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Leg pain and cold extremities ‘red flags for meningitis’

By Lilian Anekwe

Leg pain and cold extremities have emerged as leading ‘red flag' symptoms in identifying children presenting with meningococcal disease in a large UK general practice study.

Primary care researchers at the University of Oxford found that both signs are highly predictive of meningococcal disease in children and adolescents, and can help GPs distinguish children with meningitis from minor febrile illness. Their latest data will be presented at Society for Academic Primary Care annual meeting later this month.

Children with leg pain were seven times more like to have meningococcal disease - and children with cold hands and feet were twice as likely – compared to children with minor feverish illness, the study found.

The research team included a GP member of the group currently drafting NICE guidance on bacterial meningitis and meningococcal septicaemia in children, which is due out in June.

The symptoms of 924 children who presented to 15 practices in Oxfordshire and Somerset with feverish illnesses were compared to symptom frequencies recorded from 345 children with meningococcal disease.

Leg pain, cold hand or feet, confusion, photophobia and neck pain or stiffness were all rarely reported by parents of children with minor febrile illness. Leg pain had a positive likelihood ratio of 7.6, cold extremities of 2.3, photophobia 6.5, neck pain and stiffness 5.3, confusion 24.2 and a rash 5.5 – all symptoms were ‘highly specific for meningococcal disease', researchers said, but pallor and headache had little diagnostic value.

Dr Tanya Haj-Hassan, a researcher in childhood infections at the University of Oxford, concluded: ‘The early red flag features of leg pain and cold extremities, as well as classical features of photophobia and neck pain and stiffness, are all highly specific for meningococcal disease.'

‘Confusion also emerged as an important red flag in children with meningococcal disease, and was as sensitive and specific as classic and red flag features.

‘When these symptoms are reported by parents they should usually prompt an urgent face to face assessment with a clinician to exclude meningococcal disease.'

Dr Anthony Harnden, a GP in Wheatley, Oxfordshire, and a researcher in childhood infections: ‘The one thing we found that did not occur in children with other acute infections was limb pain. Limb pain in early febrile illness in association with fever is a sign that GPs should consider whether a child has a more serious illness or septicaemia.'

Dr John Crimmins, a GP in Llantwit Major in Wales with an interest in paediatrics, said: ‘If reliable red flag symptoms were available everybody would be very happy. But the problem is that it's very difficult to pick it up very early and very often it has to depend upon subjective GP assessments rather than objective criteria.'

Red flag signs for suspected meningococcal disease

Symptom Positive likelihood ratio
Leg pain 7.6
Cold hands or feet 2.3
Photophobia 6.5
Neck pain/stiffness 5.3
Confusion 24.2
Rash 5.5

Source: Haj-Hassan et al, SAPC 2010 abstract 2a3



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