DISCUSSION
In this case, we suspected meningitis based on a positive ocular globe
compression sign, and made a diagnosis of aseptic meningitis by repeat
LP. A longer clinical course (7–18 days) characterizes enteroviral
meningitis in comparison to other types of viral
meningitis,1 which was consistent with this case. A
previous study reported the sensitivity and specificity (respectively)
of meningeal tests as follows: nuchal rigidity (46.1%, 71.3%), jolt
accentuation test (52.4%, 71.1%), Kernig’s sign (22.9%, 91.2%), and
Brudzinski’s sign (27.5%, 88.8%).2 The ocular globe
compression sign (applying digital pressure to both eyeballs and
observing the presence and degree of pain reaction to the stimulus) was
proposed in 2002,3 and has a sensitivity and
specificity of 34.5% and 78.6%, respectively.4 In
our patient, all the meningeal signs, except for the ocular globe
compression sign, were negative. Moreover, the return to negativity of
the ocular globe compression sign coincided with an improvement in his
symptoms. Further studies are needed to clarify the clinical
significance of the ocular globe compression sign in the diagnosis of
aseptic meningitis and its relationship with the clinical course. In a
previous study of patients with suspected meningitis and initial
negative CSF findings, 88% had an elevated CSF cell count on repeat
LP.5 However, the sensitivity and specificity of
repeat CSF tests in viral meningitis are unknown. PCR testing for
viruses is not routinely available; therefore, clinical signs are useful
in the diagnosis of aseptic meningitis. A diagnosis of meningitis should
not be excluded if the first LP is normal. It is important to perform
repeated CSF and meningeal sign tests to reduce the risk of missing the
diagnosis.