Jolt Accentuation Research Articles

Sensitivity and Specificity of Jolt Accentuation Maneuver in Diagnosis of Acute Meningitis

Background: Acute meningitis is a potentially fatal illness that necessitates immediate identification and medical intervention. The Jolt Accentuation Maneuver (JAM) is a straightforward and non-invasive diagnostic test that can help in diagnosis of acute meningitis. Objectives: This study assessed the accuracy of JAM in detecting acute meningitis by evaluating its sensitivity and specificity. Methods: The study was done at Pak Emirate Military Hospital, Rawalpindi, from January 2024 to June 2024, using prospective observational method. 280 patients with symptoms indicative of meningitis were included in the study. Every patient received JAM procedure, followed by an examination of CSF, which was used as the definitive method for diagnosis. Results: The study group had average age of 35.2 years and was almost equally divided between males (50.7%) and females (49.3%). The prevalent symptoms consisted of headache (97.1%), fever (92.9%) and neck stiffness (82.1%). The JAM test demonstrated sensitivity of 88.9% (p<0.001) and specificity of 60.0% (p<0.05). The positive predictive value (PPV) was 80.0% (p<0.05) and negative predictive value (NPV) was 75.0% (p<0.05). The overall accuracy of the data was 82.1% (p<0.001) indicating statistical significance. The study of ROC curve revealed an area under the curve of 0.90, indicating a high level of diagnostic accuracy. Conclusions: JAM is a diagnostic test for acute meningitis that is quite sensitive and has a decent level of specificity. Due to its high sensitivity, it is highly effective tool for initial screening, particularly in emergency circumstances. Nevertheless, because of its moderate specificity, it is necessary to confirm positive JAM results with other diagnostic testing. Incorporating JAM into clinical practice can expedite diagnosis and prompt treatment, potentially enhancing patient outcomes. Keywords: Acute meningitis, Diagnosis, Jolt Accentuation Maneuver, Sensitivity, Specificity.

Case Study: A Heart Transplant Recipient with New, Severe Headache (P3-12.011)

<h3>Objective:</h3> To describe a case and raise awareness of tick-borne disease as an important cause of secondary headache in transplant recipients. <h3>Background:</h3> Tick-borne illness is an uncommon but important cause of secondary headache, especially within the transplant population. Organ transplant recipients have a 2.3-fold relative risk of death and of severe, systemic infection. Identification of risk factors for tick-borne disease is essential to reduce morbidity and mortality in this patient population. <h3>Design/Methods:</h3> Case Study <h3>Results:</h3> A middle-aged patient with history of a prior heart transplant was admitted with headache for four days. The pain was mild initially but soon worsened and was exacerbated by bright lights, coughing, and changes in head position. He had never experienced similar pain or migraine. Medications included daily sirolimus, tacrolimus, and prednisone. The patient lived in the rural Midwest. The patient was afebrile and other vital signs were stable. Exam was notable for positive Jolt accentuation and negative Kernig/Brudzinski signs and no noticeable rashes. He was oriented but was unable to spell the word “world” backwards. Otherwise, exam was normal. Lumbar puncture revealed clear CSF with 0 RBC/cumm, 0 Nucleated cells/cumm, Protein 57 mg/dL (H), Glucose 62 mg/dL (serum glucose 100 mg/dL). Bacterial/fungal cultures demonstrated no organisms on Cytospin gram staining. VZV, CMV, WNV, and HSV PCR analyses were sent. Other labs were significant for hyponatremia (132 mmol/L), leukopenia (1.9 K/cumm), microcytic anemia (Hgb 10.9 g/dL, MCV 74 fL), and thrombocytopenia (81 K/cumm). CT Head and MRI brain were normal. This patient’s CSF viral PCR studies returned negative. A qualitative blood PCR assay for <i>Ehrlichia chaffeensis, E. ewingii</i>, and <i>E. canis</i> returned positive. The patient received doxycycline for a 10-day course with improvement. <h3>Conclusions:</h3> Identification of tick-borne disease in patients with a history of chronic immune suppression is necessary to avoid complications related to this relatively uncommon cause of infection. <b>Disclosure:</b> Dr. Anderson has nothing to disclose. Mary Petrulis has nothing to disclose. Dr. Wu has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Progentec. Dr. Wu has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Wu has received personal compensation in the range of $0-$499 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Neuroimmunology. Dr. Wu has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Department of Justice.

