Elsevier

The Lancet

Volume 367, Issue 9508, 4–10 February 2006, Pages 397-403
The Lancet

Articles
Clinical recognition of meningococcal disease in children and adolescents

https://doi.org/10.1016/S0140-6736(06)67932-4Get rights and content

Summary

Background

Meningococcal disease is a rapidly progressive childhood infection of global importance. To our knowledge, no systematic quantitative research exists into the occurrence of symptoms before admission to hospital.

Methods

Data were obtained from questionnaires answered by parents and from primary-care records for the course of illness before admission to hospital in 448 children (103 fatal, 345 non-fatal), aged 16 years or younger, with meningococcal disease. In 373 cases, diagnosis was confirmed with microbiological techniques. The rest of the children were included because they had a purpuric rash, and either meningitis or evidence of septicaemic shock. Results were standardised to UK case-fatality rates.

Findings

The time-window for clinical diagnosis was narrow. Most children had only non-specific symptoms in the first 4–6 h, but were close to death by 24 h. Only 165 (51%) children were sent to hospital after the first consultation. The classic features of haemorrhagic rash, meningism, and impaired consciousness developed late (median onset 13–22 h). By contrast, 72% of children had early symptoms of sepsis (leg pains, cold hands and feet, abnormal skin colour) that first developed at a median time of 8 h, much earlier than the median time to hospital admission of 19 h.

Interpretation

Classic clinical features of meningococcal disease appear late in the illness. Recognising early symptoms of sepsis could increase the proportion of children identified by primary-care clinicians and shorten the time to hospital admission. The framework within which meningococcal disease is diagnosed should be changed to emphasise identification of these early symptoms by parents and clinicians.

Introduction

Meningococcal disease is a global problem. In epidemics in developing countries, the incidence can be higher than 500 per 100 000.1 In endemic periods in developed countries, it is the leading infectious cause of death in children, with an incidence of at least four per 100 000, and killing 10% of those with the disease.2, 3, 4, 5, 6 Despite the disease's prevalence, several researchers have reported that many children who are admitted to hospital with meningococcal disease had been initially misdiagnosed by a doctor before admission.7, 8, 9 Since infection can progress from initial symptoms to death within hours, individuals must be diagnosed as early as possible.

One reason why clinicians working in the community may find it difficult to identify meningococcal disease is that they see so few cases in their lifetime—many children will be first examined by a clinician who has never before seen a case outside hospital. Identification of the disease will therefore depend on clinicians' experience in hospital and on textbook descriptions of classic features such as haemorrhagic rash, meningism, and impaired consciousness that occur late in the illness.10, 11, 12, 13, 14, 15, 16

As far we are aware, there has been no systematic assessment of the sequence and development of early symptoms of meningococcal disease before admission to hospital. We sought to determine the frequency and time of onset of clinical features of the disease to enable clinicians to make an early diagnosis before the individual is admitted to hospital. Parents also need to be aware of the importance of early symptoms to avoid delay in seeking medical care.

Section snippets

Participants

Participants came from a study originally designed to determine the clinical and health service factors associated with fatal and non-fatal outcomes from meningococcal disease in hospitals.17 Between Dec 1, 1997, and Feb 28, 1999, we identified children aged 0–16 years who died from meningococcal disease. We did this by using the Public Health Laboratory Service network of regional epidemiologists and consultants in communicable disease control in England, Wales, and Northern Ireland.

In

Results

Of the 448 children with meningococcal disease, 103 died. 296 (66%) children were classified by the expert panel as having predominant septicaemia, 99 (22%) with meningitis, and 53 (12%) with features of both. In the 307 (68%) children in whom meningococcal serogrouping data were available, those in serogroup B accounted for 152 (50%) cases, serogroup C for 146 (47%), and W135 and Y serogroups collectively for 9 (3%).

Children who died were more likely to have had septicaemia (84% vs 61%,

Discussion

Our results provide the first description—as far as we are aware—of the time course of the clinical features of meningococcal disease in children and adolescents before admission to hospital. We have identified three important clinical features—leg pain, cold hands and feet, and abnormal skin colour—that are signs of early meningococcal disease in children and adolescents. These features generally occur within the first 12 h of the onset of illness, and are present at the first consultation

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