A Unique Child: Health - A doctor's diary ... meningitis

A mother called the practice for medical advice about her five-year-old daughter, Hannah. She hadn't been very well for two days and had been sent home from school with a fever.

Since it was Friday, the mother wanted to get some medical advice before the weekend. During our conversation, she commented that although her daughter had a high fever, she wasn't concerned about Hannah having meningitis because she didn't have a rash.

COMMON MISCONCEPTION

It is a commonly-held belief that a diagnosis of meningitis can only be made if a child has a rash, and conversely, that if a child doesn't have a rash, they do not have meningitis. Unfortunately, this misconception puts many lives at risk.

Meningitis describes inflammation of the covering of the brain and spinal cord, known as the meninges. Some of the most serious cases are caused by bacteria such as Neisseria meningitidis.

In the early stages of the disease, children may present with a variety of seemingly trivial or vague symptoms such as feeling unwell, fever, nausea or vomiting. They may also complain of abdominal pain and perhaps have diarrhoea. In some cases, meningitis may masquerade as the common cold or a simple cough.

As the disease takes hold and bacteria continue to multiply, some children begin to complain of leg pain. By this stage, they may also have cool hands and feet, complain of a headache and say that the light hurts their eyes - a condition known as photophobia. Once the disease is fully established, the child may have a stiff neck.

Babies may appear vacant or breathless, have a high-pitched cry, or merely be irritable and off their food. The 'soft spot' on a baby's head, known as the fontanelle, may be tense or even bulge once the illness has progressed.

Not all patients with meningitis will have a rash and of those that do, it often appears in the latter stages of the illness, when it may be too late for treatment to be effective.

The classic rash of meningitis is known as a 'purpuric rash'. This occurs when the toxins released by bacteria stop the blood from clotting properly, causing bleeding into the skin.

A purpuric rash doesn't blanche under pressure. It may occur anywhere on the body and it is often said to 'appear in front of one's eyes'. In a third of cases, the rash will start as a blanching rash - that is, one that does disappear on pressure.

It is easy to check whether a rash blanches by pressing a clear glass against it. If it disappears, the rash is said to blanche.

Blood poisoning, otherwise known as septicaemia, may be caused by the same bacteria as meningitis, but is considered to be more dangerous.

Early on in septicaemia, the child may have a fast pulse rate. Other important signs are mottling of the skin, and cool hands and feet. The child can also appear to have breathing difficulties.

The rash is often more aggressive in septicaemia than in meningitis, but again it occurs once the disease has taken hold, rather than early on. By this stage, treatment may be too late, and death literally minutes away.

PREVENTION

Children who have been vaccinated against meningitis are still susceptible, as the vaccine doesn't protect against all forms of the disease.

It is not fully understood why some children develop full-blown meningitis or septicaemia, and while the number of cases have fallen recently, it remains a serious threat to life.

Exposure to cigarette smoke has been shown by research to increase the chance of contracting meningitis. Those under the age of five, particularly babies, are most vulnerable.

COMPLICATIONS

Meningitis or septicaemia may kill a child within hours of contracting the illness. While it kills one patient per day in England and Wales, patients who survive may suffer serious complications that include brain damage, amputation, epilepsy and deafness.

MAIN MESSAGE

The message here is a simple one: the rash occurs late in meningococcal disease and the absence of a rash doesn't exclude a diagnosis of meningitis.

If you suspect a child has a serious illness, seek medical help early.

Children with apparently trivial symptoms such as diarrhoea should be watched closely and medical advice sought if they deteriorate.

- Dr Raj Thakkar BSc(Hons) MBBS MRCGP MRCP(UK) is a full-time GP in Buckinghamshire

Reference: www.meningitis.org