Petechiae and Purpura: the Ominous and the Not-So-Obvious? Stan L

Healthy Baby Practical advice for treating newborns and toddlers.

Petechiae and Purpura: The Ominous and the Not-So-Obvious? Stan L. Block, MD, FAAP

Abstract tient does not appear to be acutely ill or The next considerations will be three Petechiae and purpura are among the prostrate or to have meningismus. If you other sometimes not-so-obvious blood/ most alarming findings a pediatrician will are observing this scenario, you will then vasculitic disorders: autoimmune throm- commonly observe in the office. Severity of be making immediate arrangements for bocytopenias (eg, idiopathic thrombo- illness can range from a temper tantrum, to blood culture, intravenous access, pos- cytopenia [ITP], systemic lupus ery- common viral infections, to the most dead- sibly an in-office parenteral dose of cef- thematosus [SLE]), and the not-so-rare ly infections and diseases. To avoid many triaxone (which is available in nearly all Henoch-Schoenlein purpura (HSP). of the pitfalls in diagnosis, practitioners pediatric offices), and emergency trans- But the most common pathogens as- will need to be thorough in history taking, port to your nearest capable emergency sociated with petechiae/purpura will assessing fever and immunization status, department. However, this highly urgent usually be the more innocuous infec- and physical examination. In addition, a scenario is, fortunately, exceedingly rare tious agents, such as viral infections you few simple laboratory tests will usually be in most of our lifetimes. commonly see in your practice, includ- needed and possibly a manual differential. Instead, typically, you will be encoun- ing mononucleosis, enterovirus, and [Pediatr Ann. 2014;43(8):297-303.] tering a young patient who is non-toxic, parvovirus infections.2 Schneider and who may or may not be febrile, who is colleagues3 reported that most cases of hether the child is febrile, alert, is speaking normally, and has nor- petechiae seen in a hospitalized popula- well, or ill, whenever you mal vital signs. You should first attempt to tion of German children (average age, Wsee a patient with petechiae ensure that you are not seeing a case of 3.8 years) were viral in origin (39 of 58), and/or purpura in your office, you should low-grade early meningococcemia, which with a positive blood culture in only one first take a deep breath. Then your index could evolve extremely rapidly into full- child. However, as a major limitation of of suspicion and your pediatric instincts blown shock. The good news: The former the study, they excluded from the report should override everything else in your disease has become an increasingly un- children who had any purpuric lesions. life or office. You should obtain a full set common encounter, with apparently only Also, fewer than 10 petechiae were re- of vital signs, including blood pressure about 1,000 cases of invasive meningo- ported in 23% of children in the series as and oximeter, and make sure your pa- coccal disease (IMD) occurring annually well. Be forewarned, as I have person- in the United States in recent years.1 But ally seen merely four petechiae, fever, when you practice in rural Kentucky, any and arthralgia as the initial presenting Stan L. Block, MD, FAAP, is Professor of Clinical esoteric disease may be lurking. signs of IMD.4 Pediatrics, University of Louisville, and University Next on your list of urgent and poten- of Kentucky; President, Kentucky Pediatric and tially devastating diseases are what I term APPROACH TO PETECHIAE/ Adult Research Inc.; and General Pediatrician, the “big 3” group of very ominous pete- PURPURA Bardstown, Kentucky. chial illnesses: 1) renal group: hemolytic Upper Body Location of Petechiae Address correspondence to Stan L. Block, MD, uremic syndrome (HUS), 2) cancer/hema- Although still ripe with diagnostic FAAP, via e-mail at [email protected]. tology group: leukemia/lymphoma/neuro- pitfalls, a much easier presumptive diag- Disclosure: Dr. Block has no relevant financial blastoma/aplastic anemia, and 3) Rocky nosis for you will occur when the pete- relationships to disclose. Mountain spotted fever (RMSF) group, chiae are relegated above the nipple line doi: 10.3928/00904481-20140723-03 including ehrlichiosis and anaplasmosis. on physical examination. The diagnoses

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A B eliminate the diagnosis of HSP. l Urine analysis (UA). Certain abnormalities suggest HUS, rarely RMSF group or HSP In the more ill or febrile child consider: l Complete metabolic panel (CMP; ie, electrolytes, renal and liver func- Images courtesy of Stan L. Block, MD, FAAP. MD, Block, Images courtesy L. of Stan tions). Certain abnormalities suggest the RMSF group, mononucleosis, C HUS, or meningococcemia. l Blood culture. l Lumbar puncture. Primarily performed for any stable child with nuchal rigidity or altered mental status; however, it will likely be too difficult to obtain in the office setting for all but infants and toddlers. Then make a calculated guess

