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Three Part Question

in [a child aged <18yr] is [a non-blanching rash a good indicator] to [diagnose meningococcal disease]

Clinical Scenario

A 4 year old child presents to the Emergency Department with a history of fever and symptoms of a viral upper respiratory tract infection. On examination the child is well and apyrexial. However you notice a non-blanching rash over the child's hip. You wonder whether the child will need further investigations or a period of observation to exclude meningococcal disease.

Search Strategy

Medline 1966-01/07 using the OVID interface.
[exp meningococcal OR meningococcal.mp] AND [exp diagnosis OR diagnosis.mp OR OR sensitiv$.mp OR specificit$.mp] AND [exp rash OR rash.mp OR petechiae OR petechial] LIMIT to human AND English language

Search Outcome

58 papers were found from the above search. 56 were found to be irrelevant or of insufficient quality. The remaining 2 papers are shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wells, L C. Smith, J C. Weston, V C. Collier, J. Rutter, N. September 2001	218 children aged 15 years or less with a non-blanching rash	Cohort	Purpura	Sensitivity 83% (95% CI 68-98); Specificity 88% (95% CI 84-93); Positive Predictive Value 47 (95% CI 32-61); Negative Predictive Value 98 (95% CI 92-100)	Follow up action not stated
			Rash beyond distribution of superior vena cava	Sensitivity 100% (95% CI 94-100); Specificity 38% (95% CI 31-45); Positive Predictive Value 17 (95% CI 11-23); Negative Predictive Value 100 (95% CI 91-100)
Nielsen, H E. Andersen, E A. Andersen, J. Bottiger, B. Christiansen, K M. Daugbjerg, P. Larsen, S O. August 2001	264 children aged 1 month - 16 years with a rectal temperature >38.0 degrees centigrade and skin haemorrhages	Cohort	>20 skin haemorrhages	74% of patients meningococcal disease v 51% wth no invasive bacterial disease. P<0.05	Does not assess a non-blanching rash in isolation but assesses it with fever. Aetiology of 45% of patients with fever and skin hemorrhages was not known when only 18.9% of patients were excluded due to insufficient information. No PCR assay testing for meningococcal diagnosis. Maximum follow-up was too short at only 24 hours.
			Maximum skin haemorrhage diameter >1mm	95% of patients meningococcal disease v 22% wth no invasive bacterial disease. P<0.001
			Maximum skin haemorrhage diameter >2mm	74% of patients meningococcal disease v 8% wth no invasive bacterial disease. P<0.001
			Universal distribution of skin haemorrhages	92% of patients meningococcal disease v 40% wth no invasive bacterial disease. P<0.001
			Skin haemorrhages representing type 2 meningococcal disease wen compared to clinical photographs	82% of patients meningococcal disease v 7% wth no invasive bacterial disease. P<0.001

Comment(s)

There is a statistically significant increase in the incidence of skin haemorrhages presenting in children with meningococcal disease compared to those with no invasive bacterial disease. Purpura has shown to be a specific and sensitive marker for meningococcal disease. The Wells study commented that a non-blanching rash confined to the distribution of the superior vena cava ie above the nipple line, was most likely to be associated with vomiting rather than meningococcal disease. This is an interesting point but further focused studies should be conducted to evaluate its merit. Given the high mortality and morbidity associated with this condition, any predictive markers should be considered seriously and the child admitted and treated without delay depending on the presence/absence of other clinical features.

Clinical Bottom Line

A non-blanching rash is an important diagnostic marker of meningococcal infection and all children presenting with this symptom should as be admitted for a period of observation as a minimum.

References

1. Wells, L C. Smith, J C. Weston, V C. Collier, J. Rutter, N. The child with a non-blanching rash: how likely is meningococcal disease? Archives of Disease in Childhood. 85(3):218-22, 2001 Sep.
2. Nielsen, H E. Andersen, E A. Andersen, J. Bottiger, B. Christiansen, K M. Daugbjerg, P. Larsen, S O. Lind, I. Nir, M. Olofsson, K. Diagnostic assessment of haemorrhagic rash and fever. Archives of Disease in Childhood. 85(2):160-5, 2001 Aug.