Non blanching rash (18/1700)

A 7yo child is brought to the ED with a 1 day hx of being restless. On examination, the child is
drowsy with an extensive non-blanching rash. What advice would you give the parents?

a. All family members need antibiotic therapy
b. Only the mother should be given rifampicin prophylaxis
c. All family members need isolation
d. All family members should be given rifampicin prophylaxis
























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answer: D
nice:

• Prophylaxis against meningococcal disease should be considered for the following close contacts, regardless of meningococcal vaccination status:
• People who have had prolonged close contact with the case in a household-type setting during the 7 days before onset of illness.
• For examples: people who are living or sleeping in the same household (including extended household), pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence.

dx: meningitis until proven otherwise


Management of the child with a non-blanching rash non-blanching rash
Children commonly present with a non blanching rash +/- fever. The important  diagnosis to exclude in these patients is meningococcal disease. However, most (> 90%) of these children who are well with the rash will have viral infections that require no treatment.

Diagnosis
There are a group of conditions which present with a non blanching rash, but have
specific features which will identify them easily:
•    Henoch Schonlein purpura (HSP}
•    Idiopathic thrombocytopenia (ITP)
•    Acute leukaemia
•    Haemolytic uraemic syndrome (HUS)

HSP
Usually a classical distribution of purpura, bruising and urticaria on the buttocks and
extensor surfaces of the limbs, sometimes associated with joint or abdominal pain
ITP
Usually well children with multiple bruises and petechiae noted over several days
Acute Leukaemia
Symptoms of slower onset associated with anaemia, lymphadenopathy or
hepatosplenomegaly
HUS
Oliguria/anuria associated with anaemia, usually following a diarrhoeal illness

Once the above conditions are ruled out clinically, (see individual guidelines for
assessment and management), we are left with a differential diagnosis as follows:
•    Meningococcal disease (MCD)
•    Sepsis with other bacteria (uncommon)
•    Viral illnesses
•    Trauma//NAI
•    Mechanical e.g. due to raised intrathoracic pressure from coughing or vomiting in
superior vena caval distribution (above nipple line).

The presence of purpura make meningococcal disease more likely. (Petechiae are
pinpoint non-blanching spots. Purpura are larger non-blanching spots (>2mm).