Fungal meningitis physical examination

As in the case of any disease, a complete physical exam must be done on the patient looking for positive and negative symptoms. The clinical presentation of fungal meningitis is usually obscure as are the findings on physical exam. The pertinent findings are low grade fever and possible neurological signs like focal weakness, loss of sensation and cranial nerves involvement. Physical exam findings, including presence of rashes, lymphadenopathy, hepatomegaly, pulmonary disease, ocular pathology (eg, endophthalmitis, vitritis, chorioretinitis, uveitis, optic nerve involvement), and cranial nerve (CN) palsies, may narrow the differential. Papilledema and abducens nerve palsy suggest the presence of increased intracranial pressure (ICP). Kernig’s sign and brudzinski’s sign are not typically present in fungal meningitis.

• Patient may look distressed
• Altered mental status

Temperature

• A low grade fever is often present

• Nystagmus may be present.
• Extra-ocular movements may be abnormal
• Ophthalmoscopic exam may be abnormal with signs consistent with papilledema and may indicate increased intracranial pressure.
• Inflamed sinuses with facial tenderness in some cases.
• Signs of infection indicating sinusitis, mastoiditis, and otitis media may help identify the source of infection and give a clue about diagnosis.

• Neck stiffness is strongly suggestive of meningitis.

• The mental status is usually intact
• Muscular strength is usually intact, but focal deficits might be present
• Sensation is usually intact, but focal deficits might be present
• Hyperactive reflexes may be present
• Deficits in cranial nerves might be present: decreased vision acuity, facial muscle weakness, decreased hearing (CN VIII), and diplopia
• Gait might be altered

Following are the special tests for meningitis. Positive tests provide a strong suspicion for meningeal irritation:^[1]

• Kernig’s sign

• Postive kernig’s sign indicate meningitis.

• Brudzinski’s sign

• Positive brudzinski’s sign may suggest meningitis

• It should be noted that Kernig’s sign and brudzinski’s sign are not typically present in fungal meningitis.
• Jolt accentuation:^[2]

• Exacerbation of headache by moving head in horizontal direction two to three times indicate positive test.

• Decreased heart rate indicates increased intracranial pressure

• Neck stiffenss or hypotonia
• Altered mental status
• Bulging fontanelle
• Convulsions
• Petechial rash

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