Recognizing Meningococcal Disease
ABSTRACT & COMMENTARY
Synopsis: Only 16 of 31 children later diagnosed with meningococcal disease had a characteristic hemorrhagic rash when first seen by their primary practitioner. Six others had non-specific rashes. Twenty-two had clinical findings suggesting severe disease.
Source: Granier S, Recognizing meningococcal disease in primary care: Qualitative study of how general practitioners process clinical and contextual information. BMJ 1998; 316:276-279.
Current knowledge about the presentation of meningococcal disease has been largely defined by information from hospital based studies where the disease is usually seen at a late stage. Granier and associates reviewed the office and hospital records of 31 children younger than 16 years old with meningococcal disease in order to assess how primary care providers process clinical and contextual information in their initial evaluations of such children to reach a decision to hospitalize the children.
The key clinical feature, a hemorrhagic rash, was present in only half of the children, but 22 of 31 children had some kind of rash. Twenty-two children had clinical features (high fever, lethargy, altered mental state) suggesting severe illness. The practitioners' knowledge of the family, including their usual pattern of seeking medical attention and their usual degree of anxiety, also influenced the decision to hospitalize. Early treatment improves outcome, but, in a quarter of cases, the diagnosis is delayed by more than 48 hours after the onset of the illness.
Granier et al conclude that physicians should not be deterred from suspecting meningococcal disease and starting antibiotic treatment if the rash has an unusual or scanty distribution or if the rash is non-hemorrhagic.
COMMENT BY EUGENE D. SHAPIRO, MD
Early identification of the child with meningococcal infection is one of the most daunting challenges faced by the primary care practitioner. Granier et al have tried to define, qualitatively, what it was that led 26 general practitioners to identify 31 children in their practices who presented to them with meningococcal disease. Not surprisingly, a petechial rash, present in about 50% of the children, was the most common feature that raised the suspicion of meningococcal disease.
There is substantial evidence from other studies (as well as from this one) that experienced practitioners, because of their extensive knowledge of what is "normal" behavior for sick children, are able to identify those whose behavior deviates substantially from the norm. Such practitioners use clues such as poor eye contact or an abnormal cry to help identify children who are severely ill.
Other features, shared by many of the children in this study, were substantially altered mental status or "paradoxical irritability" (unlike many ill children who are comforted when picked up by a parent, children with meningitis often prefer not to be moved). A factor identified as important in this study that has rarely been mentioned in other studies was an unusual degree of concern about the illness by parents whose level of anxiety was normally appropriate led the practitioner to suspect the diagnosis in nearly 50% of the children. This was a particularly important factor in children who did not have a petechial rash.
A major shortcoming of the study is that there is no denominator. How often did these practitioners incorrectly suspect that an ill child had meningococcemia? We do not know whether the practitioner who identified a child as possibly having meningococcemia because the child was "lethargic" is an extremely astute observer or overcalls serious illness.
This study reminds us that practitioners should not be deterred from suspecting a serious illness such as meningococcemia in children (even in those without the characteristic petechial rash) whose behavior is not that expected of a child with a self-limited viral illness. (Dr. Shapiro is Professor of Pediatrics and Epidemiology, Yale University School of Medicine.)
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