Management of the Child with a Non-Blanching Rash

Paediatric Clinical Guideline Resus/A&E 13.1 February 2002 MANAGEMENT OF THE CHILD WITH A NON-BLANCHING RASH.

Children commonly present with a non-blanching rash, with or without other features of illness. They are a diagnostic dilemma. The minority with invasive meningococcal disease and other invasive bacterial infections (about 10%) need to be distinguished from the majority with benign self-limiting illnesses. Recent studies 1-5 have allowed us to derive an evidenced-linked guideline for the management of these children.

Differential Diagnosis.

The differential diagnosis of a non-blanching rash includes:  Meningococcal disease (MCD)  Sepsis with other bacteria (uncommon)  Viral illnesses  Trauma/Mechanical/NAI

The following groups are distinct and usually not difficult to diagnose:  Idiopathic thrombocytopenia (ITP)  Henoch Schonlein purpura (HSP)  Acute leukaemias  Haemolytic uraemic syndrome (HUS)

They have other specific signs or symptoms:

ITP: Usually well children with multiple bruises and petechiae noted over several days

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

Acute leukaemias: Symptoms of slower onset associated with anaemia, lymphadenopathy or hepatosplenomegaly

HUS: Oliguria/anuria associated with anaemia, usually following a diarrhoeal illness

This leaves a further group of children in whom we need to distinguish MCD and other bacterial sepsis, from self- limiting viral illness or trauma.

of 5 Paediatric Clinical Guideline Resus/A&E 13.1 February 2002

The following algorithm is based on observation and investigation of these children and provides a simple guide to their assessment and management. Prior administration of penicillin does not alter the algorithm but these children should have a senior review prior to discharge in order to reassure parents.

Non blanching rash

Purpura Yes (lesions >2mm in diameter)

Admit and treat as MCD at once No (See MCD Protocol)

Ill (irritable, lethargic, toxic) and/or Yes Capillary refill > 2secs and/or Hypotensive

Rash confined to the SVC distribution (above the nipple line)

No Yes

Admit and observe FBC, blood culture, CRP and Discharge if no other meningococcal PCR clinical concerns

If well, no spread of rash and CRP<6mg/l, discharge - otherwise admit and treat as MCD

References

1. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteraemia in infants and children with fever and petechiae Journal of Pediatrics 1997;131:398-404

2. Brogan P, Raffles A. The management of fever and petechiae: making sense of rash decisions. Arch Dis Child 2000;83:506-507.

3. Marzouk O, Bestwick K, Thomson AP, Sills JA, Hart CA. Variation in serum C- reactive protein across the clinical spectrum of meningococcal disease. Acta Paediatr 1993 82:729-33.

4. Nielson HE et al. Diagnostic assessment of haemorrhagic rash and fever. Arch Dis Child 2001 85:160-165.

5. Wells LC, Smith JC, Weston V, Collier J, Rutter N. The child with a non-blanching rash: How likely is meningococcal disease? Arch Dis Child 2001 85:218-222.

of 5 Paediatric Clinical Guideline Resus/A&E 13.1 February 2002 PAEDIATRIC CLINICAL GUIDELINES

ISSUE: VERSION: FINAL

Title: Management of the Child with a Non-blanching Rash

Author: Dr Louise Wells Job Title: Paediatric Specialist Registrar

First Issued: February 2002 Date Revised: Review Date: February 2005

Document Derivation: Consultation Process: i.e. References:

Included in document

Ratified By: Paediatric Clinical Guidelines Committee Chaired By: Dr Kate Armon

Consultant with Responsibility: Dr Stephanie Smith

Distribution: All wards QMC and CHN

Training issues: Included in Induction Programme

Audit:

This guideline has been registered with Nottingham City Hospital NHS Trust and QMC Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’ only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

MANUAL AMENDMENTS RECORD

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