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CASE HISTORY
Two hours after admission:
P178, BP 112/60 RR 46.
Increasing rash, drowsy, some response to parents.
No urine output.
Results:
WCC 3.2, INR 2.2,Urea 8.3.
Hb 9.5, Pl 60, Na 132 K 3 Urea 8.3 Creatinine 100
Chest X-ray shows pulmonary oedema.
Frusemide given and fluids slowed down. The child has had a total of 80mls/kg by now.
SHO review: very fast tachycardia, ? need blood gas, ? needs LP.
Six hours after admission:
HR 194, not recognising parents. Doctor reviewed child, advised that Mannitol infusion be considered if further decrease CNS. 2.5 year old boy admitted with purpura and fever.
Paediatric assessment:
Temp 39.3, Pulse 134, RR 40, CRT 6 seconds, BP unrecordable, femoral pulses present but weak.
Cyanosed, Saturation 75% in air. Widespread creps.
GCS 9/15, Neck stiffness+
Purpuric rash on chest.
Bloods sent for FBC, clotting, U&E, and culture
Diagnosis:Meningococcal meningitis.
Treatment:Antibiotics intravenously.
Fluids 40 ml/kg colloid in 2 boluses and 10 ml/kg crystalloid over 1 hour, then maintenance fluids.
Some improvement of CRT so left on the ward.
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QUESTIONS ON CASE 3
 
Q 5 of 14: Features of severe disease present?
YesNo 
INCORRECT
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Further Information
Clinical features of severe disease
The diagram above illustrates the main causes of death from MD. In the majority of patients, one disease process predominates. Patients presenting with mixed disease will also tend, as the disease worsens, to become either profoundly septicaemic or profoundly meningitic. A few will have combined severe septicaemia with shock and severe meningitis with raised intracranial pressure and these need expert management. Patients presenting with septic shock without meningitis carry the worst prognosis8 13. Although a few patients with meningitis will die from raised intracranial pressure, most deaths from MD result from shock and multi-organ failure14.
Features which predict poor prognosis at the time of presentation include13 14
- Presence of shock
- Absence of meningism
- Rapidly progressive purpuric rash
- Low peripheral white blood cell count
- Thrombocytopenia
- Markedly deranged coagulation
- Depressed conscious level
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