Campylobacter fetus bacteremia and meningitis in an acute lymphoblastic leukemia patient undergoing maintenance therapy: a case report

BackgroundCampylobacter fetus is an uncommon Campylobacter species, and its infections mainly cause infective endocarditis, aortic aneurysm, and meningitis rather than enteritis. It is more likely to be detected in blood than Campylobacter jejuni or Campylobacter coli, specifically reported in 53% of patients. In our case, C. fetus was detected in both blood and cerebrospinal fluid (CSF) cultures.Case presentationA 33-year-old woman, who was on maintenance chemotherapy for acute lymphoblastic leukemia (ALL), presented to our clinic with chief complaints of severe headache and nausea. Blood and CSF cultures revealed C. fetus. We administrated meropenem 2 g intravenously (IV) every 8 h for 3 weeks, and she was discharged without neurological sequelae.ConclusionWe encountered a case of C. fetus meningitis without gastrointestinal symptoms, neck stiffness or jolt accentuation in a patient with ALL. Undercooked beef was considered the source of C. fetus infection in this case, suggesting that the need for a neutropenic diet and safe food handling be considered.

Xanthochromia: yellow color is a red flag.

A 72-year-old previously healthy man consulted in our hospital for persistent moderate headache, accompanied by flexor pain of both thighs and low-grade fever for five days. Although the symptoms were worsened by motion, he noticed the flexor pain was most severe when taking a bow. On physical examination, he was fully alert and oriented to person, place, and time. His body temperature, blood pressure, pulse, and respiratory rate were 37.6 °C, 126/81 mmHg, 67 beats/min, and 16 breaths/min, respectively. His neck was supple. Kernig's and Brudzinski's signs were negative. There was a positive jolt accentuation test. No other neurologic findings were remarkable. Head computed tomography (CT) was normal; therefore, a lumbar puncture was performed, following suspicion of meningitis. Cerebrospinal fluid (CSF) analysis revealed 14 cells per microliter (mononucleosis was dominant), protein 185 mg/dL, and glucose 34 mg/dL. The opening pressure was 13 cmH2O. The CSF had an orange-yellow appearance (Figure 1a). This was suggestive of xanthochromia. Contrast-enhanced head CT and head magnetic resonance imaging were performed, and a ruptured anterior communicating artery aneurysm was detected (Figure 1 b). He was diagnosed with aneurysmal subarachnoid hemorrhage (SAH), which was classified as Grade 1 and Group 1, according to the World Federation of Neurological Surgeons subarachnoid hemorrhage grading scale and Fisher grade of cerebral vasospasm risk, respectively. Regarding the presenting symptoms, thigh flexor pain and low-grade fever were symptoms of breakdown of blood products within the CSF, which led to aseptic meningitis, also called meningismus. He was admitted to the intensive care unit for neurological and hemodynamic monitoring. Aneurysm repair with surgical clipping was performed, and after 4 weeks of rehabilitation, he was discharged ambulatory.

What is the accuracy of jolt accentuation for detecting acute meningitis in people presenting with headache in the emergency setting?

What is the accuracy of jolt accentuation for detecting acute meningitis in people presenting with headache in the emergency setting?

Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting.

