MANAGEMENT OF PETECHIAL RASH IN INFANTS AND CHILDREN

• Diagnostics
• Definitions
• Figure 1 - Managemwnt Flowchart
• Alternative diagnoses and treatment
• Empirical treatment
• DIscharge
• Footnotes
• Appendices
• Background

This guideline covers treatment for infants and children who present with a petechial rash. If a petechial rash has been confirmed it is crucial to assess for red flags in the history and examination. An unwell or systemically unstable patient with a petechial rash must be managed as having evolving meningococcal disease or other serious bacterial infection irrespective of temperature. It is important to be vigilant for early symptoms of meningococcal disease which include limb pain, cold hands and feet and abnormal skin colour. These symptoms are usually present in the first 12 hours of the illness. The classic symptoms of rash, meningism and impaired consciousness are late signs of the meningococcal disease. 

The incidence of meningococcal disease in patients presenting with petechial rash is low. The majority of patients with petechial rash will be well and require consideration of other diagnoses, usually self-limiting viral infections. The absence of a fever on initial assessment does NOT rule out meningococcal disease. 

If the child is unwell, please refer to the ‘Considering Sepsis in Paediatrics’ guideline.

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DIAGNOSTICS

All patients	Full exposure and documentation of the petechial rash using a body map Hourly observations for at least 4 hours (including BP)
Fever (≥38°C)     or history of recent fever	FBC CRP Coagulation Profile Blood Gas
Unwell patient (see figure 1) Take and send blood tests in this order	Blood Culture Blood Gas/ Blood Sugar FBC Coagulation Profile U&Es/Bone Profile/LFTs/CRP Blood Meningococcal and Pneumococcal PCR (Separate EDTA bottle) Group and Save NPA for Respiratory Viruses Consider LP if there are no contraindications CSF MCS, CSF Protein, CSF Glucose and CSF PCR

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DEFINITIONS

Petechiae: is a pinpoint non-blanching lesion that measures <2mm in diameter
Purpura: is a non-blanching lesion measuring ≥2mm in diameter. 
Non-blanching rash: may be used to describe both a petechial and purpuric rash. 

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Figure 1: Management flowchart

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ALTERNATIVE DIAGNOSES AND TREATMENT

Afebrile patient with a petechial rash: In a well, afebrile patient with no history of fever and a petechial rash NOT limited to the superior vena cava (SVC) they should have hourly observations for 4 hours. If the rash does not spread and the child remains well then meningococcal disease is unlikely. Additionally, if the petechial rash has been there for >24 hours and is non-spreading then meningococcal disease is unlikely. It is essential that a bleeding history is taken. In these patients consider an FBC, Blood Film and/or Coagulation Profile

Deranged Coagulation
If a coagulation profile has been performed in a well patient who presents with a petechial rash without a medical or family history of excess bleeding and the APTT, Fibrinogen or PT is deranged a repeat sample should be performed in the first instance. If the repeat result is abnormal then this should be discussed with the on-call paediatric haematology team.

If a medical history reveals a medical or family history of a bleeding disorder this patient will need discussion with on-call paediatric haematology team to ensure that the correct coagulation studies are performed.

Rash Confined to SVC: A petechial rash limited to the superior vena cava (SVC) distribution (above the nipple line) may be caused by mechanical forces related to coughing or vomiting. In a well patient, independent of temperature a petechial rash limited to the SVC is unlikely to be caused by meningococcal disease. They will need to be observed for 4 hours to ensure that the rash has not spread. No blood tests are routinely required.

Henoch-Schonlein Purpura (HSP) may present as a purpuric rash limited to the extensor surfaces of the lower limbs. A patient with suspected HSP who presents unwell as defined in Figure 1 should be managed as per meningococcal disease, with additional investigation for HSP. See full guideline ‘Management of Henoch-Schonlein Purpura in Patients Under 16 Years’.

Idiopathic Thrombocytopenia Purpura (ITP) may present with petechiae and isolated thrombocytopenia. A blood film must be sent to rule out differential such as malignancy and Thrombotic Thrombocytopenia Purpura (TTP).

Non accidental injury (NAI) petechiae in association with bruising are a strong predictor of abusive injury. Inflicted injuries may not always have associated bruising and may leave a ‘negative’ imprint of the object used. Following a high-velocity injury, an unbruised negative image may be outlined by a fine rim of petechiae.

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EMPIRICAL TREATMENT

Ambulatory antibiotics: If patient is to be treated on this pathway please refer to the ambulatory antibiotic guideline.

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DISCHARGE

Patients with a petechial rash and fever with a low CRP and a normal WCC can be discharged after 4 hours with safety net advice on when to re-attend. Parents should be given a sepsis leaflet.

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FOOTNOTES

1. It is a clinical decision what constitutes as a raised CRP. A CRP <6 makes Meningococcal disease very unlikely.
2. A raised or low White Cell Count (WCC) is defined by the reference ranges on ICE results
3. The preferred administration route is IV injection or infusion. If IV route not available CEFTRIAXONE (80mg/kg) + 1% Lidocaine can be given IM. For further information on making up IM Ceftriaxone with 1% Lidocaine please review the Leeds formulary.
4. If LFTs are normal, then CEFTRIAXONE can be used in the 1-3-month age group for ambulatory purposes

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APPENDICES

Table 1. Symptoms of sepsis and meningitis - symptoms in bold are early features of meningococcal disease

Table 2. Signs of sepsis and meningitis; signs in bold are early features of meningococcal disease

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Background

The majority of patients presenting for assessment with a petechial rash will not have meningococcal disease. A prospective study by Waterfield et al. (2020) reported that 1% of patients with fever (>38.0) and petechiae had confirmed meningococcal disease. Furthermore, petechiae can be found in up to 3% of asymptomatic well infants.

Meningococcal disease is caused by Neisseria Meningitidis which can cause meningitis or sepsis. Patients with meningococcal disease may have a mixture of these two processes occurring during their illness - although one disease process tends to predominate. Due to the severity and rapid progression of meningococcal disease, this diagnosis must be given serious consideration to all patients who present with a petechial rash.

Thompson and Ninis et al. describe that symptoms of leg pain, cold hands and feet and abnormal skin colour are early signs of meningococcal disease usually present within the first 12 hours. The typically symptoms of rash, meningism and impaired consciousness are later signs of meningococcal disease. In the early stages of meningococcal disease, the rash may appear as a blanching maculopapular rash which may go on to become a non-blanching rash. If the rash progresses to purpura then a diagnosis of meningococcal disease is increasingly likely and all such patients such be treated as such. It is also important to consider that approximately 30-35% of 1-16-year-old with meningococcal disease will not develop the typical ‘haemorrhagic rash’. Therefore, the absence of a non-blanching rash does not equate to the absence of meningococcal disease.