Infants with meningitis often present with nonspecific findings of fever, poor feeding, lethargy (or decreased interaction with caregivers), vomiting and irritability. They sometimes have a rash. Inconsolable crying, prolonged or worsening irritability or progressive lethargy are also important clinical features that may indicate a central nervous system (CNS) focus such as meningitis. Nuchal rigidity is uncommon in infants; however, the specific symptoms of meningitis such as headache, nuchal pain and impaired consciousness as well as other nonspecific symptom are see in older children. Respiratory status and inclusive neurological examinations is performed to diagnose any focal neurological signs, postural abnormalities, cranial nerve involvement and evaluation of level of alertness.

Full investigations of patients should be performed, For CSF analysis (cell count, glucose and protein levels spinal centeses is done, microbiological culture and molecular detection of bacterial DNA [if clinical suspicion is high and bacterial cultures are negative] and viral studies where appropriate, as well as inspection for specific testing for tuberculosis in high-risk children) is mandatory for the definitive diagnosis of meningitis. A Lumber puncture (LP) should always be attempted unless there are contra-indications. Molecular investigations may still be beneficial even if antimicrobials have been administered, and other options should be discussed with a pathologist. Contraindications to spinal tap include coagulopathy, cutaneous lesions at the puncture site, and findings of brain herniation or shock. If there is papilledema, the presence of focal neurological signs, decreased level of consciousness or coma, a LP should be deferred until imaging (a contrast-enhanced computed tomography and/or magnetic resonance imaging of the head) is performed and the risk of potential herniation is ruled out. Lumber puncture complication like herniation is rare in meningitis in the absence of focal CNS lesions [15].

Our study included a total of 100 children meeting criteria of our study. Of these 100 children, 62 (62 %) were boys and 38 (38 %) were girls. A study organized by Bari et al. [16] from Lahore also reported male gender predominance with 63.8 % which is close to our study results. Fayyaz et al. [17] from Karachi has reported 69.8 % male gender predominance which is close to our study results. Khan et al. [18] from Rawalpindi has also reported male gender preponderance with 58 % boys with meningitis which is in compliance with our study results. Sallam et al. [19] from Yemen has also documented 69 % male gender predominance which is close to our study results. A study conducted by Rashid et al. [20] has reported 62 % male gender predominance which is in compliance with our study results. A study conducted by Asghar et al. [21] from Rawalpindi has also reported 60 % male gender dominance which is close to our study results.

Mean age of our study cases was 3.92 ± 2.12 years (with minimum age of our study cases was 2 years while maximum age was 11 years). Our study results have suggested that majority of our study cases i.e. 82 (82 %) were aged less than 5 years. A study operated by Bari et al. [16] from Lahore reported 11.3 ± 12 months which is less than that of our study results, the reason for this difference is due to our inclusion criteria as we only included patients having ages more than 2 years. Tajdin et al. [22] from Lahore has also reported similar conclusions. Fayyaz et al 17 from Karachi has reported 4.8 ± 4.14 years mean age which is close to our study results. Khan et al 18 from Rawalpindi has also reported 6 years mean age which is close to our study results. Sallam et al. [19] from Yemen has also documented 4.1 ± 0.71 years mean age which is close to our study results. A study conducted by Rashid et al 20 has reported similar outcomes. A study conducted by Asghar et al. [21] from Rawalpindi has also reported mean age was 4.0 ± 3.9 months which is close to our study results Our study has a limitation in aspect of number of patients. More number of patients may depict more sensitivity and specificity.

Recently, magnetization transfer MRI has been proposed as a useful tool in the diagnosis of tuberculous meningitis. Visibility of the meninges on precontrast T1-weighted magnetization transfer images may be considered highly suggestive of tuberculous meningitis [23]. Post contrast FLAIR MRI findings were positive in 48 (48 %) while negative in 52 (52 %) while lumbar puncture revealed positive findings in 51 (51 %) while negative in 49 (49 %). Sensitivity of the post contrast FLAIR MRI was 78.43 % while specificity was 83.67 %, diagnostic accuracy was 81.00 %, positive predictive value was 83.33 % and negative predictive value was 78.84 %. In a study done by Aneel kumar et al 14 for the diagnosis of meningitis, the sensitivity of Post-Contrast FLAIR sequence was 96% and specificity 85.71% which is in compliance with our study results.