Meningitis is inflammation of the meninges, the layers that protect the brain and spinal cord. Acute meningitis is an emergent disease that develops over the course of hours to several days. Delay in treatment can lead to serious outcomes. Inflammation of the meninges is assessed by analysing cerebrospinal fluid. Identifying the pathogen in cerebrospinal fluid is another way to diagnose meningitis. Cerebrospinal fluid is collected by doing a lumbar puncture, which is an invasive test, and can be avoided if a physical examination excludes the diagnosis of meningitis. However, most physical examinations, such as nuchal rigidity, Kernig's test, and Brudzinski's test, are not sufficiently sensitive to exclude meningitis completely. Jolt accentuation of headache is a new and less well-recognised physical examination, which assesses meningeal irritation. It is judged as positive if the headache is exacerbated by rotating the head horizontally two or three times per second. A 1991 observational study initially reported high sensitivity of this examination to predict pleocytosis. Pleocytosis, an abnormally high cerebrospinal fluid sample white cell count, is an accepted indicator of nervous system infection or inflammation. Jolt accentuation of headache may therefore accurately rule out meningitis without the use of lumbar puncture. However, more recent cross-sectional studies have reported variable diagnostic accuracy. To estimate the diagnostic accuracy of jolt accentuation of headache for detecting acute meningitis in emergency settings. Secondary objectives: to investigate the sources of heterogeneity, including study population, patient condition, and types of meningitis. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and Embase (Elsevier) to 27 April 2020. We searched ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and Ichushi-Web Version 5.0 to 28 April 2020. We included cross-sectional studies that assessed the diagnostic accuracy of jolt accentuation of headache for people with suspected meningitis in emergency settings. We included participants of any age and any severity of illness. Meningitis should be diagnosed with any reference standard, such as cerebrospinal fluid pleocytosis, proof of causative agents, or autopsy. Two review authors independently collated study data. We assessed methodological quality of studies using QUADAS-2 criteria. We used a bivariate random-effects model to determine summary estimates of sensitivity and specificity where meta-analysis was possible. We performed sensitivity analyses to validate the robustness of outcomes. We assessed the certainty of the evidence using the GRADE approach. We included nine studies (1161 participants). Five studies included only adults. Four studies included both adults and children; however, the proportion was not reported in three of these studies. The youngest child reported in the studies was aged 13 years. There was no study including only children. The reference standard was pleocytosis in eight studies, and the combination of pleocytosis and increased protein in the cerebrospinal fluid in one study. Two studies also used smear or positive culture of cerebrospinal fluid. Risk of bias and concern about applicability was high in the participant selection domain for all included studies and the consciousness subgroup. Overall, pooled sensitivity was 65.3% (95% confidence interval (CI) 37.3 to 85.6), and pooled specificity was 70.4% (95% CI 47.7 to 86.1) (very low-certainty evidence). We established the possibility of heterogeneity from visual inspection of forest plots. However, we were unable to conduct further analysis for study population, types of meningitis, and participants' condition, other than disturbance of consciousness (a secondary outcome). Amongst participants whose consciousness was undisturbed (8 studies, 921 participants), pooled sensitivity and specificity were 75.2% (95% CI 54.3 to 88.6) and 60.8% (95% CI 43.4 to 75.9), respectively (very low-certainty evidence). Jolt accentuation for headache may exclude diagnoses of meningitis in emergency settings, but high-quality evidence to support use of this test is lacking. Even where jolt accentuation of headache is negative, there is still the possibility of acute meningitis. This review identified the possibility of heterogeneity. However, factors that contribute to heterogeneity are incompletely understood, and should be considered in future research.

Sensitivity and specificity of meningeal signs in patients with meningitis.

BackgroundSeveral types of physical examinations are used in the diagnosis of meningitis, including nuchal rigidity, jolt accentuation, Kernig's sign, and Brudzinski's sign. Jolt accentuation was reported to have sensitivity of nearly 100% and to be highly efficient for excluding meningitis, but more recent studies showed that a number of patients with meningitis may present negative in this test.MethodsWe systematically reviewed studies on the above‐mentioned physical examination tests and performed meta‐analysis of their diagnostic characteristics to evaluate the clinical usefulness. Nine studies, comprising a total of 599 patients with pleocytosis in the cerebrospinal fluid (CSF) and 1216 patients without CSF pleocytosis, were enrolled in the analysis.ResultsJolt accentuation showed a decent level of odds ratio (3.62; 99% confidence interval (CI): 1.13‐11.60, P = 0.004) comparable to that in nuchal rigidity (2.52; 1.21‐5.27, P = 0.001) for the correct prediction of CSF pleocytosis among subjects with suspected meningitis. The estimated sensitivity was relatively high (40%‐60%) in nuchal rigidity or jolt accentuation tests. On the other hand, Kernig's and Brudzinski's signs exhibited relatively low sensitivity (20%‐30%). The estimated specificity was higher in Kernig's and Brudzinski's signs (85%‐95%) than in nuchal rigidity or jolt accentuation tests (65%‐75%).ConclusionApproximately half of the patients with meningitis may not present typical meningeal signs upon physical examination. Combining several examinations for the detection of meningeal signs may decrease the risk of misdiagnosis.

