Sometimes the simple tools are the best. I trained in an era when meningitis was a relatively common diagnosis. I made the diagnosis many times and it was always what I was fearful I might miss. Because of vaccinations for H. influenza, Streptococcus, and Meningococcus, it is very conceivable that a doctor, even a Pediatrician, could go through his entire residency without seeing a cause of meningitis, but I do not remember a month of ward or ER duty without a lot of cases. I always found that one of the best tools for evaluating a child for meningitis is car keys. In those bad old days, the peak age for meningitis was 8 months, so using things like confusion and altered consciousness that the books recommended were useless. And bending the neck of any child will cause them to cry. What I found to be the most helpful signs were unusual irritable and refuse to bend the neck on his own. So every time I went into a room with an irritable child with fever, I took out my keys and started rattling them before the child’s face. Almost always, the child became fascinated and his eyes were locked on the keys. So as I continued to rattle, I lowered the keys down to the point that the child needed to bend his neck. If he bent his neck and continued reaching for the keys, I felt meningitis was unlikely. I did a few other things, but if he would not lock in on the keys or would not bend his neck, he usually ended up with a lumbar puncture, and many of those ended up being meningitis. On rounds yesterday we had several irritable children. Two of the children followed the keys into their laps. I looked in their ears and they both had ear infections. A third child had fever at admission, but the fever had resolved, yet the child was still remarkably irritable. I pulled out my keys and his eyes did lock in, but he would not bend his neck, though I tried several times to get him to. I was unwilling to call him meningitis at that point, but I told the nurses to keep an eye on him. That afternoon he spiked a high fever and was quite stiff. The nurses, appropriately, started him on Ceftriaxone and he was much better and far more relaxed this AM.
At clinic today, Andrew Marial, one of my good friends from ACROSS, came to inform us that in a relatively near village they had made the diagnosis of meningitis in three children. None of us have confirmed the tests using a lumbar puncture, much less through culture, and one of the most common signs (petechiae [small nonblanching red dotes on the skin]) is invisible in Dinkas because of the color of their skin, but four cases of meningitis in one day gets your notice. Then Gordon Mayom told me a young boy from his church started with fever and “joint pains” (body aches), progressed to a headache and neck stiffness and died the same night. The most common organism in the epidemic form of meningitis is Meningococcus. It is also the one that is most common in adults, and it is the most likely to result in death. It is almost undoubtedly the organism that claimed the life of our beloved Rose’s eldest child when he was away at school and which her older girl contracted while Rose was at her eldest’s funeral (she was brought to the hospital, was treated and lived). That was in 2007-8, when a large epidemic swept through Africa, as tends to happen every 3-4 years, so we think we are on the cusp of another.
Last time we intervened with the Meningococcal vaccine, and though the hospital was swamped (by report, I was not here), our deaths were relatively few compared to much of Sudan. We are trying to get in the vaccines and prepare our medical supplies now. Please pray for us.
-- Dr. Clarke
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