Often it is stated that fever and petechial rash equates to meningococcemia (or serious bacterial blood stream infection) until proven otherwise… is that correct? Yes and No. You should have this on your differential, but nothing in life is that easy.

Meningococcemia and Petechiae

• Several studies have looked at presentation of meningococcemia and have found that while the presence of petechiae is important, petechiae is not the sine qua non.
• In fact, as it often is with children, the overall appearance of the child is more important (irritability, lethargy, and low cap refill – correlate with the presence of bacteremia).
• Unfortunately, meningococcemia can be rapidly progressive and devastating. The classic presentation of nuchal rigidity, altered mental status, and petechiae/purpura are all late findings (too late many times). So it would be nice to pick up on it before the child declines.

• One study found that the earliest symptoms were non-specific complaints of leg pains, cold hands and feet, and skin color change.

So what to do with the kid who has fever and petechiae?

{What follows is recommended based on literature and expert opinion (and was presented at ACEP SA).}

• If the child with petechiae appears ill (irritable, lethargic, poor cap refill), has purpura (petechiae > 2mm), or has hypotension, then treat him/her aggressively (no-brainer).
• If the child appears well and has:
  • Petechiae ABOVE nipple line (SVC distribution)
    • Unlikley to be meningococcemia, but a period of observation is appropriate.
    • Petechiae above the nipple line are often seen in children with vomiting, coughing, or valsalva.
    • Many would check a CBC for platelets (add a differential to it… and consider CRP). If no bandemia, reassuring WBC and normal CRP in conjunction with no change in exam and no progression of petechiae, then that patient may be managed according to the age-appropriate fever guidelines.
  • Petechaie BELOW nipple line (greater concern for bacteremia!)
    • Draw CBC, Differential, CRP, and Blood Culture (+/- LP) and administer antibiotics.
    • Observe and await lab results.
    • If labs are within normal limits and the exam is unchanged (no progression of petechiae, no change in pateint’s appearance) after 4 hours then patient may be discharged with close follow-up (12-24 hours) and good anticipatory guidance.
    • If labs are abnormal (CRP >6) or exam worsens, then admit.

Klinkhammer, M.D. and J.E. Colletti, Pediatric myth: fever and petechiae. CJEM, 2008. 10(5): p. 479-82.