Outbreak of aseptic meningitis caused by echovirus 30 in Kushiro, Japan in 2017

Background: Echovirus 30 (E30) is one of the most common causative agents for aseptic meningitis.Objectives: In the autumn of 2017, there was an outbreak caused by E30 in Kushiro, Hokkaido, Japan. The aim of this study was to characterize this outbreak.Study design: Fifty-nine patients were admitted to the Department of Pediatrics, Kushiro Red Cross Hospital (KRCH) with clinical diagnosis of aseptic meningitis. Among those, 36 patients were finally diagnosed as E30-associated aseptic meningitis by the detection of viral RNA using reverse transcription-polymerase chain reaction (RT-PCR) and/or the evidence of more than four-fold rise in neutralizing antibody (NA) titers in the convalescent phase relative to those in the acute phase. We investigated these 36 confirmed cases.Results: The median age was 6 years (range: 6 months–14 years). The positive signs and symptoms were as follows: fever (100%), headache (94%), vomiting (92%), jolt accentuation (77%), neck stiffness (74%), Kernig sign (29%), and abdominal pain (28%). The median cerebrospinal fluid (CSF) white cell count, neutrophil count, and lymphocyte count were 222/μL (range: 3–1434/μL), 144/μL (range: 1–1269/μL), and 85/μL (range: 2–354/μL), respectively. Although the detected viral genes demonstrated same cluster, they were different from E30 strains observed in Japan between 2010 and 2014.Conclusion: We mainly showed clinical and virological features of the E30-associated aseptic meningitis outbreak that occurred in Kushiro. To prevent further spread of E30 infection, continuous surveillance of enterovirus (EV) circulation and standard precautions are considered essential.

Association between aseptic meningitis and jolt accentuation of headache in adults

The purpose of this study was to elucidate the association between aseptic meningitis and jolt accentuation of headache (JAH) in adults. 87 patients with meningeal irritation (age; 35.6 ± 13.3 years old, 45 males) who were admitted to our hospital from 1st August 2013 to 31st August 2018 were included. The diagnosis was determined according to the following criteria:, aseptic meningitis was defined as cerebrospinal fluids (CSF) pleocytosis with no evidence of bacterial infection, fungal infection or carcinomatous findings; meningism was defined as the absence of CSF pleocytosis. None of these patients had consciousness disturbance and focal neurological abnormalities. The blood and CSF data were reviewed for analysis. 61 patients were in aseptic meningitis group, 26 patients were in meningism group. Multiple logistic regression analysis showed older age (OR 1.059, 95% Confidence interval (CI) 1.012-1.108, P = 0.013), lower CRP (OR 0.803, 95%CI 0.697-0.925, P = 0.002) and absence of JAH (OR 0.048, 95%CI 0.004-0.554, P = 0.015) were significantly associated with aseptic meningitis. The sensitivity and specificity of JAH in aseptic meningitis were 68.9%, 3.8%.

Does This Adult Patient With Jolt Accentuation of Headache Have Acute Meningitis?

In order to identify appropriate candidates with suspected meningitis for lumbar puncture (LP), study designs and diagnostic values of jolt accentuation of headache (JA) were reviewed. Acute meningitis is a life-threatening disease that requires LP for accurate diagnosis. JA was reported the most sensitive indicator of cerebrospinal fluid pleocytosis; however, subsequent studies have failed to confirm this claim. We reviewed articles concerning JA, published prior to December 2017, using MEDLINE and Japanese medical databases. Seven original articles based on independent cohorts were eligible for inclusion and articles citing these 7 were thoroughly searched (11 in total). Additionally, all medical records of our previously reported cohort were reviewed again to explore how the patients' background influenced diagnostic values of JA. We hypothesized that an oversimplified dichotomy of JA findings, pleocytosis, and meningitis created a misconception that JA is a universal indicator of meningitis. We clarify the difference between them and present altered mental status (AMS) as a key to decrease the sensitivity of JA. Notably, the sensitivity and specificity of JA were relatively low in unselected groups, while they tended to be high in the selected sub-groups with acute onset of headache and fever, without AMS or neurological deficits. Unselected populations included etiologies of pleocytosis other than acute meningitis, which might weaken the association between JA and pleocytosis. JA is not a universal, stand-alone, indicator of meningitis in febrile patients with headache. Therefore, we propose a stepwise approach for patients with suspected acute meningitis. AMS or neurological deficits suggest an intracranial pathology, which may necessitate a lumbar puncture. JA seems a useful tool for distinguishing acute aseptic meningitis from upper respiratory infection when used in the selected cohort of febrile patients (≥37°C) with recent-onset headache (within 2 weeks before presentation) and normal mental status. This approach and diagnostic values of JA should be further investigated by prospective studies using operationally sorted candidates.

