Clinical features

Meningococcal disease or Invasive Meningococcal Disease (IMD) commonly presents as meningitis, septicaemia or a combination of both (1)

• incubation period is from two to seven days
  • onset of disease varies from fulminant with acute and overwhelming features, to insidious with mild prodromal symptoms (1)

Meningococcal disease in its initial stages may present with non specific clinical features such as malaise, pyrexia, vomiting, lethargy and headaches (2)

• classical features of IMD are uncommon in primary care
• in infants and young children, the onset may be insidious and the signs non-specific such as poor feeding, irritability, a high-pitched cry and a full fontanelle (without ‘classical’ features of meningitis) (2)

The following features in an ill child should prompt the diagnosis of IMD:

• petechial rash
• altered mental state
• cold hands and feet
• extremity pain
• fever
• headache
• neck stiffness
• skin mottling (2)

It is important for health professionals not to automatically excludethe possibility of meningococcal infection in a young child presenting with non specific symptoms such as vomiting, pyrexia, lethargy poor feeding,non-blanching rash, irritability and if still patent, raised anterior fontanelle tension within the first four to six hours of illness (2)

• clinical deterioration may be very rapid with poor peripheral perfusion, pallor, tachypnoea, tachycardia and the emergence of the meningococcal rash. In severe cases, patients may present with hypotension or in coma

In meningococcal septicaemia, a rash may develop along with signs of advancing shock and isolated limb and/or joint pain. The rash may be non-specific early on but as the disease progresses the rash may become petechial or purpuric and may not blanch

• can readily be confirmed by gentle pressure with a glass (‘the glass test’) when the rash can be seen to persist

NICE suggest that, in a child less than 5 years, one should consider the disease if:

• there is a non-blanching rash, particularly with one or more of the following:
  • an ill-looking child
  • lesions larger than 2 mm in diameter (purpura)
  • a capillary refill time of >= 3 seconds
  • neck stiffness

Reference:

• (1) Immunisation Against Infectious Disease - "The Green Book".Chapter 22 Meningococcal (August 2006)
• (2) Scottish Intercollegiate Guidelines Network (SIGN) 2008. Management of invasive meningococcal disease in children and young people. A national clinical guideline.
• (3) NICE (May 2007). Feverish illness in children Assessment and initial management in children younger than 5 years