Figure 1. An 18-year-old female with history of “possible spider bite” punctum on right lower rib area whether to: (A, blue arrow). Forty-eight hours after the initial bite, she has developed marked confluent erythroder- l Initiate empiric antibiotics (orally or ma on the lateral trunk, in contrast with the more maculo-papular pinpoint rash on the abdomen, as parenterally). well as a thick, scarlet fever–like rash on the abdomen, neck, and elbow creases (B). At 96 hours, the rash has progressed. It is more petechial and pruritic on the knees (C), despite 48 hours of oral clindamycin l Use doxycycline to cover for the and 24 hours of doxycycline therapy to cover for potential methicillin-resistant Staphylococcus aureus- RMSF group and/or ceftriaxone to related surgical scarlet fever and Rocky Mountain spotted fever, respectively, from the insect bite. Are you more concerned that the bite may have initially been from a tick instead? cover for meningococcemia. l Hospitalize your patient. l Send home with careful follow-up. are more likely to be benign: streptococ- with oximetry. You should inspect the You must be keenly aware that the cal pharyngitis, forceful vomiting, se- skin carefully for distribution of pete- earliest finding and only good clue for vere cough.5 But still be very cautious chiae and purpura and other types of IMD in nearly one third of infected pa- when making this assumption in any rashes—especially for lesions below tients was an elevated band count on the febrile child. For these patients, I would the nipple line, any elevation and non- manual differential of the CBC.6 Regard- still consider obtaining a complete blood blanching of lesions, and sclera icterus. ing the “RMSF triad,” as I discussed in count (CBC), possibly with a manual The patient’s general demeanor and level my July 2014 article,7 most patients with differential, along with close follow-up of alertness and toxicity are important to RMSF will, initially or over a few days, within the next 24 hours by phone and/ note. A thorough physical examination have at least one or more of the three fol- or in the office the next day.6 is essential, including at minimum: most lowing laboratory manifestations: low node regions, neck suppleness, pharynx, leukocyte count with a high band count, History heart, lungs, liver, spleen, abdomen, and thrombocytopenia, and/or hyponatre- You will want to ascertain most of the joints. mia.8 In addition, those with Ehrlichio- following factors in your history: level sis will usually have elevated hepatic of fever, tick bites in the last 3 weeks, Laboratory Assessments transaminases. An empiric course of recent travel, recent camping trips, con- I suggest the following basic and sim- doxycycline should be considered. stitutional symptoms such as weight loss ple laboratory assessments for patients These medical decisions are among and fatigue, urine output and color, vac- with petechiae and/or purpura: the most difficult for both experienced cination status, sore throat, headaches, l CBC with a manual differential (can and novice practitioners. Remember that and joint aches. be performed by capillary stick). Cer- almost no in-office hematology machine tain abnormalities suggest meningo- and leukocyte counter can perform a Physical Examination coccemia, RMSF, ehrlichiosis, HUS, band count or examine a peripheral Vital signs should be assessed, along and cancer group, and will usually blood smear for “blasts” or hemolysis.