Accuracy of Neck stiffness, Kernig, Brudzinski, and Jolt Accentuation of Headache Signs in Early Detection of Meningitis.

The diagnostic value of clinical signs in early diagnosis of meningitis has been evaluated but the existing results are contradicting. The present study aimed to evaluate the accuracy of Kernig, Brudzinski, neck stiffness, and Jolt Accentuation of Headache (JAH) signs in this regard. In this diagnostic accuracy study, patients with suspected meningitis who were referred to the emergency department were examined regarding presence or absence of the mentioned clinical signs and screening performance characteristics of the signs were calculated. Cerebrospinal fluid analysis was used as the reference test. 120 cases with mean age of 48.79 ± 21.68 years (18 - 93) were studied (63.3% male). Diagnosis of meningitis was confirmed for 45 (37.5%) cases. Neck stiffness (p < 0.001), Kernig (p < 0.001), Brudzinski (p < 0.001), and JAH (p < 0.001) had significantly higher frequency among patients with meningitis. The accuracy of neck stiffness, Kernig, Brudzinski, and JAH signs in early detection of meningitis were 0.676 (95% CI: 0.575-0.776), 0.667 (95% CI: 0.552-0.782), 0.720 (95% CI: 0.619-0.821), 0.749 (95% CI: 0.659-839), respectively. It seems that diagnostic value of JAH is higher than other clinical signs but the accuracy of all signs is in poor to fair range. JAH had the highest sensitivity and Kernig and Brudzinski had the highest specificity.

Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting

Background Meningitis is inflammation of the meninges, the layers that protect the brain and spinal cord. Acute meningitis is an emergent disease that develops over the course of hours to several days. Delay in treatment can lead to serious outcomes. Inflammation of the meninges is assessed by analysing cerebrospinal fluid. Identifying the pathogen in cerebrospinal fluid is another way to diagnose meningitis. Cerebrospinal fluid is collected by doing a lumbar puncture, which is an invasive test, and can be avoided if a physical examination excludes the diagnosis of meningitis. However, most physical examinations, such as nuchal rigidity, Kernig's test, and Brudzinski's test, are not sufficiently sensitive to exclude meningitis completely. Jolt accentuation of headache is a new and less well-recognised physical examination, which assesses meningeal irritation. It is judged as positive if the headache is exacerbated by rotating the head horizontally two or three times per second. A 1991 observational study initially reported high sensitivity of this examination to predict pleocytosis. Pleocytosis, an abnormally high cerebrospinal fluid sample white cell count, is an accepted indicator of nervous system infection or inflammation. Jolt accentuation of headache may therefore accurately rule out meningitis without the use of lumbar puncture. However, more recent cross-sectional studies have reported variable diagnostic accuracy. Objectives To estimate the diagnostic accuracy of jolt accentuation of headache for detecting acute meningitis in emergency settings. Secondary objectives: to investigate the sources of heterogeneity, including study population, patient condition, and types of meningitis. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), and Embase (Elsevier) to 27 April 2020. We searched ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and Ichushi-Web Version 5.0 to 28 April 2020. Selection criteria We included cross-sectional studies that assessed the diagnostic accuracy of jolt accentuation of headache for people with suspected meningitis in emergency settings. We included participants of any age and any severity of illness. Meningitis should be diagnosed with any reference standard, such as cerebrospinal fluid pleocytosis, proof of causative agents, or autopsy. Data collection and analysis Two review authors independently collated study data. We assessed methodological quality of studies using QUADAS-2 criteria. We used a bivariate random-effects model to determine summary estimates of sensitivity and specificity where meta-analysis was possible. We performed sensitivity analyses to validate the robustness of outcomes. We assessed the certainty of the evidence using the GRADE approach. Main results We included nine studies (1161 participants). Five studies included only adults. Four studies included both adults and children; however, the proportion was not reported in three of these studies. The youngest child reported in the studies was aged 13 years. There was no study including only children. The reference standard was pleocytosis in eight studies, and the combination of pleocytosis and increased protein in the cerebrospinal fluid in one study. Two studies also used smear or positive culture of cerebrospinal fluid. Risk of bias and concern about applicability was high in the participant selection domain for all included studies and the consciousness subgroup. Overall, pooled sensitivity was 65.3% (95% confidence interval (CI) 37.3 to 85.6), and pooled specificity was 70.4% (95% CI 47.7 to 86.1) (very low-certainty evidence). We established the possibility of heterogeneity from visual inspection of forest plots. However, we were unable to conduct further analysis for study population, types of meningitis, and participants' condition, other than disturbance of consciousness (a secondary outcome). Amongst participants whose consciousness was undisturbed (8 studies, 921 participants), pooled sensitivity and specificity were 75.2% (95% CI 54.3 to 88.6) and 60.8% (95% CI 43.4 to 75.9), respectively (very low-certainty evidence). Authors' conclusions Jolt accentuation for headache may exclude diagnoses of meningitis in emergency settings, but high-quality evidence to support use of this test is lacking. Even where jolt accentuation of headache is negative, there is still the possibility of acute meningitis. This review identified the possibility of heterogeneity. However, factors that contribute to heterogeneity are incompletely understood, and should be considered in future research.

