Taking a history

Meningococcal disease is extremely unpredictable. The presentation can be very varied and patients may be difficult to differentiate from those with viral illnesses during the early stages. Most children with MD present as an acutely febrile child and may not have a rash at first.

It is important to take a detailed history and ask parents about the specific symptoms of septicaemia and meningitis. Beware of simply ‘eyeballing’ a child and assuming they have a trivial illness. This is how many mistakes are made. Make sure you have understood what exactly is worrying the parent and why they are seeking help at this point. Be careful if the child has had contact with a case of meningococcal disease even if they have had prophylactic antibiotics as they can still become ill. Ask about travel to sub-Saharan Africa or contact with Hajj pilgrims.^{15 16}

At the initial assessment look for signs and symptoms of septicaemia or meningitis. Some symptoms can be subtle and must be specifically asked about when taking a history.

Symptoms of septicaemia

• Fever
• Many children become suddenly ill with a fever: the classic picture is of a disease of rapid onset. However, some children develop septicaemia after a simple viral illness. In these cases the symptoms may be initially trivial and last for some time and then suddenly become more serious with a high fever and other symptoms of sepsis.
• A history of a fever in a child presenting afebrile is important.
• Not all children with meningococcal disease (or other serious bacterial infection) have fever¹⁷. A fever that subsides after antipyretics cannot be dismissed as viral in origin.
• Hypothermia, especially in infants, may also indicate serious infection ¹⁸
• Rigors Children with septicaemia often have rigors¹⁹. Occasionally the shaking, if very severe may be mistaken for fitting, but children having rigors will remain conscious.
• Aches They usually experience very bad muscle aches and joint aches making them restless and miserable.
• Limb pain Isolated severe limb pain in the absence of any other physical signs in that limb is a well-established phenomenon in MD^{20 7}. The pain can be very severe and children have been mistakenly put into plaster to treat presumed fractures.
• Gastrointestinal symptoms vomiting, nausea and poor appetite (poor feeding in babies) are common in septicaemia. Abdominal pain and diarrhoea (leading to faecal incontinence in some cases) are less common but well documented²¹. This can create confusion with gastro intestinal infections.
• Weakness This can become profound.
• Rash Ask about any new rashes or marks on the child’s skin that the parents may have noticed. Note that parents may not realise that the petechiae or purpura or 'bruises' on the child’s skin are a rash as they associate the word ‘rash’ more with a pink ‘measles-like’ rash. They may use other words to describe the rash, for example bruise, spot, freckle, blister, stain or mark on the skin – like chocolate, etc.
• Urine output Ask whether the child has passed urine or had a wet nappy recently. Oliguria is one of the early signs of shock
• Cold hands and feet, mottled skin As septicaemia advances, cold hands and feet and mottled skin are signs of circulatory compromise that parents notice.
• Signs of circulatory compromise - complications of septicaemia

Symptoms of meningitis

The main symptoms of meningitis are all due to the dysfunction of the central nervous system. Be aware that symptoms can vary according to the age of the child. Symptoms include:

• Fever
• Headache
• Vomiting
• Drowsiness/confusion
• Fits
• Photophobia (less common in young children)
• Neck stiffness (less common in young children)
• Signs of raised intracranial pressure – complications of meningitis

Young children may have fever and vomiting associated with irritability, drowsiness and confusion. They may be very hard to assess and parent’s anxieties about their state of responsiveness and alertness must always be taken seriously. ²²

Older children are more likely to have fever, vomiting and complain of headache, stiff neck and photophobia. ⁷

Teenagers may present with symptoms related to a change in behaviour such as confusion or aggression. These may mimic the symptoms of alcohol or drug intoxication 23.