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

Abstract

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.

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

“…As shown in Table , inclusion criteria, patient characteristics, and diagnostic values of sensitivity and specificity varied in each study, whereas CSF pleocytosis was used as the gold standard to diagnose meningitis in all studies. The number of bacterial meningitis cases was limited except in one study . Studies with different prerequisites need to be distinguished; however, no reports, except for our study and our letters, mentioned this fact.…”

“…We reviewed articles published prior to December 2017 using MEDLINE and Japanese medical databases (medical online and I‐chu‐shi) to identify studies on the diagnostic values of JA. The search term “Jolt accentuation” [All Fields] identified 7 eligible original articles based on independent cohorts. Additional 2 articles citing these 7 were thoroughly searched using Google Scholar.…”

“…We contacted the authors for further information by email when necessary. Finally, 6 prospective articles, 3 retrospective articles in English, and 2 conference reports in Japanese were reviewed (Fig. ).…”

Clouding Jolt Accentuation by Cloudy Clinical Setting for Lumbar Puncture

“…Now, Sato et al challenge this diagnostic value of JA by asking “Can we rule out meningitis from negative jolt accentuation?” in an extended retrospective cohort without such patient selection. Because negative JA in patients with pleocytosis has been noted in a patient with Sjogren syndrome in the initial study and has been since confirmed by subsequent retrospective studies, the answer to the authors’ question is apparently “No.” The results on JA have been variable due to population bias (where the study was performed), how the patients were recruited to the study (recruitment bias), how the data were collected, and how the data were interpreted (interpretation bias) to settle clinical questions . Anyway, it was fortunate that this simple method has been routinely used in an emergency setting to raise suspicion of meningitis.…”

“…Anyway, it was fortunate that this simple method has been routinely used in an emergency setting to raise suspicion of meningitis. Unfortunately, however, this simple method was extended to the cohorts with or without fever, headache, or those with neurological deficits . As expected, application of JA to such heterogeneous cohorts might have greatly reduced the original sensitivity and specificity of JA initially obtained in a relatively homogeneous cohort.…”