CASE 1 venously. Within 48 hours, the patient is A At 48 hours after a possible “spider feeling much better, and her rash is fad- bite,” an 18-year-old female presents ing rapidly. The RMSF and ehrlichiosis with a fulminant erythroderma (Figure titers that you obtained earlier were neg- 1A) mixed with a scarlet fever–like rash ative. She recovers uneventfully. (Figure 1B) on her lateral torso and ab- Diagnosis: Petechiae/purpura sec- domen, respectively. Unlike most cases ondary to brown recluse spider bite. of alleged spider bites seen in the office, which are usually staphylococcal Discussion pyodermas not associated with a bite, a Brown recluse spider bites can cause small bite punctum is actually present on systemic toxicity, including fever, chills, her side (Figure 1A, arrow). She is afe- nausea, malaise, and a diffuse macular brile, affable, and feels fine. Her physi- rash with petechiae.9,10 Hemolysis, co- cal examination and vital signs are nor- agulopathy, and renal failure have also mal. Because you are concerned that this been reported in children. In one series may be a Staphylococcus aureus “surgi- of adult patients, 5% were hospitalized, B cal scarlet fever” reaction, you initiate 3% required surgical debridement, and oral clindamycin therapy. When seen 24 9% received Dapsone antibiotic (not for hours later, the rash is still spreading, so children).10 you initiate doxycycline therapy for possible tick-borne illnesses. CASE 2 After 48 hours of antibiotics, the An 11-year-old male who was be- C rash has progressed, now covering her ing treated with amoxicillin for a typi- lower extremities in a highly petechial cal streptococcal pharyngitis, develops but pruritic rash (Figure 1C). The pe- a morbilliform measles-like dermatitis 4 techiae can now be seen on her palms days into therapy (Figure 2A). He still (Figure 1E), as well as on her face. Her has a sore throat and remains febrile at leukocyte count has increased to 18,500, 101°F; his cervical lymph nodes and ab- with 90% segmented neutrophils. Her domen are normal; his leukocyte count serum chemistries and urine analysis are is normal. normal. Upon further questioning, you His rapid test for mononucleosis is D surmise that she may have actually been positive today. Thus, you assume this is bitten by a brown recluse spider. She is just the purported “typical” mononucle- still smiling, although with some gener- osis rash triggered by amoxicillin and alized malaise. not a drug hypersensitivity reaction or other complication. The rash is non-pru- Diagnosis ritic and not urticarial. Four days after Figure 2. An 11-year-old White male who devel- You are now concerned that the pro- you switch his antibiotics to oral cepha- oped this morbilliform measles-like rash 4 days gression of the rash may indicate either lexin, he has now developed a petechial into treatment with amoxicillin for streptococcal pharyngitis (A). His fever is still 101°F, his lymph an indolent meningococcemia or RMSF and lumpy purpuric rash over his entire nodes and abdomen are normal, and his leuko- infection from a tick bite instead. You body (Figures 2B-2C). He is non-toxic, cyte count is normal. Further testing? When the patient showed a positive monospot test, his hospitalize her at your children’s hos- talkative, and feels fine. He is afebrile doctor switched him off amoxicillin and substi- pital, where the infectious disease con- with normal vital signs and physical ex- tuted oral cephalexin. Four days later, the patient sultant elects to go “mostly” with your amination. developed this full-body “lumpy” purpuric rash (B, C). He is now afebrile and has minimal other first diagnosis of a spider bite, second- symptoms. Allergic reaction? Refer? Hospitalize? arily infected with bacteria such as S. Diagnosis Treatment? The morbilliform purpuric rash in the 11-year-old male has markedly dissipated 24 aureus or others. They initiate high-dose Although he has classic palpable pur- hours after being treated with which drug (D)? intravenous clindamycin and ampicillin/ pura, the distribution of the rash is too (Answer can be found in the text.) sulbactam. However, hedging their bets, extensive to be typical for HSP or immu- they also continued doxycycline intra- noglobulin A (IgA) vasculitis. Or is it?

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A ensure you are not witnessing a case of Monitoring in HSP early meningococcemia or hemolytic Careful follow-up over the first few uremic syndrome, ITP, or SLE. All labo- weeks is still essential, despite the low ratory tests are normal, thus you default incidence of nephritis. In the otherwise to the HSP diagnosis. uncomplicated afebrile case after HSP How common is HSP? You audited diagnosis is made, you may typically your charts for the diagnosis of either recommend: 1) two additional visits anaphylactic purpura of HSP over the within the first week, and then two more past 5 years. In your busy, seven pediatri- weekly visits; and 2) to return at any cian private practice of children and ado- time if the family notices the child has lescents, you found 27 cases within the developed puffy eyes, bad headaches, 60-month interval—about one episode off-colored urine, decreased urine out- every 2 months may occur in your office. put, abdominal/genital/joint pain or Only three patients were adolescents. swelling; 3) at each visit, a CBC, UA, B You are well aware that the IgA vascu- and serum chemistries as well as obtain- litis can primarily affect (early on or lat- ing weight, vital signs (blood pressure er) four other organ systems besides the especially), and a physical examination. skin, such as: 1) glomerulonephritis, 2) abdominal pain (rarely along with intus- Treatment of HSP susception), 3) arthritis, and 4) orchitis/ This is a fairly controversial area, but oophoritis. Although these sequelae have the literature suggests a possible role for been reported in 50% to 75% of children9 steroid therapy, at least in hospitalized (who were mostly hospitalized), they are patients. I think that two recent stud- actually uncommon (< 5%-10%) in your ies conducted by Weiss et al,11,12 have experience with outpatients in the gener- shown that steroids may cause a modest al pediatrics office. You are quite attuned reduction in renal disease and significant to possible secondary nephritis, which reductions in surgery (odds ratio: 0.39), may have particularly severe long-term endoscopy (odds ratio: 0.27), and ab- sequelae. However, in fact, you have dominal imaging (odds ratio: 0.5). only seen this occur in two patients dur- When the child with HSP did not have ing 30 years of general pediatric practice. severe abdominal pain, I have personally Both patients are doing well, but both only used oral steroids in an outpatient still require antihypertensive medication. setting one time—in this case. And, the And, you learned this week in the office, results appeared to be dramatic within 24 one young girl had just finished receiv- hours of initiation of oral steroids (Fig- ing immune suppressants for more than ure 2D). My rationale was based on the 3 years. Only a few of your patients have severity of his vasculitic rash in this case also experienced severe abdominal pain and the fact that steroids have also shown to the point of requiring surgical evalu- a modest benefit in some cases of severe ation and hospitalization. In one of these mononucleosis. The earlier steroids are

