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Rash to dismiss bruising

01 November 2004

Meningococcal septicaemia can progress very rapidly, and early administration of benzyl penicillin is a crucial weapon to avert death or severe morbidity.

The presence of a non-blanching purpuric rash is a crucial diagnostic pointer, but this may not appear until late in the course of the infection in the early stages the rash may be macular or erythematous and may blanch on pressure. It is more obvious where there is pressure from clothing, so a thorough examination of the skin is vital. The rash may also appear as bruising, as in the following case.

Mrs T was in her forties (an unusual age for meningococcal disease). She had started to feel unwell at about 1 pm, first with a headache, but quickly progressing to aching, shivering and pain in her legs and left shoulder.

By 10pm she was feeling so bad that she called her GPs out-of-hours service. Dr Y arrived half an hour later; she recorded the above history and diagnosed a possible flare-up of a pre-existing musculoskeletal condition or a flu-like infection.

It seems that Dr Y did not examine Mrs T. She advised her to take co-proxamol and to contact the GP surgery again if her condition worsened.

At 4 30 the following morning, Mrs T contacted the out-of-hours service again. Dr D attended about 40 minutes later. His notes read as follows: Seen by own Dr at 10.00pm and was given Naproxen. Now C/O pain arms and legs. Temp . BP 130/80. Pulse 90. Bruises all over. Stiffness +. Throat inflamed. Neck stiffness++. Vomiting. ? Meningism. Admitted.

Within an hour, Mrs T was being examined by an SHO at the hospital. He recorded the history given by Dr D, together with his findings on examination: These were negative for clubbing and injury, but noted a purpuric skin rash over Mrs Ts arms and legs painful on palpation and sub-conjunctival blood. BP was 90/50. Pulse 96.He suggested a possible diagnosis of acute gastro-enteritis, septicaemia or DIC.

He ordered a series of investigations, including FBC, coagulation screen and blood culture, but allowed 35 minutes to elapse before prescribing cefotaxime 2g stat, 1g tds.

The microbiology report came back six hours later. It suggested that flucloxacillin 2g IV 6 hourly be added to the cefotaxime and intimated the possibility of meningococcal septicaemia; this diagnosis was later confirmed. Mrs Ts condition deteriorated, requiring CVP monitoring and inotropic support with dobutamine.

Two days later, it was decided that her legs (which were paralysed and numb and covered with purple rashes) were not viable. She underwent below-knee amputations to reduce the risk of myoglobinuria and was transferred to ICU where, unfortunately, she developed ARDS.

Mrs T was eventually discharged home after six months, but she had to return a few months later for an above-knee amputation of her right leg.

Expert opinion

In the opinion of experts, Dr D should have administered an IM injection of benzylpenicillin before transferring Mrs T to hospital. The SHO should also have suspected meningococcal septicaemia and administrated antibiotics immediately on her arrival at hospital. Even so, the experts concluded that some degree of amputation would have been inevitable.

The above-knee amputation (and a resultant osteomyelitis) could probably have been avoided had antibiotics been given earlier.

The claim was settled for £100,000 plus costs.

Learning points

Despite vaccination programmes, meningococcal meningitis and septicaemia remain relatively common and their incidence continues to rise. The two forms of the disease present differently and signs of meningitis are usually absent when septicaemia is the mode of presentation.

Symptoms of meningococcal disease in children and adults include:

  • headache 
  • fever 
  • vomiting
  • neck stiffness and joint pain
  • drowsiness and confusion
  • rash, especially if reddish-purple spots or bruises
  • photophobia

Key points for all clinicians suspecting a diagnosis of meningococcal disease:

Clinicians are reminded to consider the diagnosis of meningococcal infection, especially in the presence of a fever and a haemorrhagic rash, and particularly if accompanied by altered consciousness. Early treatment with Benzylpenicillin should be given as soon as the diagnosis is suspected, if possible given intravenously.

(Suitable doses of benzylpenicillin are: 300mg for children under 1 year of age; 600mg for children aged 1 to 9 years; and 1,200mg in all other cases.)

Benzylpenicillin should be withheld only in individuals who have a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication.

General Practitioners should not worry that administering benzylpenicillin when they think it is clinically indicated will either waste precious minutes in transferring the patient to hospital nor that the injection will mask diagnosis later. Patients with meningococcal infection can deteriorate very swiftly and early administration of intravenous benzylpenicillin, followed by rapid transfer to hospital can be life saving.

  1. Royal College of Pathologists of Australasia, Fact Sheet on Meningococcal Disease