What I learned from my meningitis near miss
In our new series, GPs recall cases that could have ended disastrously – but didn’t – and describe what they learned. Here, Dr Tonia Myers remembers a child who looked perfectly healthy apart from a rash
In our new series, GPs recall cases that could have ended disastrously – but didn't – and describe what they learned. Here, Dr Tonia Myers remembers a child who looked perfectly healthy apart from a rash
Shortly after the meningitis C vaccine was introduced, we received a call at lunchtime from a woman whose eight-year-old daughter had developed a rash on her arm that ‘failed the glass test'. Fortunately I was around and the receptionist had the sense to phone through to me, so I told the mum to bring the child straight down.
In walked the mother with a perfectly healthy-looking child who appeared much older than nearly nine.
Quite by chance the mum had noticed several small purple marks on her daughter's arm when they were clothes shopping. She had a high index of suspicion about meningitis after the publicity surrounding the launch of the vaccine, which her daughter had received just six days before the rash.
There were a number of non-blanching purple lesions on the child's upper arm. She had no other symptoms, was apyrexial, and had no meningism or any other physical signs suggestive of meningitis.
But these were suspicious lesions and I was frankly unsure of what to do so I rang the local paediatric team for advice.
In those days, the consultant paediatrician held a brilliant rapid response clinic and she advised me to give penicillin V and transfer immediately. The child was a very big girl, so I weighed her. She weighed 57kg (nine stone) – an adult weight – so the consultant advised me to give 1.2g benzyl penicillin IM (two vials).
Then followed a stressful few minutes. The emergency box only had one vial of water for injection. After a rummage round the surgery I managed to find enough in-date water to administer the penicillin IM – one jab in each buttock.
After discussion we decided mum should drive her to hospital, as at that point she still seemed perfectly well, so it seemed inappropriate to call an ambulance.
I wrote a referral letter, including what medication had been given and off they went to A&E. Later I was to learn what happened once they got there.
Soon after the child arrived she rapidly deteriorated and – despite the penicillin I was thankfully able to give her – still needed intensive treatment. She was diagnosed as having meningococcal septicaemia and fortunately after several days in hospital made a full recovery.
Later I received a discharge summary stating a presumed diagnosis of meningococcal septicaemia.
Blood and CSF cultures were negative, presumably because of the penicillin I'd given her. So we never knew for sure if this was meningitis B or C.
Why it nearly went wrong
There were several points in this story where fortune was on our side. The child was not at school and her mum noticed the rash early. Our receptionist acted promptly, and luckily there was a GP available.
Obviously, it was important that I recognised the rash, but I was definitely put off by the fact that the child was otherwise completely well.
Perhaps crucial was realising the significance of the child's weight and giving a therapeutic dose of penicillin – in the days before the paediatric BNF.
A significant event was that the emergency box only had enough water for one penicillin vial, but fortunately I was able to fine more without much delay.
Finally, if she had collapsed on the way to hospital, the decision not to call an ambulance would have been critical.
The moral of the story
I learned a number of lessons from this case, not least to take purpuric rashes very seriously, even in a well person.
Second, it was a reminder that a child's weight is more important than their age in determining doses.
Third, this was a trigger to check our procedures for replenishing stocks of emergency drugs – something I'm sure we all do routinely these days.
Finally, to consider carefully whether to call an ambulance in such cases – balancing the risk of delay with the consequences of a patient collapsing on the way.
Thankfully, this was a near miss that turned out to be one of my finest hours – and the thank you card from the family still has pride of place in my PDP folder.
Dr Tonia Myers is a GP in Chingford, EssexA purpuric rash can appear before the child becomes unwell A purpuric rash can appear before the child becomes unwell Have you had a near miss?
Have you had a near miss - a case where something could have gone badly wrong, but didn't?
If you think GPs could learn from your case then send a brief description to clinical editor Adam Legge
I was definitely put off by the fact that the child was otherwise completely well.