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We read with interest the study by Shacham et al . 1 Out of 153 children with fever and bulging fontanelle, only one child had bacterial meningitis. However, we disagree with their suggestion of withholding lumbar puncture in this group of children. In their cohort, 41 out of 153 children had aseptic meningitis; however, cerebrospinal fluid (CSF)viral cultures and PCR studies were only done in children who have received antibiotics and had an abnormal CSF chemistry. These cases would have been easily missed and not diagnosed without a lumbar puncture (LP).
Exclusion of meningitis in infants is often very difficult even for an experienced physician as clinical signs are non-specific. Bulging fontanelle in an infant can be a sign of raised intracranial pressure, and exclusion of central nervous system (CNS)infection...