Non-blanching rash, management in children

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Objectives

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. 

Scope

Children presenting with a non-blanching rash.

Audience

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.

Diagnosis

There are a group of conditions which present with a non blanching rash, but have specific features which will identify them easily:

  • Henoch Schonlein purpura (HSP)
  • Idiopathic thrombocytopenia (ITP)
  • Acute leukaemia
  • Haemolytic uraemic syndrome (HUS)

They have other specific signs or symptoms:

HSP
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

ITP
Usually well children with multiple bruises and petechiae noted over several days

Acute Leukaemia
Symptoms of slower onset associated with anaemia, lymphadenopathy or hepatosplenomegaly

HUS
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:

  • Meningococcal disease (MCD)
  • Sepsis with other bacteria (uncommon)
  • Viral illnesses
  • Trauma//NAI
  • Mechanical e.g. due to raised intrathoracic pressure from coughing or vomiting in superior vena caval distribution (above nipple line).

Evidence is based on retrospective and prospective observational studies, specific points include:

  • It is highly unlikely significant bacteraemia is present if the rash is localised to a superior vena-caval distribution.
  • No single factor, i.e. fbc, CRP can rule out significant bacterial illness on its own.
  • Observation of 4 hours is recommended in the majority of cases where diagnosis is uncertain.
  • The presence of purpura make meningococcal disease more likely. (Petechiae are pinpoint non-blanching spots. Purpura are larger non-blanching spots (>2mm).

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.

Non-blanching rash algorithm

Prior administration of penicillin does not alter the algorithm

 

 

Images

References

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 knowledge@nes.scot.nhs.uk 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

Editorial Information

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