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Editor,—I was dismayed to see your publication of the letter by Dr Sam regarding the role of lumbar puncture in meningococcal disease.1 While fully understanding the need to get as much information as possible, the benefits of isolating the causative organism need to be weighed against the risk of causing clinical deterioration in a patient who may have cardiovascular compromise and/or raised intracranial pressure, both of which are recognised contraindications to lumbar puncture.2 There are clear and recognised risks of performing this procedure in such patients.
The potential benefits of lumbar puncture include making a diagnosis of meningitis and isolation of the organism for epidemiological and sensitivity testing. In the UK the typical haemorrhagic rash of meningococcal infection is pathognomonic of the disease and should be treated as such prospectively, until further confirmatory evidence is available. With polymerase chain reaction (PCR) of meningococcal DNA in blood allowing up to 100% sensitivity for diagnosis in the first 24 hours of illness,3 there is little to be gained from looking for bacteria or cells in the cerebrospinal fluid (CSF).
The antibiotic regimen is no different for either meningococcal meningitis or septicaemia, with seven days of a third generation cephalosporin being the treatment of choice because of improved CSF penetration.4 There are no reports of meningococcal resistance to this treatment in the UK, so performance of a lumbar puncture for bacterial sensitivity testing appears to be unnecessary.
Prospective therapy while awaiting results of culture or PCR from blood seems to be a small price to pay in this life threatening illness. An analogy could be drawn from the management of epiglottitis. It is generally accepted that throat swabs should not be taken from children with epiglottitis until the child's airway has been protected, because of the risk of clinical deterioration. It is time that textbooks of emergency paediatrics stated clearly that lumbar punctures on children with a haemorrhagic rash, and clinical signs of meningococcal infection, should be not be carried out until the clinical condition has been stabilised, and only if the procedure will add further valuable information that cannot be obtained elsewhere.