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CASE HISTORY
Diagnosis: meningococcal septicaemia with shock.
18:15 hours paediatric registrar and SHO
History taken as above; rash noted to be purpuric.
Initial examination (in oxygen): airway clear, good saturations, equal breath sounds, no crepitations. Heart rate fast at 143, capillary refill time 6 seconds at feet. Heart sounds: gallop rhythm. BP 114/72. Rash is spreading, now on legs as well. Responding to voice, no neck stiffness, equal pupils. Blood gas taken to assess the degree of metabolic acidosis: pH = 7.2, BE= - 9. Case History
12 year old boy referred to hospital by his GP. He was found to be febrile & drowsy with a few non-blanching spots. The GP gave a dose of intra-muscular penicillin and sent him into hospital as an emergency.
18:00 hours ED triage
Fever for a day, generally unwell with headache, regular paracetamol during day. No urine output since very early morning. No neck stiffness or vomiting. Temperature not coming down, new rash on back, increasingly drowsy.
Observations: temp 39.5, pulse 148, RR40, Cold hands and feet. Sats 92% in air.
Conscious level is V (AVPU scale). Widespread non- blanching rash on trunk
Nursing actions: probable meningococcal disease, put out emergency call for paediatrics. High-flow oxygen started via facemask. BM done = 6.5.
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QUESTIONS ON CASE 8
 
Q 6 of 10: Are there clinical features of severe disease?
Yes  No
CORRECT
: Presence of shock, absence of meningism, rapidly progressive purpuric rash, depressed conscious level. The laboratory markers of severe disease namely low white cell count, thrombocytopenia, deranged coagulation may be present and should be investigated in the initial blood tests.
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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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