Clinical Practice Guidelines

Fever and petechiae - Purpura

  • Background

    Petechiae are pinpoint non-blanching spots. Purpura are larger non-blanching spots (>2mm).

    There are many causes of fever and petechiae. These include:

    • Viral infections including enteroviruses and influenza
    • Neisseria meningitidis (meningococcal) disease
    • Other causes of bacteremia including Streptococcus pneumoniae and Haemophilus influenzae
    • Other diseases including Henoch Schonlein purpura, ITP and leukaemia
    • Illness characterised by vomiting or coughing causing petechiae around the head and neck

    All children with fever and petechiae should be reviewed by a registrar or consultant.

    Notes

    • The majority of children with fever and petechiae do not have a cause identified - they are presumably due to viral infections.
    • At least 90% of children with fever and petechiae will NOT have meningococcal disease. However, recognition and early treatment of the child with meningococcal disease is paramount.
    • Clinical signs and laboratory investigations will help determine those who should be treated for suspected meningococcal disease
      (see flow chart below).

    Unwell children with fever and petechiae

    Indicators of meningococcal disease (or other serious bacterial infection) include:

    • The unwell child (see below)
    • Purpura > 2mm (unless the clinical picture is suggestive of Henoch Schonlein purpura)
    • Abnormal blood indices (including WCC >15x10^9/L and <5x10^9/L and raised CRP>8 mg/L)

    Children should be considered unwell when they have the following features:

    Abnormal vital signs

    • Tachycardia
    • Tachypnoea and or desaturation in air
    • Increasing systolic to diastolic difference in blood pressure (ie widened pulse pressure)

    Poor peripheral perfusion

    • Cold extremities
    • Prolonged capillary refill

    Altered conscious state

    • Irritability (inconsolable crying or screaming)
    • Lethargy (including as reported by family or other staff)

    Important principles in the management of meningococcal disease include immediate fluid resuscitation, early administration of antibiotics (3rd generation cephalosporin) and involvement of intensive care staff.
    See  Acute Meningococcal Disease Guidelines for details on the management of a child with suspected meningococcal disease.

    Well children with fever and petechiae

    Purpura in well children

    Purpura > 2mm may be an indicator of meningococcal disease. If the clinical picture is suggestive of Henoch Schonlein purpura (purpura on the lower limbs and buttocks in a well child, with or without arthritis or abdominal pain), treat as per HSP guideline

    Petechiae in well children due to mechanical causes

    Children who are well and have a clear history of a mechanical cause for their petechiae do not require investigation and may be discharged with review planned within 12 - 24 hours.
    Mechanical causes of petechiae are:

    • Coughing or vomiting leading to petechiae around the head and neck
    • Local physical pressure such as a tight tourniquet or being held tightly for procedures

    If there is any doubt about the aetiology of the petechiae, children should be managed as below.

    Petechiae in well children not due to mechanical causes

    Children with fever and petechiae who do not have a mechanical reason for their petechiae warrant blood tests as part of their management. Blood tests are useful to help in excluding other diagnoses such as ITP and leukaemia. They are also a way of stratifying risk.

    Children with ALL of the following features have a very low risk of meningococcal disease and may be discharged from the emergency department after 4 hours observation:

    • Well and
    • WCC 5 - 15x10^9/L and
    • CRP < 8 mg/L and
    • No deterioration in clinical state or progression of the rash over 4 hours

    NB. If there is any clinical deterioration or progression of the petechial rash during the 4 hours of observation, treat as per Acute Meningococcal Disease Guidelines

    Well children with fever and petechiae who have received prior antibiotics

    Management of these children is the same as above, although partially treated meningitis must be considered.

    All children with fever and petechiae should be reviewed by a registrar or consultant.

    Fever Petechiae flowchart pic
    click here for larger view