In infants, reluctance to feed, with unusual irritability alternating with periods of lethargy and drowsiness are particularly important. Helpful pointers to the diagnosis may be absent. For example, the anterior fontanelle may have closed and even if still open may not always 'bulge', particularly if dehydration is present. Meningeal signs like neck stiffness, diagnostic in older children and adults, may be absent. The older child or adult may complain of a headache.
Vomiting is frequent in all age groups.
Children aged between six months and two years of age seem particularly prone to pneumococcal bacteraemia with apparently unexplained fever and no localising symptoms or signs. It is usually best to speak to the patient, or if that is not possible, to the parent, relative or friend who has been providing care. It is better to see the patient when requested than to refuse, and then to educate the patient if the consultation was unnecessary. A perceived refusal to see the patient will make rapport with a family more difficult, and will be remembered if things go wrong. Failure to see the patient when requested - Case 1 On Christmas Eve, a mother telephoned her GP at 8.00 pm and asked for an immediate consultation.