Clinical and laboratory features of viral and bacterial meningitis in children

Feature	Viral meningitis	Bacterial meningitis
Seasonal pattern	Enteroviral infections (the most common cause of viral meningitis) occur mostly in summer and fall	No characteristic seasonal pattern
Clinical features
Fever, headache, stiff neck, photophobia	Common	Common
Ill appearance	Uncommon	Common
Petechiae or purpura	Absent	May be present
Other manifestations of enteroviral infection (eg, rash, conjunctivitis, herpangina, pharyngitis)	Common	Uncommon
Symptoms after LP	Often, there is improvement	No improvement
CSF parameters
WBC count	Typically 10 to 500 cells/microL	Typically >1000 cells/microL, but can be lower, particularly early in the course
Differential	Mononuclear predominance	Neutrophil predominance
Glucose	Normal or slightly reduced Usually ≥40% of serum value	Usually <60% of serum value Often <40 mg/dL
Protein	Normal to slightly elevated Usually <150 mg/dL	Typically 100 to 500 mg/dL

This table summarizes the typical findings in viral and bacterial meningitis in children. However, there is considerable overlap between the two conditions and these features do not reliably distinguish between them. In addition, there is considerable overlap between viral meningitis and Lyme meningitis, which is also characterized by lymphocyte-predominant pleocytosis. In Lyme-endemic areas during the summer and fall, it can be difficult to distinguish Lyme meningitis from enteroviral meningitis unless the patient had a known tick bite and/or erythema migrans. For additional details, including use of clinical prediction rules to identify children at low risk of bacterial meningitis, refer to separate UpToDate content on viral, bacterial, and Lyme meningitis.

LP: lumbar puncture; CSF: cerebrospinal fluid; WBC: white blood cell.

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Clinical and laboratory features of viral and bacterial meningitis in children