In Reply

In Reply: I appreciated the comments by McIntosh et al related to isolated torticollis as “an unusual and poorly recognized presenting sign of bacterial meningitis” and agree that this association should be referred to as “Isaac’s Sign.”1,2 David Isaacs, an Australian-based pediatric infectious diseases physician, and his colleagues McIntosh et al2 were the first to publish the association between torticollis and bacterial meningitis. They described 2 children whose presumptive diagnosis of Haemophilus influenzae B meningitis was delayed. “Neck stiffness is one of the oldest and most well-recognized features of bacterial meningitis. However, torticollis, which is presumably unilateral neck rigidity, is a much rarer and less well-recognized association.”2 Just greater than a decade later, Mukherjee and Sharief3 described 2 cases of bacterial meningitis associated with torticollis in children. The first was a neonate with presumed congenital torticollis who subsequently developed seizures and fever at 11 days of age and was diagnosed with Streptococcus agalactiae meningitis, and the second was a 4 year-old boy with presumed viral torticollis who was subsequently diagnosed with Neisseria meningitidis meningitis. In both cases, the torticollis resolved while receiving antibiotic therapy. In 2012, Chirurgi and Kahlon4 described a 59-year-old diabetic who presented with unexplained torticollis. While there was some pain relief with antiinflammatories and analgesia, the torticollis did not resolve and upon his third visit to the emergency room (day 15 with torticollis), he was noted to be tachycardic and he had a high peripheral white blood cell count. He was diagnosed with S. agalactiae meningitis and his torticollis resolved with antimicrobial therapy. Torticollis associated with bacterial meningitis is likely related to unilateral spinal nerve root irritation that leads to the involuntary contractions of neck muscles and abnormal postures and head movements. Differential diagnoses for torticollis include neck trauma, infection involving pharyngeal or cervical neck structures, cervical disc disease, drug ingestions and rarely, spinal cord tumors.2,3 The patients in these case reports experienced a delay in their diagnosis of bacterial meningitis. This was likely due to the lack of recognition of this association between torticollis and bacterial meningitis and the absence of the “classical” eponymous signs of meningitis.4 In the cases described, the sensitivity of signs by Kernig and Brudzinski was likely reduced in the neonate, the adult who received analgesia, and in the children who had partially treated meningitis. Given the possible delay in diagnosis, the presence of Isaac’s Sign in a child (or in an immunocompromised patient) warrants consideration of a lumbar puncture and empiric antimicrobial therapy.1–4 Sarah E. Forgie, MD, MEd, FRCPC Department of Pediatrics Stollery Children’s Hospital and University of Alberta Edmonton, Alberta

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