How much rash do you need to diagnose meningococcal disease?
A few petechiae on mottled skin Especially in the early stages, or when meningitis predominates, rash may be scanty, blanching or even absent.
Remember that the process of meningitis or septicaemia can be quite advanced before the rash starts to appear, so if you suspect that a child may have meningococcal disease then do not wait for more rash to develop, treat the child immediately.
2 year old boy seen by the GP: acutely unwell with high temp, vomiting, lethargy, unable to keep fluids down. Extra concern - close contact has been diagnosed as having Meningococcal Meningitis
GP examination fever 38.6, pale, no rash, tachycardic but not shocked, irritable on handling.
Seen in hospital: Pale and quiet Temp 39.6, P 155, RR 58 , No rash, thirsty
Given paracetamol, vomited immediately
SHO examination: Very lethargic, sleepy but rousable, Pale
RR 60, P140, No neck stiffness, 2 petechiae in nappy area
Diagnosis ? viral illness
Reviewed by registrar: diagnosis - this was likely to be a viral illness and to admit for observations, to have antibiotics if more rash appeared.
12 hours later- consultant ward round- looking worse with more rash. Investigations initiated.
Hb 10 , WCC 22.5 , Pl 244
pH 7.29 , pCO2 4.39, pO2 4.6, BE -10
INR 2.0 , APTR 1.3
Child deteriorated quickly at this point and died
Other rashes.
If you diagnose a child as having another illness characterised by a rash, make sure that your diagnosis is likely or even possible.
You may be sure of your diagnosis, but if you decide the child is well enough to be sent home, remember to advise parents to return if their child becomes more unwell, even if this is only shortly after being seen.
Teenagers
Approximately 25% of teenagers carry meningococci in the nasopharynx
Teenagers are a vulnerable group. There is a secondary peak in incidence of meningococcal disease amongst young adults aged 15-20 years, with an increased risk of mortality39.
As shown in this learning tool, in the section Development of Symptoms in Meningococcal Disease, signs and symptoms develop later in teenagers than in younger children. Teenagers present to GPs and to hospital later than younger children do, and on average the disease is further advanced in teenagers by the time they get to hospital.
He walked into ED - no rash, alert and orientated. HR 160, RR20, Temp 39, BP80/40, saturations 96% in air.
After 30 minutes he developed rapidly spreading purpura.
Hb 13.7, WCC 1.4, platelets 9.
Na 134, K 3.2, Urea 6.2, creat 163
PH 7.1, pCO2 4.9, pO2 4.1, BE -13.8
He was resuscitated aggressively but died.
Does your diagnosis make sense?
Assessing febrile children and trying to decide what is wrong with them is one of the most difficult tasks in paediatrics
It takes time to take a good history and examine a child properly. Before you discharge the patient from your care make sure that what you have done makes sense and that you can explain your actions and decisions to anyone who may ask.
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