Level 1 of 6Core

Fever with rash and meningococcal disease

The core to-do list — diagnose and manage, at a glance

Diagnose— recognise it

A non-blanching rash with fever is meningococcal disease until proved otherwise — fewer than 10% of children presenting this way actually have it, but treat presumptively and immediately, then let culture and the clinical course sort the cohort out.
Undress the patient completely and examine the whole skin in good light — buttocks, perineum, palms, soles, conjunctivae, palate — testing every lesion for blanching with a clear glass. Petechiae are under 3 mm, ecchymoses over 3 mm; purpura by definition does not blanch. Mark the rash margin with a skin pen and record the time: extension beyond that line within the hour indicates fulminant disease.
Do not be reassured by an absent or blanching rash: the rash develops in more than 80% of cases but is often absent early, is usually initially blanching and indistinguishable from viral rashes, and some patients with overwhelming sepsis have no rash at all. Limb pain, pallor or mottling, and cold hands and feet frequently precede the rash.
Look for shock — and in a child never accept a normal blood pressure as reassurance: hypotension is a late sign; children present with compensated shock — tachycardia, poor peripheral perfusion, capillary refill over 3 seconds, mottling, falling conscious level and oliguria — with a normal blood pressure.
Look separately for raised intracranial pressure, because it pulls management the opposite way: reduced consciousness, relative bradycardia with hypertension, focal signs, abnormal posturing, unequal or poorly reactive pupils, seizures, bulging fontanelle — most deaths from meningococcal meningitis alone are associated with raised intracranial pressure.
Treat the paradoxical signs as markers of severe disease, not mild illness: absence of meningism, a temperature below 38°C, leucopenia, thrombocytopenia and a low CRP or ESR all predict poor outcome — the quiet, cool patient without neck stiffness is the more worrying. A GMSPS score of 8 or more identifies severe disease with high risk of death.

Manage now— do this, in order

Give ceftriaxone within minutes of suspecting the diagnosis — and suspect it on the rash alone: adult 2 g IV 12-hourly; paediatric in practice 50 mg/kg IV 12-hourly, maximum 2 g per dose (75–100 mg/kg/day, maximum 4 g/day). Alternative: cefotaxime, adult 2 g IV 6-hourly, paediatric 50 mg/kg IV 6-hourly. Take cultures before the first dose only if venous access is quickly obtained — investigation must never delay the antibiotic.Doctor / NurseNot available at your setup — Blood culture. No cephalosporin available: benzylpenicillin 2.4 g IV (paediatric 50 mg/kg, maximum 2.4 g); severe beta-lactam allergy: chloramphenicol 1 g IV 6-hourly (paediatric 25 mg/kg IV 6-hourly) — a delayed correct drug is worse than an immediate imperfect one.
Under 1 month of age avoid ceftriaxone (bilirubin displacement; precipitation with calcium-containing fluids) — give cefotaxime 50 mg/kg IV 6–8-hourly plus ampicillin 50 mg/kg IV 6-hourly.Doctor / Nurse
Open the airway and give oxygen — airway patency may be compromised by a depressed conscious level from shock or raised intracranial pressure, and pulmonary oedema or pulmonary oligaemia (presenting as hypoxia) requires oxygen therapy or elective endotracheal intubation.
Resuscitate with titrated boluses: 500 mL balanced crystalloid over about 15 minutes in an adult (towards 30 mL/kg within the first hour if perfusion is not restored), 10–20 mL/kg in a child — reassess heart rate, capillary refill, conscious level and urine output after each bolus, examine the chest after every bolus, and track cumulative volume in mL/kg explicitly.Doctor / Nurse
If shock persists after 40 mL/kg the risk of pulmonary oedema is high — elective intubation is recommended, with noradrenaline as first-choice vasopressor when perfusion remains inadequate despite volume, and an inotrope where myocardial depression predominates.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Infusion pump.
Where raised intracranial pressure predominates, do the opposite: this patient must not be flooded and must not be tapped — correct coexistent shock, elevate the head, protect the airway, maintain normocapnia and control seizures.
Steroids — two separate questions: for suspected bacterial meningitis give dexamethasone 0.15 mg/kg IV (adult 10 mg) 6-hourly for 4 days, with or just before the first antibiotic dose; for meningococcal septicaemia therapeutic glucocorticoids are not recommended — the only exception is replacement hydrocortisone 50 mg IV 6-hourly in an adult (1–2 mg/kg in a child) for refractory shock with impaired adrenal responsiveness.Doctor / Nurse
Anticipate and correct the metabolic derangements: treat hypoglycaemia with 10% dextrose 2 mL/kg IV in a child or 50–100 mL of 50% dextrose in an adult, and recheck hourly, since it recurs; treat acidosis by restoring perfusion, never with bicarbonate; correct calcium and magnesium actively. Support the coagulopathy: fresh frozen plasma 15 mL/kg for prolonged clotting with bleeding, platelets below 50 × 10⁹/L with bleeding, cryoprecipitate for hypofibrinogenaemia.Doctor / NurseNot available at your setup — Blood & blood products.
Notify on clinical suspicion, apply droplet precautions (discontinue after 24 hours of effective therapy), and give chemoprophylaxis to close contacts — household members, room-sharers in the 7 days before onset, intimate and kissing contacts: ciprofloxacin 500 mg orally single dose (over 12 years), rifampicin 600 mg orally 12-hourly for 2 days (child 10 mg/kg, infant under 1 month 5 mg/kg), or ceftriaxone 250 mg IM single dose (child under 15 years 125 mg; preferred in pregnancy).

GMSPS component	Points
SBP < 75 mmHg (< 4 y) or < 85 mmHg (≥ 4 y)	3
Skin-to-core temperature gap > 3°C	3
Coma score < 8, or fall ≥ 3 points in 1 h	3
Deterioration in the last hour	2
Absence of meningism	2
Extending purpura / widespread ecchymoses	1
Base deficit > 8.0 mmol/L	1
Score ≥ 8 = severe, high risk of death (max 15)

Refer / escalate

Escalate immediately — and transfer to intensive care — for shock persisting after 40 mL/kg of fluid (elective intubation recommended), a falling conscious level, signs of raised intracranial pressure, extending purpura or peripheral ischaemia, a GMSPS of 8 or more, or any need for vasoactive support, ventilation or renal replacement; call for help while giving the first dose of ceftriaxone, never after it.

Rabies: post-exposure prophylaxis and established disease — Level 6: DepthPrevious Fever with rash and meningococcal disease — Level 2: Must-rememberNext

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