Figure 3. Note the full body (A) and arm (B) distri- patients who was febrile, despite 48 started in more severe cases of HSP, the bution of the lumpy purpuric rash in this 13-year- hours of an initial diagnosis of HSP and greater the benefit will be, in my opinion. old white female who is afebrile and has no other the later development of a typical HSP Obviously, I did not want to wait for se- symptoms. rash, the blood culture obtained in the verity requiring hospitalization. After all, you have been taught that the emergency department revealed that she rash rarely goes superior to the waistline actually had a meningococcal serogroup Mononucleosis Rash Due to or on the arms. But one of the keys to B infection. So be very careful with the Amoxicillin this diagnosis is the usual lack of any diagnosis of HSP in the febrile child. A I believe this may be one of the most systemic illness signs or fever. continued physical and laboratory evalu- unsubstantiated “factoids” in pediatric You obtain a CBC, UA, and CMP to ation is very important. medicine; and any entrenched mythol-

Figure 6. Eight-year-old female with strep throat and fever to 102°F, who has developed this peri- C oral and peri-orbital petechial rash.

Diagnosis: Petechiae and purpura Figure 4. Note the petechiae on the trunk and up- secondary to HSP. per extremity in this 12-year-old white male who is afebrile and has no other symptoms. Is further testing needed? CASES 6 AND 7 Figure 5. An irritable, unhappy 2-year-old white Each of these photographs (Figures ogy is hard to extinguish. For years in male who has developed this alarming petechial 6 and 7) shows some of the most com- and purpuric rash on the legs (A), arm and below our office, we have been treating strep- the waistline (B), and peri-orally (C). Is further mon presentations of petechiae in oth- tococcal pharyngitis with amoxicillin testing needed? erwise healthy white children who have as the first-line agent. We observe prob- the uncharacteristic distribution of the streptococcal pharyngitis and fever. ably 50 to 100 cases of mononucleosis palpable purpuric and petechial rash in Neither child had a history of cough or annually, of which at least 5% are co- HSP. Cases 3 and 4 were distributed all vomiting. Note the facial distribution of infected with streptococcal pharyngi- the way up the back and onto the arms. petechiae without any other body pete- tis, and several will also develop acute Case 5 shows another alarmingly dif- chiae in each case. Because of the fever otitis media or sinusitis, which we have fuse HSP rash that appeared not only on and illness, these children usually need almost uniformly treated with amoxi- the arms but also the face. The rash may more careful evaluation and follow-up cillin, as well. We rarely ever have ob- be associated with pruritus and excoria- the next day or two, even though they served a rash in this group of children. tions. In each of the cases, the CBC and both have a documented case of strep- A recent report regarding Israeli chil- platelet counts were normal. The child tococcal pharyngitis. You will usually dren seems to confirm our anecdotal in Case 5 was also the most worrisome still perform a CBC, preferentially with findings. Among children with mono- due to his difficult examination in the a smear for a manual band count, plate- nucleosis, the incidence of rash was office and the severity of his rash. A lets, and evidence of hemolysis. Note not any different for children who had blood culture was obtained in his case, that the leukocyte and band count both received amoxicillin versus those who but no antibiotics were started in light may be elevated notably in children had not (29.5% vs 23%).13 of his normal CBC and other laboratory with streptococcal pharyngitis, creating Diagnosis: Petechiae/purpura second- findings. some consternation on your part. Oc- ary to HSP; possibly related to mononu- However, the young boy in Case 4 casionally, you may be worried enough cleosis or group A Streptococcus.14 with the least alarming rash was one initially to perform a blood culture and of the only two children in our practice sometimes even to administer paren- CASES 3, 4, AND 5 over 30 years who actually developed teral ceftriaxone, if you have significant Each of these children (ages 13 [Fig- renal complications of azotemia and suspicion for early meningococcemia ure 3], 12 [Figure 4], and 2 years old hypertension. His renal condition has despite your positive rapid strep test. [Figure 5], respectively), who were resolved, but he still requires an antihy- To make your overall assessment even otherwise healthy and afebrile, shows pertensive daily. more complex, remember that some of

