• 
• 

Three Part Question

[In children with a clear history of cough/vomiting/straining], is a [petechial rash limited to the distribution of the superior vena cava] a clinical feature of [meningococcal disease]?

Clinical Scenario

A 7-year old girl is brought in the ED by her father who is concerned about a petechial rash over her face and neck only. She developed a dry cough the day before. Her observations and are normal and the child looks well. You have heard about petechiae developing in the distribution of the superior vena cava secondary to increased intrathoracic pressure and wonder if it is safe to discharge the patient without further investigations.

Search Strategy

Medline using the Ovid interface (1950-2010)
EMBASE (1980- present)
Cochrane Library
Medline:{((Exp non-blanching OR exp non blanching) AND (rash$)) OR (purpur$ OR petechia$ OR exp purpura)} AND {(exp cough OR cough$) OR (exp vomiting OR vomit$) OR (exp defecation OR defecat$) OR retch$}, limit search to English language and humans EMBASE:(exp petechia AND exp rash) OR (exp petechia AND exp face rash) OR (exp petechia AND exp neck rash).

Search Outcome

Several papers addressed the question of petechial rash in children but none of them were relevant to our three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

This is a difficult clinical question in a world where ED time targets are often difficult to meet, but a cautious approach is needed to potential life-threatening disease. The management of the well child with petechia has been addressed by several authors, mainly through retrospective/prospective audits and literature reviews (Brogan, Klinkhammer). However, no papers were found relevant to the specific question, despite the fact that this is a well described and recognised phenomenon in the paediatric population.

Clinical Bottom Line

There is currently no evidence to state that a child with a clear history of cough/vomiting/straining with a petechial rash in the territory of the SVC only, can be discharged home without a period of observation and/or blood investigations. There has not been enough research to date on this specific question, and, until hard evidence is published, the described phenomenon is anecdotal (Pitt) and a cautious approach should be taken when adhering to local guidelines.

References

1. P A Brogan, A Rafles. Short Report: The management of fever and petechiae: making sense of rash decisions. Arch Dis Child 2000;83;506-507.
2. M D Klinkhammer, J E Colletti. Pediatric myth: fever and petchiae. CJEM 2008;10(5):479-482.
3. P W Pitt. Purpura associated with vomiting BMJ 1973 June 16; 2(5867): 667.