• Non-blanching rash in children is common.

• The majority of these will not be serious illness.

• It is important to assess and manage appropriately to avoid missing patients with serious illness requiring immediate antibiotics.

• Treat with iv antibiotics and admit all children with petechial rash who appear ill, in shock or have spreading petechiae or purpura.

• If there is associated fever and raised CRP/WCC treat with antibiotics and admit.

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Abbreviations

Children commonly present with a non-blanching rash, with or without other features of illness. The relative rarity of life-threatening infectious illnesses among children presenting to hospital makes diagnosis all the more challenging. The minority with invasive meningococcal disease and other invasive bacterial infections (less than 10%) need to be distinguished from the majority with benign self-limiting illnesses.

Following the introduction of the meningococcal vaccination programme, rates of this disease are in significant decline. Nonetheless, confirmed cases in 2018 were still several hundred and the potential for devastating or fatal consequences remains. Early recognition and treatment improve outcome.

This guidance is primarily based on NICE guidance “Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management” published in 2010 and updated in 2015. It is recognised that these guidelines will treat many children without serious bacterial infection, but this is inevitable in order to ensure that those with serious bacterial infection are not missed

Differential diagnosis of non-blanching rash

• Viral illnesses

• Sepsis with other bacteria (uncommon)

• Trauma/Mechanical/NAI

• Meningococcal disease (MCD)

• Idiopathic thrombocytopenic purpura (ITP): Usually well children with multiple bruises and petechiae noted over several days

• Henoch Schönlein purpura (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

• Acute leukaemias: Symptoms of slower onset associated with anaemia, lymphadenopathy or hepatosplenomegaly

• Haemolytic uraemic syndrome (HUS): Oliguria/anuria associated with anaemia, usually following a diarrhoeal illness 

ITP, HSP, leukaemias and HUS have generally distinct features. The main difficulty is distinguishing MCD and other bacterial sepsis, from self- limiting viral illness or trauma.

The following algorithm is based on observation and investigation of these children and provides a simple guide to their assessment and management.