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A A

Figure 7. Six-year-old male with Streptococcal pharyngitis, lymphadenitis, and fever 101°F, who has developed this petechial rash on his face. B B these children with a positive streptococcal pharyngitis test, may actually be streptococcal carriers. Diagnosis: Petechiae secondary to strep throat.

Figure 9. Worrisome petechiae rash on the soles CASE 8 (A) and palms (B) of a 13-year-old male who has This toddler had such a severe sore throat and fever (102.5°F). It is summer, and he has been camping, but the mother can recall screaming temper tantrum the night be- no tick bites recently. Further testing? Or a more fore the office visit that she developed thorough physical examination? this highly concentrated localization of petechiae from the clavicle to the scalp graph (Figure 11) is more ill appear- Figure 8. Afebrile toddler in the full throes of the line (Figure 8). She was not ill other- “terrible two’s”, who has no cough, vomiting, or ing and sleepy. He has been previously wise; she had absolutely no history of illness. You are perplexed as to the cause of her healthy and has no history of tick bites facial petechiae. She is certainly not happy that vomiting, cough, or pharyngitis. Her you are visiting with her today. or travel. He has had a fever for the past CBC and platelets were also normal. 2 days (101.3°F today), headache, mod- Without any spread or other triggers of to this diagnosis and carefully assess for erate photophobia, no nuchal rigidity, petechiae, could this be a case of early a history of any tick bites. This is sum- and some lower extremity joint aches. ITP or leukemia? The petechiae dissi- mertime, after all. You think that a CBC, He also has moderate abdominal pain, pated moderately over the next 48 hours serum chemistries, and UA are a prudent so you are also worried about the vas- when she was seen back in the office, starting point in the evaluation. culitis of HSP. The rash is scarlet fever– and she has remained well and without But these two patients do not appear like with macule-papules interspersed any evidence of petechiae over the next ill. Thus, if you were to carefully assess with petechiae. month. the oropharynx of these two patients, Diagnosis: Petechiae secondary to you have a distinct likelihood of uncov- Discussion the “terrible two’s.” ering some red, round, yellow-centered In your office, you obtain a CBC, blisters in the posterior pharynx or on UA, and serum chemistries, which only CASES 9 AND 10 the lips. Remember that the peak season show a low leukocyte count. Because These two patients with streptococ- for very commonly encountered entero- your automated office hematology ma- cal pharyngitis show a worrisome dis- viral infections is also summer, and en- chine does not perform a leukocyte dif- tribution of petechiae (ie, on the feet teroviral infections can also cause pete- ferential, you send the bloodwork to the and palms, extending up to the knee) chiae,14 which it did in these cases. hospital. Although you were not initially (Figures 9-10). Because RMSF classi- Diagnosis: Enteroviral infection. certain of the severity of his illness, cally presents with a rash starting on the when the band results (28%) arrive a few hands and feet, which spreads centrip- CASE 10 hours later, you call the patient back in etally, you must be particularly attuned The 10-year-old male in this photo- to the office. You have observed enough.

Figure 10. A worrisome petechial rash on the dor- sum of the feet and up to the knees (not shown) in an afebrile 14-year-old female who only reports a sore throat. A careful physical examination may reveal the causative pathogen.

