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Guidance for the diagnosis and management of children presenting with a non-blanching rash. It includes a management algorithm and photo's to aid the clinician.
Children presenting with a non-blanching rash.
Medical and nursing staff in the Emergency Department and Acute Care Environments.
Children commonly present with a non blanching rash +/- fever. The important diagnosis to exclude in these patients is meningococcal disease. However, most (> 90%) of these children who are well with the rash will have viral infections that require no treatment. They have long presented a diagnostic dilemma to paediatricians.
There are a group of conditions which present with a non blanching rash, but have specific features which will identify them easily:
They have other specific signs or symptoms:
Usually a classical distribution of purpura, bruising and urticaria on the buttocks and extensor surfaces of the limbs, sometimes associated with joint or abdominal pain
Usually well children with multiple bruises and petechiae noted over several days
Symptoms of slower onset associated with anaemia, lymphadenopathy or hepatosplenomegaly
Oliguria/anuria associated with anaemia, usually following a diarrhoeal illness
Once the above conditions are ruled out clinically, (see individual guidelines for assessment and management), we are left with a differential diagnosis as follows:
Evidence is based on retrospective and prospective observational studies, specific points include:
Use the following algorithm to help discriminate who needs admission and IV antibiotics and who can be discharged. If in doubt TREAT AS MENINGOCOCCAL SEPSIS.
Prior administration of penicillin does not alter the algorithm
1. Brogan P, Raffles A. The management of fever and petechiae: making sense of rash decisions. Arch Dis Child 2000;83:506-507.
2. Nielson HE et al. Diagnostic assessment of haemorrhagic rash and fever. Arch Dis Child 2001 85:160-165.
3. Wells LC, Smith JC, Weston V, Collier J, Rutter N. The child with a non-blanching rash: How likely is meningococcal disease? Arch Dis Child 2001 85:218-222.
4. Van Nguyen Q, Nguyen EA, Weiner LB. Incidence of invasive bacterial disease in children with fever and petechiae. Pediatrics 1984; 74:77-80. [NOTE: contact firstname.lastname@example.org quoting your Athens username to receive the publisher password for this journal]
5. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr 1997;131:398-404.
6. Klinkhammer M. Colletti J. Pediatric myth: fever and petechiae. CJEM 2008;10(5):479-82
Last reviewed: 24 February 2017
Next review: 13 November 2019
Author(s): Steve Foster
Approved By: Clinical Effectiveness
Reviewer Name(s): Paediatric Clinical Effectiveness & Risk Committee