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Classic Signs of Meningitis Flunk Accuracy Test. (Kernig's, Brudzinski's Sign).

SAN FRANCISCO - The diagnostic accuracy of three time-honored -clinical signs of meningitis proved abysmal in their first-ever rigorous prospective evaluation.

Kernig's sign, Brudzinski's sign, and nuchal rigidity have been written about and widely utilized in the clinical diagnosis of bacterial meningitis for more than 100 years, Dr. Vincent J. Quagliarello noted at the annual meeting of the Infectious Diseases Society of America.

But the diagnostic accuracy of these three signs had never been assessed using a control group, so there were no data as to the signs' sensitivity and specificity, according to Dr. Quagliarello, professor of medicine at Yale University in New Haven.

Dr. Quagliarello and his coinvestigator Karen Thomas, a Yale medical student, assembled a prospective cohort of 297 adults with suspected bacterial meningitis.

All of them underwent diagnostic lumbar puncture, which confirmed meningitis in 28%.

The sensitivity of a positive Brudzinski's or Kernig's sign for the diagnosis of meningitis proved to be a mere 5%. There was no patient subset in which the meningeal signs had genuine diagnostic accuracy. (See chart.)

Positive predictive values hovered around 25% and negative predictive values approximated 73%-"nowhere near the range that one would want as a clinician to make a definitive diagnosis or clinical decision as to whether to do a [lumbar puncture] in a patient," he said.

"In the days when these signs were originally described, patients who had meningitis were the most severe cases... .They presented with the most purulent cerebrospinal fluid findings.

In contemporary cases, where there's such a wide spectrum of pathogens and hosts and heterogeneous clinical presentations in terms of severity, classical clinical signs actually have very little diagnostic accuracy," Dr. Quagliarello concluded.
Diagnostic Accuracy of Classic Signs of Meningitis in 297 Patients

 Sensitivity Specificity PPV (*) NPV (**)

Kernig's sign 5% 95% 27% 72%
Brudzinski's sign 5% 95% 27% 72%
Nuchal rigidity 30% 68% 26% 73%

(*)Positive predictive value.

(**)Negative predictive value.

Source: Dr. Vincent J. Quagliarello
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Author:Jancin, Bruce
Publication:Internal Medicine News
Geographic Code:1USA
Date:Jan 1, 2002
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