Can We Rule Out Meningitis from Negative Jolt Accentuation? A Retrospective Cohort Study.

Jolt accentuation has been considered to be the most sensitive physical finding to predict meningitis. However, there are only a few studies assessing the diagnostic accuracy of jolt accentuation. Therefore, we aimed to evaluate the diagnostic accuracy of jolt accentuation and investigate whether it can be extended to patients with mild altered mental status. We performed a single center, retrospective observational study on patients who presented to the emergency department in a Japanese tertiary care center from January 1, 2010 to March 31, 2016. Jolt accentuation evaluated in patients with fever, headache, and mild altered mental status with Glasgow Coma Scale no lower than E2 or M4 was defined as "jolt accentuation in the broad sense." Jolt accentuation evaluated in patients with fever, headache, and no altered mental status was defined as "jolt accentuation in the narrow sense." We evaluated the sensitivity and specificity in both groups. Among 118 patients, the sensitivity and specificity of jolt accentuation in the broad sense were 70.7% (95% confidence interval (CI): 58.0%-80.8%) and 36.7% (95% CI: 25.6%-49.3%). The positive likelihood ratio and negative likelihood ratio were 1.12 (95% CI: 0.87-1.44) and 0.80 (95% CI: 0.48-1.34), respectively. Among 108 patients, the sensitivity and specificity of jot accentuation in the narrow sense were 75.0% (95% CI: 61.8%-84.8%) and 35.1% (95% CI: 24.0%-48.0%). The positive likelihood ratio and negative likelihood ratio were 1.16 (95% CI: 0.90-1.48) and 0.71 (95% CI: 0.40-1.28), respectively. Jolt accentuation itself has a limited value in the diagnosis of meningitis regardless of altered mental status. Therefore, meningitis should not be ruled out by negative jolt accentuation.

