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Editor,—Pollard et alpresented a comprehensive personal view on the emergency management of meningococcal disease.1 I wish however to take issue with one point concerning lumbar puncture. Lumbar puncture should certainly be deferred in certain instances but should not be avoided as could be interpreted from the article. All children with suspected meningitis should, in my opinion, have a lumbar puncture at some stage in their illness. The reasons for lumbar puncture include:
- the presence or absence of meningitis should influence the choice and, perhaps, duration of antibiotic treatment
- the presence or absence of meningitis should influence fluid management once the initial shock is treated
- accurate anatomical diagnosis of meningitis is important for epidemiological purposes
- the presence or absence of meningitis is very relevant to neurodevelopmental prognosis and possible hearing impairment.
I increasingly meet paediatric trainees who seem to accept that a clinical and polymerase chain reaction based diagnosis of meningitis is sufficient. I would prefer if Pollardet al replaced (in the figure) the capitalised order DO NOT LUMBAR PUNCTURE (sic) with the instructions DEFER LUMBAR PUNCTURE and discuss its performance later in the illness.
Dr Pollard and colleagues comment:
The role of lumbar puncture in the management of children with meningococcal disease deserves scrutiny, and an ongoing study by the Royal College of Paediatrics and Child Health will examine this issue (Ninis N, personal communication, 1999). We are, therefore, pleased that Professor Gill supports our avoidance of lumbar puncture in special circumstances (cardiorespiratory insufficiency or shock, raised intracranial pressure, and coagulopathy).
He mistakenly interprets our article as advocating the complete avoidance of lumbar puncture in all cases of meningitis. We do not consider lumbar puncture necessary in the emergency management of children presenting with the characteristic petechial/purpuric rash of meningococcal disease. Although other pathogens (Haemophilus influenzae type b andStreptococcus pneumoniae) may also cause a non-blanching rash, because of the potential risks involved in the critically ill child, and the possibility of rapid deterioration in those who appear well on first assessment, we stated that “lumbar puncture should probably be avoided or deferred in the initial assessment of all patients with clinically obvious meningococcal disease”.
Early lumbar puncture is not only hazardous but may provide false reassurance as patients with meningococcal septicaemia may have no cerebrospinal fluid (CSF) changes on presentation, even though the organism can be cultured from the CSF sample. CSF changes may develop later and full neurological evaluation at follow up is mandatory in patients with septicaemia or meningitis. Our personal practice is to avoid lumbar puncture in meningococcal disease because we consider that the test adds little useful information to the clinical diagnosis, it could be misleading,1-1 1-2 and does not affect clinical treatment. Alternative microbiological samples (blood cultures, throat swab, skin lesion aspirate) and molecular diagnostic techniques on blood are both essential and helpful in identifying the organism for epidemiological purposes and potentially for identification of antibiotic resistance.
Gill suggests that presence or absence of meningitis in meningococcal disease would influence the choice or duration of antibiotic treatment. We advocate use of a third generation cephalosporin in a child with meningococcal disease for seven days regardless of the predominant clinical syndrome for the reasons described in our article. Central nervous system infection commonly coexists with septicaemia1-3 and does not require a unique approach to antibiotic treatment. Furthermore, accurate anatomical diagnosis of meningococcal meningitis does not provide useful epidemiological information, as the collection of separate data for meningococcal meningitis and septicaemia are obscured by the overlap between the two clinical syndromes.
Because of this overlap between meningitis and septicaemia, the emphasis in the acute stage of meningococcal disease presenting with shock, should be on maintaining an adequate mean blood pressure by volume resuscitation and inotropic support, thus ensuring adequate cerebral perfusion pressure. When clinically apparent raised intracranial pressure is present, correction of coexistent shock, followed by cautious fluid management and measures to reduce intracranial pressure are necessary. In children without features of shock or raised intracranial pressure, fluid restriction in the management of meningitis in children has been widely advocated but has been challenged and may even have an adverse effect on outcome.1-4 1-5