History Taking Format: Pediatric Meningoencephalitis

Patient Identification (Biodata)

• Name
• Age / Date of Birth
• Sex
• Weight (important for dosing)
• Address / Residence
• Informant (parent/guardian) and reliability of history

Chief Complaint

"My child has had fever, headache, and has been very irritable for the past 2 days."

History of Present Illness (HPI)

1. Onset and Duration

• When did symptoms begin? (exact date/time)
• Sudden vs. gradual onset
• Course: improving, worsening, or fluctuating?

2. Fever

• Onset, duration, pattern (continuous, intermittent, remittent)
• Maximum temperature recorded
• Response to antipyretics
• Note: hypothermia may be present in severely ill neonates/infants

3. Meningeal Symptoms (more prominent in older children)

• Headache: location, character, severity, aggravating/relieving factors
• Neck pain or stiffness: when noticed, severity, any limitation of neck movement
• Photophobia: sensitivity to light
• Phonophobia: sensitivity to noise
• Vomiting: onset, frequency, projectile or non-projectile, relation to headache

4. Encephalitic Symptoms (brain parenchyma involvement)

• Altered level of consciousness: confusion, excessive drowsiness, unresponsiveness
• Behavioral change: unusual behavior, personality change, emotional lability, agitation
• Psychiatric features: hallucinations, psychotic symptoms (raises suspicion for anti-NMDA receptor encephalitis)
• Cognitive changes: memory disturbances, disorientation
• Speech disturbances: aphasia, dysarthria

5. Seizures

• Type: focal vs. generalized
• Duration and number of episodes
• Postictal state (drowsiness, weakness - Todd's paralysis)
• Prior febrile seizure history

6. Infant-Specific Symptoms (for neonates and infants < 2 years)

• Poor feeding / refusal to feed
• Excessive irritability (paradoxical - worsens when held/cuddled)
• High-pitched cry (shrill cry)
• Lethargy or drowsiness beyond normal
• Apnoea episodes
• Temperature instability (hypothermia OR hyperthermia)
• Vomiting and/or diarrhoea
• Hypotonia or hypertonia
• Bulging fontanelle noticed by caregiver

7. Neurological Symptoms

• Focal neurological deficits (weakness of limbs, facial asymmetry)
• Abnormal movements (chorea, dyskinesia)
• Visual disturbances
• Hearing impairment

8. Prodromal Illness

• Recent upper respiratory tract infection (URTI) - rhinorrhoea, cough, sore throat
• Recent ear infection (otitis media) or sinus infection
• Recent viral illness (e.g., varicella, mumps, measles)
• Rash: nature, distribution, timing in relation to fever
  • Petechial or purpuric rash -> strongly suggests meningococcal disease
  • Vesicular rash -> consider HSV encephalitis

Past Medical History

• Previous episodes of meningitis or CNS infection
• CNS anatomical abnormality or presence of VP shunt / ventriculoperitoneal drain
• Recurrent bacterial infections (suggests immunodeficiency)
• Sickle cell disease, asplenia or splenectomy (risk for pneumococcal)
• Basilar skull fracture (risk for pneumococcal/H. influenzae)
• Dermal sinus tracts
• HIV/AIDS or known immunosuppression
• Any active malignancy or history of chemotherapy

Drug History

• Recent antibiotic use: name, dose, duration (may mask or modify presentation)
• Chronic steroid use
• Immunosuppressants
• Any known drug allergies

Immunization History

• Is the child fully vaccinated for age?
• Specifically ask about:
  • Hib vaccine (Haemophilus influenzae type b)
  • PCV (Pneumococcal conjugate vaccine)
  • MenACWY / MenB (Meningococcal vaccines)
  • MMR vaccine (measles, mumps, rubella)
  • Varicella vaccine
• Any recent vaccinations (within 2 weeks - rare post-vaccine encephalitis)

Exposure History

• Travel history: recent travel to endemic areas (meningococcal belt of Africa, Japan encephalitis-endemic Asia, etc.)
• Contact history: close contact with a person diagnosed with meningitis
• Animal exposure: bites from animals (rabies), bat exposure (rabies), rodent contact (lymphocytic choriomeningitis virus)
• Insect exposure: mosquito or tick bites (arboviral encephalitis - Japanese encephalitis, West Nile virus, tick-borne encephalitis)
• Geographic/environmental: living in a specific endemic region

Perinatal History (especially relevant for neonates and infants)

• Gestational age at birth
• Mode of delivery (vaginal delivery increases GBS exposure)
• Maternal infections during pregnancy or at delivery:
  • Maternal HSV (herpes simplex) - critical question for neonatal HSV encephalitis
  • Group B Streptococcus (GBS) status
  • Maternal fever during labor
  • TORCH infections (Toxoplasma, Rubella, CMV, HSV)
• Prolonged rupture of membranes (> 18 hours)
• Any NICU admission or prior infections in neonatal period

Family History

• Consanguinity
• Immunodeficiency disorders in family members
• Recurrent serious infections in siblings
• Family history of neurological or metabolic disease (to help differentiate from inherited encephalopathies)

Nutritional History

• Breastfeeding or formula feeding
• Current diet and nutrition status
• Vitamin deficiencies

Developmental History

• Developmental milestones (to establish baseline neurological function)
• Any prior developmental delay or regression (may suggest underlying metabolic or genetic disorder)
• School performance

Social History

• Daycare or school attendance (exposure to pathogens)
• Socioeconomic status and living conditions (overcrowding - meningococcal risk)
• Sick contacts at home, school, or daycare
• HIV status of parents (if infant < 1 year)

Review of Systems (Relevant Positives/Negatives to Specifically Ask)

Summary of Red Flag Features to Note During History

• Altered consciousness / GCS < 15
• Purpuric or petechial rash with fever (meningococcemia - medical emergency)
• Bulging fontanelle in infants
• Apnoea
• Very rapid deterioration (meningococcal pattern)
• Signs of raised intracranial pressure (bradycardia + hypertension + irregular breathing - Cushing's triad)
• Age < 3 months (neonatal/young infant - atypical presentation expected)

Key Differentials to Keep in Mind While Taking History

• Viral meningitis (most common etiology overall)
• Bacterial meningitis (S. pneumoniae, N. meningitidis, H. influenzae in unvaccinated, GBS/E. coli/L. monocytogenes in neonates)
• Viral encephalitis (HSV most common treatable cause, enteroviruses, arboviruses)
• Autoimmune encephalitis (anti-NMDA receptor - psychiatric symptoms prominent, consider especially in older girls)
• ADEM (acute disseminated encephalomyelitis - post-infectious/post-vaccine)
• Tuberculous meningitis (subacute onset, contact history)
• Fungal meningitis (Cryptococcus - in immunocompromised)
• Metabolic encephalopathy (toxin ingestion, metabolic disease)