Jolt accentuation and its value as a sign in diagnosis of meningitis in patients with fever and headache

ObjectivesMeningitis is an important disease among the patients being visited in Emergency Departments (EDs). There are many signs to diagnose it with different sensitivity and specificity reported in previously done studies. Current study tries to evaluate diagnostic accuracy of “Jolt accentuation” in the diagnosis (Dx.) of meningitis in patients with fever and headache. Materials and methods48 adult patients, who were referred to two teaching EDs for fever and headache and were diagnosed as suspected meningitis, were included in this prospective observational study. Demographic characteristics of patients were recorded in data sheets, as well as the results of exams including nuchal rigidity, Kernig and Brudzinski signs, and Jolt accentuation. Then, lumbar puncture (LP) was done and cerebrospinal fluid (CSF) was analyzed for each patient; pleocytosis (more than five white blood cells in high power field) were considered as meningitis. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios (LR+ and LR−) of the above mentioned signs were compared to each other. ResultsMeningitis was proved in 33 patients (68.8% of them), according to CSF analysis. Jolt accentuation had sensitivity, specificity, PPV, NPV, LR+, and LR− of 69.6%, 33.3%, 69.6%, 33.3%, 1.02, and 0.91, respectively. Jolt accentuation had the highest sensitivity rate all of the signs mentioned above; although, it was not significant. ConclusionJolt accentuation alone cannot rule in or out the Dx. of meningitis in patients with fever and headache; LP is still recommended for these patients.

Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults

Jolt accentuation or exacerbation of a baseline headache with horizontal rotation of the neck is a physical finding believed to assess for meningeal irritation. We conducted a prospective observational study of neurologically intact emergency department (ED) patients undergoing lumbar puncture in 2 inner city academic EDs to validate the sensitivity and specificity of jolt accentuation and to assess the sensitivity and specificity of Kernig sign, Brudzinski sign, and nuchal rigidity, in predicting cerebrospinal fluid (CSF) pleocytosis in individuals being assessed for meningitis. Adult patients 18 years and older undergoing lumbar puncture between 2006 and 2009 were approached for consent. Exclusions included inability to consent and altered mental status. Physicians were asked to answer a questionnaire of physical examination findings before receiving CSF results. The primary outcome was the presence or absence of pleocytosis, defined as greater than or equal to 5 cells/high-power field in the fourth CSF tube. We calculated descriptive statistics and tests of diagnostic accuracy. A total of 230 patients consented for participation and had CSF white blood cell counts recorded. Forty-seven individuals (20%) had pleocytosis. A total of 197 patients had headache and were, hence, eligible for jolt accentuation assessment. For pleocytosis, the sensitivity of jolt accentuation was 21%, Kernig sign was 2%, Brudzinski sign was 2%, and nuchal rigidity was 13%. The specificity of jolt accentuation was 82%, Kernig sign was 97%, Brudzinski sign was 98%, and nuchal rigidity was 80%. Jolt accentuation in our cohort was poorly predictive of pleocytosis and insensitive. The presence of Kernig sign, Brudzinski sign, or nuchal rigidity has moderate positive but no negative predictive value for pleocytosis.

Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults

BackgroundMeningitis is a common emergency disease. Signs and symptoms easily observed at the bedside are needed because early recognition of the possibility of meningitis is necessary for the decision to perform lumbar puncture. Jolt accentuation of headache has been reported to be the most sensitive diagnostic test; however, limited articles have reproduced its sensitivity. MethodsThis is a single-center retrospective medical record review between 2007 and 2012. We diagnosed meningitis based on the criterion standard that cerebrospinal fluid total cells is more than 5/mm3, in accordance with previous studies. All diagnostic and management decisions including Kernig sign, nuchal rigidity, and jolt accentuation of headache were at the physician's discretion. We calculated the sensitivity and specificity of well-known signs and symptoms of meningitis and, especially, compared the efficacy of jolt accentuation of headache with previous studies. ResultsWe investigated 531 adult patients who were suspected of meningitis and had lumbar puncture performed. Of these patients, 139 had meningitis. Background characteristics and vital signs were not clinically different between the 2 groups, although classic tetralogy of bacterial meningitis (fever, nuchal rigidity, mental disturbance, and headache) was worth investigated. The sensitivity and specificity of jolt accentuation of headache were 63.9% (95% confidence interval, 51.9%-76.0%) and 43.2% (34.7%-51.6%), respectively. ConclusionThe absence of jolt accentuation of headache test cannot, on its own, accurately rule out meningitis in adults. Further studies are warranted to reproduce this result and to discover better bedside diagnostic tests.

19 Jolt Accentuation of Headache: Sensitive Enough for Pleocytosis to Rule-Out Need for a Lumbar Puncture in Diagnosing Meningitis?

