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Re: Petechiae or purpura in meningococcal disease

Wells et al are to be congratulated for their paper looking at children with a non-blanching rash. The data are indeed useful. One point where further detail would be useful is the distinction between petechial and purpuric rashes. The authors initially define petechiae as <2mm and state that only four children with meningococcal disease presented with petechiae, as opposed to purpura (>2mm). Can they provide further details of these four? Were they febrile or clearly very ill?

Some details may have been provided in the paper but the authors unfortunately used 'petechiae' synonomously with 'non-blanching' in the discussion, making interpretation a little difficult.

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Re: reply to Dr Rod Phillips

Dear Editor,

In reply to Dr Phillips' enquiry, four of the twenty four patients with proven meningococcal disease had a petechial rash alone, with no purpura. These are the clinical details of the four:

Case 1
A 3 month old with the clinical features of meningitis. The infant was apyrexial but irritable and ill. There was a petechial rash on the trunk and upper limbs. A lumbar puncture confirmed meningitis. CRP was 25 mg/l.

Case 2
A two year old judged on admission to have meningococcal disease. The child was apyrexial but ill, lethargic with depressed consciousness, prolonged capillary refill time and a spreading petechial rash on the trunk. CRP was 124 mg/l.

Case 3
An eight month old with fever (>38.5 oC), and a spreading rash on the the trunk and upper limbs. The infant was judged to be well on admission. CRP 26 mg/l.

Case 4
A one year old with a fever (>38.5 oC), a prolonged capillary refill time and a normal blood pressure. The infant was judged to be well on admission. There was a spreading petechial rash on the upper and lower limbs.

It was clear on admission that Cases 1 and 2 had meningococcal disease but Cases 3 and 4 were little different from those with similar features who did not have meningococcal disease. The rash was however noted to be spreading when the children were first seen.

Nick Rutter

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Re: Are there afebrile children with petechial rash who need neither investigation nor treatment?

Dear Editor,

Previous studies have reported on the combination of fever and rash. The paper by Wells et al [1] and the letter from Jones et al [2] are particularly valuable as they investigate afebrile children with a rash.

Jones et al had 31 patients, and none had meningococcal disease. However, Wells et al report finding 5 patients with meningococcal disease who were afebrile. May we have some clinical details about these patients? Was their rash purely petechial? Did they appear unwell? Was there any change in their condition over the first 4-6 hours in the department?

If they had only a petechial rash, appeared well, and nothing untoward developed in 4-6 hours, then the finding of menigococcaemia would mean that the suggestion of Jones et al, that such children can be discharged without investigation or antibiotics (which is also my practice), would be called into question.

Yours sincerely,

Keith Brent