You decide to admit him to the hospital for blood culture and parenteral ceftriaxone antibiotics. His mental status and Figure 11. In April, this 10-year-old male developed headache, abdominal pain, generalized arthralgias, neck suppleness remain unchanged over and fever (101.3°F) along with these petechiae all over the trunk in a scarlet fever–like distribution. In the next several hours, so you do not your practice, does this series of cases remind you of the fable of the little boy who cried wolf too many times? Is further testing needed? think a lumbar puncture is worthwhile. He does not have meningitis, so you do need to resort to a few simple laboratory vasive meningococcal infection in children . Pediatr Infect Dis J. 2013; 32:1070-1072. not think that he initially needs either tests and possibly request a manual dif- 7. Block SL. Spots and lumps: treacherous tick- 15 vancomycin or steroids as well. Within ferential, paying meticulous attention borne illnesses. Pediatr Ann. 2014;7:256-261. 24 hours, most of his fever and illness to the details in all these reports. Index 8. Mandell GL, Wilfert CM. Atlas of Infectious symptoms have dissipated, except for of suspicion and clinical gestalt are key Diseases. Pediatric Infectious Diseases. Phil- adelphia, PA: Churchill Livingstone; 1999. the joint aches. His blood culture is now as well. Be especially wary of any child 9. Kliegman RE, Stanton B, St. Geme J, Schor growing a gram-negative cocci. Your in- who has fever with his petechiae/purpu- NF, Behrman RE. Nelson Textbook of Pediat- dex of suspicion was correct: He was af- ra. Petechiae and purpura will test your rics. 19th ed. Philadelphia: Saunders Elsevier; 2011. fected by both the ominous and not-so- mettle! 10. Wright SW, Wrenn KD, Murray L, Seger obvious—early meningococcemia. D. Clinical presentation and outcome of Diagnosis: Early meningococcemia. REFERENCES brown recluse spider bite. Ann Emerg Med. 1. U.S. Centers for Disease Control and Pre- 1997;30:28-32. vention. Meningococcal disease: causes and 11. Weiss PF, Feinstein JA, Luan X, Brunham CONCLUSION transmission. http://www.cdc.gov/meningo- JM, Feudtner C. Effects of corticosteroid on Petechiae and purpura are among coccal/about/causes-transmission.html. Ac- Henoch-Schonlein purpura: a systematic re- the most alarming findings a pediatri- cessed July 22, 2014. view. Pediatrics. 2007;120:1079-1087. 2. Edmonson MB, Riedesel EL, Williams GP, 12. Weiss PF, Klink AJ, Localio R, et al. Corti- cian will commonly observe in the of- DeMuri GP. Generalized petechial rashes in costeroids may improve clinical outcomes fice. The severity of the cause of illness children during a parvovirus B19 outbreak. during hospitalization for Henoch-Schonlein can range from a simple temper tantrum, Pediatrics. 2010;125:e787-e792. purpura. Pediatrics. 2010;126:674-681. 3. Schneider H, Adams O, Weiss C. et al. Clini- 13. Chovell-Sella A, Tov AB, Lahav E. Incidence to common viral infections, to the most cal characteristics of children with viral sin- of rash after amoxicillin treatment in children deadly of infections (meningococcemia) gle- and co-infections and a petechial rash. with infectious mononucleosis. Pediatrics. and diseases (HUS). Although no cases Pediatr Infect Dis J. 2013;32(5):e186-e191. 2013;131:e1424-e1427. 4. National Public Broadcasting Network. The 14. Paller AS, Mancini AJ, eds. Hurwitz Clinical of the following were presented here, I Best Doctors in the World are Making House Pediatric Dermatology: A Textbook of Skin have seen several cases of ITP, aplastic Calls on Public Television: Healthy Body Disorders of Childhood and Adolescence. anemia, and leukemia present in similar Healthy Mind TV Series: 2204 Catching a 4th ed. Philadelphia, PA: Elsevier/ Saunders; manner as these cases. Killer: Preventing Meningococcal Disease. 2011. 2012. Episode 2204 [DVD]. 15. AAP Committee on Infectious Diseases; To avoid many of the pitfalls in di- 5. Wells LC, Smith JC, Weston VC, Collier J, Pickering LK, Baker CJ, Kimberlin DW, agnosis, practitioners will need to be Rutter N. The child with a non blanching rash: Long SS, eds. Red Book: 2012. Report of the thorough in history taking, assessing fe- how likely is meningococcal disease?. Arch Committee on Infectious Diseases (Red Book Dis Child. 2001;85:218-222. Report of the Committee on Infectious Dis- ver and immunization status, and physi- 6. Demissie DE, Kaplan SL, Romero JR, et al. eases). 29th edition. Elk Grove Village, IL. cal examination. Also, you will usually Altered neutrophil counts at diagnosis of in- American Academy of Pediatrics; 2012.

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