Effective presentations vital to prosper in modern-day practice
Dr Andrew Riordan takes a practical look at diagnosing a condition feared by doctors and patients alike
Diagnosing meningococcal disease, or worse, missing it, is a concern for many doctors. However, recognising the significance of purpura, looking for rashes in unwell children and
knowing when to give clear instructions to parents of febrile children about when to seek medical advice again may help.
Most cases of meningococcal disease present as septicaemia, not meningitis. The two clinical presentations (septicaemia and meningitis) can occur separately or together.
Septicaemia without meningitis is the cause of most deaths from meningococcal disease in the UK. GPs need to be able to recognise both septicaemia and meningitis.
GPs make the correct diagnosis in 70 per cent of children with meningococcal disease1, but there are particular problems with GPs missing early and atypical presentations.
Signs recognised by GPs are non-blanching rash and neck stiffness. If these signs are not recognised the delay in diagnosis may contribute to a fatal outcome2.
Symptoms and signs depend on the point in the disease that a child is seen (early or established disease) and on the clinical presentation (septicaemia or meningitis).
Fever, lethargy and vomiting are common early symptoms and reasons for seeking medical advice.
These symptoms are very non-specific.
Signs of septicaemia
(See table below.) The classic sign is purpura. This is a non-blanching
lesion >3mm in size (see figure 1, right).
This is present in only 50 per cent of cases when seen by a GP, but in 70-80 per cent of cases when patients arrive at hospital.
Parents are the first to notice this rash in 80 per cent of cases, and commonly seek medical advice because of it3.
Children with septicaemia have a normal conscious level until late in the disease. Neck stiffness and photophobia will not be present.
Signs of meningitis
(See table below.) This can present like other forms of bacterial meningitis. A rash may or may not be present.
Spotting atypical presentations
There are two presentations that cause diagnostic difficulty :
-a well child with a typical rash and
-an unwell child with a sparse, atypical or no rash.
Well child with typical rash
Children with septicaemia can have a normal conscious level. They are sometimes thought to be 'too well to have meningitis'.
However, the rapid progression of meningococcal septicaemia can mean these children are critically ill within a few hours.
Urgent referral to hospital should be considered in all children with purpura (figure 1).
Unwell child with a sparse, atypical or no rash
The rash of meningococcal disease may be absent, blanching or very sparse (figure 2, page 37).
These children have 'unusual or puzzling features for a self-limiting illness'4.
These include: pallor, altered consciousness, marked lethargy and abnormal behaviour.
About a third of children with meningococcal disease present with a blanching, maculopapular rash5 (figure 3, page 38).
This particular rash makes GPs less likely to diagnose meningococcal disease, and more likely to consider viral illnesses6.
The rash may have non-blanching elements, particularly in the middle of the macules.
The rash often comes out rapidly ('in front of your eyes') and occurs early in the disease (six to 18 hours of illness), unlike many viral illnesses.
When should I give benzylpenicillin?
Give parenteral benzylpenicillin whenever you suspect meningococcal disease8. Benzylpenicillin may halve the risk of death from meningococcal disease.
Many GPs are reluctant to give it because they feel unsure of the diagnosis.
However, antibiotic treatment is often not immediate when a child with meningococcal disease arrives at hospital9.
So the first doctor to consider meningococcal disease should give
the first dose of parenteral
New molecular techniques (PCR for meningococcal DNA) means the diagnosis can still be confirmed despite pre-admission antibiotics.
This is not a reason to defer early treatment. The aim is to have live children rather than live bacteria.
Andrew Riordan is a consultant paediatrician at Birmingham Heartlands Hospital
Tips to ensure you do not miss meningococcal disease
miss meningococcal disease
Ask parents why they have brought their child to see you and if they've seen a rash. Most have.
There are two occasions when a GP may see a child with meningococcal disease and not make the diagnosis:
1 during the early illness and
2 when there is an atypical presentation.
