Examining the Patient

The rash

Most patients with meningococcal septicaemia develop a rash ^{7 24 25 26} - it is one of the clearest and most important signs to recognise. A rapidly evolving petechial or purpuric rash is a marker of very severe disease.

Early stages

In the early stages the rash may be blanching and macular or maculopapular ^{24 27} (sometimes confused with flea bites), but it nearly always develops into a non-blanching red, purple or brownish petechial rash or purpura.

Macular rash

Maculopapular rash in meningococcal septicaemia

Isolated pin-prick spots may appear where the rash is mainly maculopapular ²⁴, so it is important to search the whole body for small petechiae, especially in a febrile child with no focal cause.

Maculopapular rash with scanty petechiae

Rash in ’meningitis’

In meningitis the rash can be scanty, blanching (macular or maculopapular), atypical or even absent.

Very scanty rash: just 3 petechiae on abdomen (2) and chest (1)*

A few petechiae on mottled skin

Spectrum of meningococcal rashes

Meningococcal rashes can be extremely diverse, and look different on different skin types. The rate of progression can also vary greatly.

Petechial rash*

Mixed petechial/ purpuric rash

Mixed petechial/purpuric rash* on freckled skin

Sparse purpuric rash*

Full-blown purpuric rash of septicaemia

Widespread purpuric rash of septicaemia

Atypical purpuric marks*

Atypical purpuric spots can resemble insect bites

Purple blotches may be larger, resembling bruises*

Purpuric blotches of septicaemic rash can resemble blood blisters

Spotting the rash on dark skin

The rash can be more difficult to see on dark skin,

Meningococcal rash on dark skin*

but may be visible in paler areas, especially the soles of the feet, palms of the hands, abdomen, or on the conjunctivae or palate.

Purpuric rash on dark skin - easier to see on sole of foot*


Petechial rash on conjunctivae


Widespread purpuric rash on dark skin^

Advanced Rash

Purpuric areas that look like bruises can be confused with injury or abuse.
Extensive purpuric areas often over the feet, legs and hands are usually called ‘purpura fulminans’.

Purpura fulminans*

Although some of the causes of petechial rashes are self-limiting conditions, many others, including MD are fulminant or life-threatening, and a non-blanching rash should therefore be treated as an emergency^{5 19}.

It is crucial to remember that the underlying meningitis or septicaemia may be very advanced by the time a rash appears. The rapidly evolving haemorrhagic 'text book' rash may be a very late sign, it may be too late to save the child's life by the time this rash is seen. It is very important to examine children for the signs of meningitis or septicaemia (and raised ICP or shock) and investigate and treat if necessary based on those findings.

Initial assessment of any febrile child

For all febrile children the following should be undertaken:

• Fully undress and examine systematically. Make a thorough search for a focus of infection: think about the ‘hidden sites’ such as meninges, urinary tract and bloodstream (septicaemia). Mildly pink tympanic membranes or throat do not constitute a focus.
  
  
  
• If a rash is found, it is important to decide whether it is non-blanching. All febrile children with haemorrhagic rashes must be taken very seriously. Although many children with fever and petechiae will have viral illnesses ^{17 28 29} there is no room for complacency when assessing these children. They must all have their vital signs measured, a decision made as to whether they have signs of meningitis or septicaemia and given intravenous antibiotics. A senior paediatrician should be informed immediately. Some hospitals in the UK may have local protocols on action to take when a haemorrhagic rash if found, depending on whether the rash is petechial or purpuric, and there is work underway to consolidate this⁴⁸.
  
  
  
• Children without a rash or with a blanching rash can still have MD. The rash may appear later or not at all if the child has pure meningitis and occasionally with septicaemia. Thorough clinical assessment should ascertain whether there are physical signs of serious systemic illness.
  
  
  
• If initial assessment of airway, breathing and circulation reveals that you are dealing with a seriously ill child, ABC should be rectified in line with APLS guidelines³⁰ before proceeding with the detailed examination.

The following clinical signs must be measured and recorded to complete a full assessment:

• Temperature
• Heart rate
• Respiratory rate
  
• Blood pressure
  
  
• Capillary refill time or toe-core temperature gap
  
  Standard technique for measurement of CRT is to press for 5 seconds on a fingertip or toe, or on the centre of the sternum, and count the seconds it takes for colour to return. (Capillary refill shown here on dorsum of foot to facilitate capture on film.)
  
• Oxygen saturation measurement (normal value is >95% in air)
  
  
• Assessment of conscious level (AVPU)
• Pupil size and reaction
• If rash present record whether it is blanching, extent of rash, speed of development and whether it is petechial or purpuric (Petechial <2mm diameter, purpuric >=2mm diameter). Purpura are highly predictive of meningococcal disease and should be treated as an emergency, with immediate antibiotics and admission. Petechiae alone are less predictive, but must be taken very seriously and especially in combination with other features of septicaemia should provoke urgent action.

Full-blown non-blanching haemorrhagic rash*