ArticlesClinical recognition of meningococcal disease in children and adolescents
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.
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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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Joint first authors