulsion/ OR febrile fit.mp. OR fit.mp. OR febrile seizure.mp. OR pyrexia.mp. OR exp Fever/) AND (bacterial meningitis.mp. OR exp Bacterial Meningitis/ OR exp BACTERIAL MENINGITIS OR meningitis.mp. OR exp VIRUS MENINGITIS/ OR exp MENINGITIS/ OR viral meningitis.mp. OR meningitis,listeria.mp. OR meningitis, meningococcal.mp. OR meningitis, haemophilus.mp. OR meningitis, pneumococcal.mp.) Limit to (human and english language)

Search Outcome

Medline: 44 papers found
EMBASE: 21 papers found
CINAHL: 6 papers found
Cochrane: 0 relevant papers found
When febrile seizures etc not included in search:
Medline: 523 papers found
EMBASE: 286 papers found
CINAHL: 6 papers found
Cochrane: 0 relevant papers found
6 relevant papers found, 4 from medline, 1 from EMBASE and 1 from references from

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Akpede, G.O. and Sykes, R.M. 1992 Nigeria	522 infants between 1month and 6yrs presenting to emergency dept between Oct 1988 and Oct 1989.	Cohort and mini case study	Multiple seizures p< 0.05 and focal seizures p<0./001 more freq in children with meningitis		Study only on children in developing country with higher incidence of bacterial meningits
			Number of children with meningitis	22
			Number who had meningitis but lacked meningeal signs	6
Laditan, A.A.O. 1995 Saudi Arabia	95 children presenting with their first febrile convulsion between July 1993 and June 1994. aged 6 months to 6 years	Retrospective cohort	Number who had LP	95	No tests for statistical significance carried out.
			Number of children whose CSF analysis revealed meningitis	6
			Number of children who were diagnosed with meningitis without having meingeal signs	6/95 = 6.3% of LP yield for meningitis
			Number of complex febrile convulsion cases	8
			Number with meningitis	1/8
			Number of simple febrile convulsion cases	87
			Number with meningitis	5/87
Carroll, W. and Brookfield, D. 2002 UK	15 papers	Systematic review	Risk of bacterial meningitis in absence of other signs	Extremely small less than 1 in 200.	Search strategy and outcome not documented. Some of articles in review of low grade evidence.
Kneen, R. Solomon, T. and Appleton, R. 2002 UK	52 children with unsuspected CNS infection 43 with suspected meningococcal septicaemia. Children 9 days to 16 years old.	Retrospective cohort	Number of children who had LP	25/47 (53%)	Doesn't mention if meningeal signs present.
			% CSF abnormal	7/25 (28%)
			CSF bacterial culture positive	3/7
			Number of patients CSF excluded bacterial meningitis.	15/25
Owusu-Ofori, A. Agbeyega, T. Ansong, D. and Scheld, W.M. 2004 Ghana	Children 3 months to 15 years hospitalised at teaching hospital; in Kumasi Ghana. 608 admissions 186 pts had LP	Retrospective cohort	Routine lumbar punctures	Positive yield of 10.2% for bacterial meningitis
Chin, R.F.M. Neville, B.G.R. and Scott, R.C. 2005 UK	Children between 29 days and 15 years with convulsive status epilepticus with fever.	Retrospective cohort study	Number of children with CSE with fever	49% (24/49)	Small sample size Says 49 incident cases 44 notified by telephone hotline, 29 notified by surveillance, 25 notified by both-figures don't add up. Not all children had CSF sample taken No details given on how the children were chosen to have CSF sampling done.
			Number of children above who had LP	8 children
			Number with acute bacterial meningitis	4 children (16.7%, 95% CI 15%-18%)
			Number of above children who had meningitis and signs of meningism.	0 children

Comment(s)

Meningitis is an important cause of convulsions with fever and the usual signs of meningitis are often absent in such children, especially children younger than 12 months. The lack of clinical experience should not justify a lumbar puncture whilst on the other hand we need not to avoid necessary lumbar punctures. Prolonged febrile seizures (>15 minutes) are more likely to be associated with meningitis and therefore require a lumbar puncture6. In contrast Laditan2 concluded that the type of febrile convulsion should not serve as a guideline for LP but no statistical tests were carried out.

Clinical Bottom Line

Meningitis can present with febrile convulsions and no matter what the clinical expertise cannot always be excluded on clinical grounds. An experience paediatrician may be able to distinguish between acute bacterial meningitis and other diagnoses but it is generally difficult to exclude meningitis without a lumbar puncture. It must be remembered that a previously normal lumbar puncture does not rule out bacterial meningitis.

References

1. Akpede, G.O. and Sykes, R.M. Convulsions with fever as a presenting feature of bacterial meningitis among preschool children in developing countries. Developmental Medicine and Child Neurology.Vol 34 1992 p524-529
2. Laditan, A.A.O. Analysis of the results of routine lumbar puncture after a first fevrile convulsion in Hofuf, Al-Hassa, Saudi Arabia. East African Medical Journal. Vol 72 (6) 1995, p376-378
3. Carrol, W. & Brookfield, D Lumbar puncture following febrile convulsion Arch Dis Child. 87(3) 2002, p238-239
4. Kneen, R. Solomon, T. & Appleton, R. The role of lumbar puncture in children with suspected central nervous system infection. BMC Pediatrics. 2(8) 2002, p1-4
5. Owusus-Ofori, A. Agbenyego, T. Amsong, D. & Scheld, W.M. Routine lumbar Puncture in children with febrile seizures in Ghana should it continue? International Journal of Infectious Diseases. Vol 8 2004, p353-61.
6. Chin, R.F.M. Neville, B.G.R. & Scott, R.C. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child. Vol 90 2005, p66-69.