Early meningococcal disease
Nearly 50 per cent of children with meningococcal disease are seen by a doctor during the early phase of their illness and not admitted to hospital3,6.
Most of these children have no signs that would allow a GP to make the diagnosis. Some children have a blanching rash. Up to 50 per cent have signs suggesting upper respiratory infection7.
ACTION Give parents of children with non-specific febrile illnesses advice on when to seek medical attention again (eg non-blanching rash, marked deterioration in condition).
Advice cards from the meningitis charities may be useful (see useful websites, overleaf). Parents feel reassured if a doctor has seen their child. They may not want to call the doctor again, even if the child later develops a non-blanching rash.
ACTION consider urgent hospital admission for all children with purpura (figure 1), no matter how 'well'.
ACTION look for 'unusual or puzzling features for a self-limiting illness' eg pallor, altered consciousness, marked lethargy and abnormal behaviour.
If these are present search for a rash (blanching or sparse non-blanching figures 2 & 3). Consider urgent hospital admission even if no rash present.
MDU advice on avoiding legal pitfalls
Delay or failure in diagnosis are the commonest reasons for settled claims against GPs and an MDU analysis of these delay in diagnosis claims found around 3 per cent involved meningococcal disease.
The consequences for the patient can be severe, including brain damage or death and the settlements made in these cases reflect this, with settlements running into millions of pounds not uncommon.
One of the problems with diagnosing meningococcal disease is that early symptoms can be similar to other, non-serious conditions, so how can doctors avoid some of the pitfalls of diagnosing this condition?
The MDU advises:
-Note the initial diagnosis and management plan in the record and be prepared to review and reassess the diagnosis if symptoms fail to progress as expected.
-If the patient is a child, take
parents' concerns seriously, they are often good judges of whether their child is seriously ill.
-Explain the likely response time for treatment to take effect, providing patients and carers with information about what to expect and what to do if the symptoms change
or the condition worsens. Make a note of the advice given.
-Have protocols in place covering urgent requests for visits and ensure all staff are aware of them.
-Make sure patients seen out of hours have follow-up plans if necessary and ensure mechanisms are in place to pass information promptly to the patient's own GP.
-Maintain a system to record laboratory samples and tests requested and to check results are received and acted on.
Dr Karen Roberts is an MDU clinical risk manager
copyright MDU 2004
1 Mathiassen B et al. An evaluation of the accuracy of clinical diagnosis at admission in a population with epidemic meningococcal disease.
J Int Med 1989;226:113-6
2 Slack J. Deaths from meningococcal infection in England and Wales in 1978. J Roy Col Phys London 1982;16:40-4
3 Riordan FAI et al. Who spots the spots? The diagnosis and treatment of early meningococcal disease in children. BMJ 1996;313:1255-6
4 Granier S et al. Recognising meningococcal disease in primary care: qualitative study of how general practitioners process clinical and contextual information. BMJ 1998;316:276-9
5 Marzouk O et al. Features and outcome in meningococcal disease presenting with maculo-papular rash. Arch Dis Child 1991;66:485-7
6 Sorensen HT et al. Diagnostic problems with meningococcal disease in general practice.
J Clin Epidemiol 1992;11:1289-93
7 Olcn P et al. Meningitis and bacteremia due to Neisseria meningitidis: Clinical and laboratory findings in 69 cases from Orebro County, 1965 to 1977.
Scand J Infect Dis 1979;11:111-9
8 Calman KC. Meningococcal infection: meningitis and septicaemia. PL/CMO (97)1. London: DoH, 1997
9 Riordan FAI. Improving promptness of antibiotic treatment in meningococcal disease.
Emergency Medicine Journal 2001;18:162-3
www.meningitis.org Meningitis Research Foundation, includes 'Meningococcal meningitis and septicaemia: Diagnosis and treatment in general practice' and information for the public on recognising septicaemia and meningitis highly recommended
www.meningitis-trust.org National Meningitis Trust, includes disease information, with descriptions of symptoms of meningococcal disease in babies, older children and adults