Majority of bacteriologically proven cases of meningococcal disease develop a rash during some stage of the illness (1)
- the rash can be extremely diverse (with different presentations in different skin types) and the rate of progression may vary rapidly as well
- a non blanching haemorrhagic rash is a characteristic feature of meningococcal disease (2)
- the rash may be absent, scanty or it may be blanching in the early stages (especially in pure meningitis) (2)
- a blanching, maculopapular rash at early stages of the disease may develop into a non blanching rash as the disease progress (from minutes to hours) (1)
- it is important to remember that the extent and the description of the rash doses not reflect the severity of disease e.g. - some children with severe disease will have no rash or minimal rash (1)
When a non blanching rash is present it can either be a petechial or purpuric (spots >2mm in diameter) rash (1):
- a rapidly evolving peticheal or purpuric rash indicates a very severe disease (2)
- a non blanching rash can be confirmed by the "tumbler test" - a glass tumbler is pressed firmly against the rash, the petechial or pupuric rash will not fade and will remain visible through the glass (3)
It is important to examine the whole body for a rash and unusual skin colour:
- under good lighting, look for small petechiae on the entire body especially in a febrile child with no focal cause
- in dark skin patients the rash may be seen in paler areas such as the soles of the feet, palms of the hands, abdomen or on the conjunctivae or palate (4)
- confusion can be caused by purpuric areas which looks like bruises with injury or abuse (4)
- when inquired about any new rashes or marks on their child's skin, parents may use different words to describe the rash such as bruise, spot, freckle, blister, stain or mark (4)
The following signs indicate a high risk of meningococcal disease in children and young people with a petechial rash:
- petechiae start to spread
- the rash becomes purpuric
- signs of bacterial meningitis or of meningococcal septicaemia
- the child or young person appears ill to a healthcare professional (5)
Petechiae may be seen in other conditions such as:
- infections - enterovirus, Epstein-Barr virus, adenoviruses, and respiratory viruses
- non infective - Henoch Schönlein purpura, connective tissue disorders, haematological disorders (protein C or S deficiency, idiopathic thrombocytopaenic purpura) and trauma (1)
Click here for an example image of meningoccal septicaemia
Notes:
- a non blanching rash might be caused by other infections as well but in meningococcal disease the window of opportunity to administer effective treatment is very narrow since most fatalities occur within 24 hours of the onset of symptoms. Therefore a child with a non-blanching rash and fever, or history of fever should be treated as an emergency and also a senior paediatrician should be informed (2)
- Scottish Intercollegiate Guidelines Network has recommended that a generalised petechial rash (beyond the distribution of the superior vena cava) or a purpuric rash in any location, in an ill child, are strongly suggestive of meningococcal septicaemia and should lead to urgent treatment and referral to secondary care (6)
Images of petechial, purpuric, and meningococcal rashes can be found in the document "Lessons from research for doctors in training" produced by the Meningitis Research Foundation
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