19 Jolt Accentuation of Headache: Sensitive Enough for Pleocytosis to Rule-Out Need for a Lumbar Puncture in Diagnosing Meningitis?

Accuracy of physical signs for detecting meningitis: A hospital-based diagnostic accuracy study

Objectives To evaluate accuracy of physical signs for detecting meningitis. Patients and methods We enrolled patients aged 12 years or more, admitted with acute encephalitis syndrome (fever, headache, altered mental status, vomiting, seizures, neurodeficit) to a rural teaching hospital. The design was a double-blind, cross-sectional analysis of consecutive patients, independently comparing signs of meningeal inflammation (nuchal rigidity, head jolt accentuation of headache, Kernig's sign and Brudzinski's sign) elicited by internal medicine residents against an established reference standard (cerebrospinal fluid white cell count >5 white cells/μL). Diagnostic accuracy was measured by computing sensitivity, specificity and likelihood ratios (LRs) and their 95% confidence interval (CI) values. Results Of 190 patients (119 men, 71 women; ages 13–81 years; mean 38(SD 18) years) CSF analysis identified meningitis in 99 (52%; 95% CI 44, 59%) patients. No physical sign of meningeal irritation could accurately distinguish those with and without meningitis: nuchal rigidity (LR+ 1.33 (0.89, 1.98) and LR− 0.86 (0.70, 1.06)), head jolt accentuation of headache (LR+ 5.52 (0.67, 44.9) and LR− 0.95(0.89, 1.00)), Kernig's sign (LR+ 1.84 (0.77, 4.35) and LR− 0.93(0.84, 1.03)) and Brudzinski's sign (LR+ 1.69 (0.65, 4.37) and LR− 0.95 (0.87, 1.04)). Conclusion Physical signs of meningeal inflammation do not help clinicians rule in or rule out meningitis accurately. Patients suspected to have meningitis should undergo a lumbar puncture regardless of the presence or absence of physical signs.

PP-034 Jolt accentuation of headache in diagnosis of acute meningitis

PP-034 Jolt accentuation of headache in diagnosis of acute meningitis

PP-035 Environmental surveillance for methicillin resistance coagulase negative staphylococci (MRCoNS) in Hospital Universiti Sains Malaysia (HUSM)

Background: Optimal use of the clinical examination aids physicians to identify patients with meningitis risk. The low specificity of the meningeal signs may be due to the presence of cervical arthritis and spondylosis among some patients. One of the most sensitive maneuvers in the diagnosis of meningitis is jolt accentuation of headache. Method: A descriptive research was performed on suspected acute meningitis patients. The patients were evaluated for presence of meningial signs before lumbar puncture. Results: 14 patients were evaluated. There was neck stiffness, Kernig’s, brudzinski’s and jolt sign in 78.6%, 14.3%, 14.3%, and 64.3% of patients respectively. The prevalence, sensitivity and specificity, PPV, NPV, LR+, LR of neck stiffness in comparison with pleocytosis was 50%, 100%, 57%, 70%, 100%, 2.33, and 0 respectively. The prevalence, sensitivity and specificity, PPV, NPV, LR+, LR of jolt sign in comparison with neck stiffness was 78.5%, 82%, 60%, 100%, 60%, 0, and 0.18 respectively. The prevalence, sensitivity and specificity, PPV, NPV, LR+, LR of jolt sign in comparison with pleocytosis was 50%, 100%, 71.5%, 78%, 100%, 1, and 0 respectively. Conclusion: This study shows that in evaluation of suspected meningitis patients who have some limitation to evaluate for neck stiffness, we can evaluate them with jolt sign in examination. The presence of LR (0.18) jolts sign in comparison with neck stiffness shows it is an appropriate sign in these patients. The presence of LR and LR+ (2.33, 0) for neck stiffness shows it is a good and appropriate way to diagnose meningitis. PP-035 Environmental surveillance for methicillin resistance coagulase negative staphylococci (MRCoNS) in Hospital Universiti Sains Malaysia (HUSM) I. Ibrahim1 *, H. Hasan1, Z. Abdul Rahman1. 1Universiti Sains Malaysia, Malaysia