Safety of care
Meningitis — Understanding the vulnerabilities
Originally published December 2015
Meningitis poses a significant risk of death and disability, especially in vulnerable populations. Rates of bacterial meningitis have dropped dramatically in Canada in recent decades, thanks in large part to routine vaccination against the most common bacteria that cause the disease, though youth remain especially susceptible.
Meningitis can evolve quickly, necessitating early treatment. Consequently, diagnostic issues are the biggest area of concern in medical-legal cases involving this disease. However, even with early diagnosis and appropriate treatment, severe outcomes can occur.
Forty CMPA medical-legal cases involving patients with meningitis closed over the last five years. Close to half of the patients were under age 20, with most being between the ages of 0 and 4. Only four patients were over age 65. All but three patients experienced serious outcomes. Of the patients with serious outcomes, 25 died or were left with catastrophic injuries, and the others experienced varying degrees of neurological impairment.
Patients presented with established meningitis in 28 cases, often with headache, nausea and vomiting, fever, or changes in neurological status (e.g. disorientation, drowsiness, visual disturbances), while some patients had an initial infectious process that later progressed to meningitis (e.g. sinusitis, tonsillitis, influenza, varicella, and tuberculosis). The majority of patients sought medical assistance more than once with similar or worsening complaints before the diagnosis of meningitis was made and treatment started.
Unique risks for young patients
The CMPA medical-legal cases involving young people shared common themes. These included:
- inadequate examination and investigation
- not appreciating the significance of “red flag” signs and symptoms (e.g. bulging fontanelle, fever, lethargy), or not considering meningitis in the differential diagnosis
- anchoring on common childhood ailments to explain the child’s condition
- not recognizing the severity or worsening of the child’s condition
- multiple visits with the same or worsening symptoms
Pneumococcal disease was the most common cause of meningitis in pediatric cases. Initial presentation often included signs of upper respiratory infection (e.g. sore throat, runny nose, or cough), fever, and sometimes gastrointestinal symptoms. Progression of symptoms was often noted in subsequent visits and included lethargy, vomiting, or changes in neurological status.
Cases of neonatal meningitis — most often involving Group B Streptococcus infection — were not common. There were only two cases of meningococcal disease, both in older youth.
Case example: Baby with apparent viral illness deteriorates after several healthcare visits
A mother takes her 10-month-old to a walk-in clinic. The day before, a pediatrician had diagnosed a viral illness and recommended acetaminophen and fluids, but the baby’s condition is getting worse. She has persistent vomiting, a high fever, and is lethargic. The family physician at the clinic, concerned about the possibility of dehydration and believing the patient’s condition warrants further investigation, advises the mother to take her to the emergency department (ED). He writes a referral note asking for an assessment and communicating the information of vomiting, fever, and one diaper change in more than 16 hours.
At the hospital, the infant is given 60 cc of oral electrolyte solution, which she tolerates, as well as acetaminophen. The ED physician on duty performs a brief exam and notes that the infant’s temperature, which was 40.4oC at triage, has decreased slightly. He discharges the patient two hours later with a diagnosis of gastroenteritis. Several hours later, the parents return with the baby to the ED after witnessing a seizure-like event. This time, on examination, the baby appears mottled and is unresponsive. She dies just a few hours later of complications from acute bacterial meningitis. The parents file a regulatory authority (College) complaint alleging the ED physician did not adequately examine their child.
In its decision, the College acknowledges that while meningitis can resemble viral illness, the ED physician did not adequately assess this patient. It finds that the physician should have conducted a more thorough work-up in light of the two previous clinic visits, which included the ED referral and the mother’s documented concerns about her baby’s lethargy, most notably the claim that the baby would not sit up. The examination should have included assessment of the fontanelle, neck stiffness, level of consciousness, general neurological status, and how the infant was responding to her parents. He should have also ordered tests to rule out serious conditions that could have been causing the infant’s symptoms, including bacterial infections. The College asserts that the physician should not have discharged the child after such a short trial of electrolyte fluid.
The ED physician is required to attend the College to be cautioned about the appropriate management of fever and lethargy in an infant.1
CMPA medical-legal cases involving adult patients with meningitis
Meningitis is relatively uncommon in the adult population. The CMPA medical-legal cases involving adults represented unusual clinical scenarios. When diagnosis was a factor in these cases, it was particularly challenging. Although most of the cases involving adults had unfavourable outcomes for the physicians, they were not necessarily related to the diagnosis.
Risk management considerationsPhysicians should consider the following recommendations, based on peer expert opinions from the CMPA cases concerning the diagnosis and management of possible meningitis:
- Obtain an adequate history and conduct an appropriate physical examination, taking into consideration the symptoms and signs of meningitis. Ensure that the patient’s (or parents’) concerns are acknowledged and addressed.
- Pay attention to abnormal vital signs, which may point to a serious infection or disease process.
- Review all key elements of the patient’s medical record, including earlier entries and referral notes, before establishing a diagnosis.
- Take time to pause and reflect on the differential diagnosis, being careful to consider possibilities that may be life-threatening. Obtain a second opinion if you are unsure of your diagnosis and whether or not you should rule out meningitis.
- Advise the patient or caregiver of symptoms and signs that should alert them to seek further medical attention.
- Ensure that investigations are appropriately scheduled and performed, and the resulting report is received and followed-up in a timely manner.
- Carefully document all aspects of the care provided, including pertinent clinical findings, treatment, and follow-up advice and recommendations.
- Re-evaluate the diagnostic assumption when the patient returns with the same or worsening symptoms.
- Details of the case have been modified to preserve confidentiality.