Makindo Medical Notes

Clinical History

1. Onset and Duration:
   • When did the rash start, and is it progressing?
   • Is it acute, subacute, or chronic?
2. Associated Symptoms:
   • Fever, lethargy, irritability, or malaise
   • Symptoms of upper respiratory infection or sore throat
   • Joint pain, swelling, or abdominal pain
   • Bleeding from other sites (e.g., gums, nosebleeds)
3. Medical and Family History:
   • Any history of recent infections, vaccinations, or injuries
   • Family history of bleeding disorders or autoimmune diseases
   • Recent travel history or exposure to infectious agents
4. Medication History: Review for medications that may increase bleeding risk, such as:
   • NSAIDs or aspirin
   • Antibiotics, particularly penicillin and cephalosporins
5. Diet and Lifestyle: Assess for potential vitamin deficiencies (e.g., vitamin C), nutritional status, and recent trauma or excessive physical exertion.

Physical Examination

1. General Appearance: Assess for signs of illness, such as pallor, jaundice, or lethargy.
2. Vital Signs: Measure temperature, heart rate, respiratory rate, and blood pressure.
3. Skin Examination:
   • Confirm that the rash is petechial (non-blanching, pinpoint spots)
   • Note distribution and extent of the rash (localized or generalized)
   • Look for other rashes, ecchymoses, or bruising
4. Abdominal Examination: Palpate for hepatosplenomegaly, which may indicate an underlying hematologic or infectious cause.
5. Joint Examination: Check for joint swelling, tenderness, or restriction of movement (may indicate vasculitis or systemic inflammatory disease).
6. ENT Examination: Assess for signs of throat infection, tonsillar exudate, or lymphadenopathy, especially in suspected streptococcal or viral infections.

3. Investigations

1. Blood Tests:
   • Complete Blood Count (CBC): Evaluate for thrombocytopenia, anaemia, or leucocytosis.
   • Coagulation Profile (PT, aPTT): Assess for coagulation disorders.
   • C-reactive protein (CRP) and ESR: Markers for inflammation or infection.
   • Liver Function Tests: To rule out liver disease as a cause of coagulopathy.
   • Renal Function Tests: If systemic illness is suspected, especially in vasculitis.
2. Microbiological Testing:
   • Blood cultures if sepsis or meningococcaemia is suspected.
   • Throat swab if streptococcal infection is suspected.
   • Serology for viral infections (e.g., Epstein-Barr virus, CMV) if viral aetiology is suspected.
3. Bone Marrow Aspiration: Consider in cases of unexplained thrombocytopenia or pancytopenia to evaluate for leukaemia or aplastic anaemia.
4. Additional Tests: Vitamin levels (e.g., vitamin C) if nutritional deficiency is suspected; autoantibody panel if autoimmune causes are suspected.

4. Possible Causes of Petechial Rash in Children

• Infectious Causes:
  • Meningococcal sepsis or meningitis
  • Viral infections (e.g., enterovirus, adenovirus)
  • Group A streptococcal infection or scarlet fever
  • Rocky Mountain spotted fever or other tick-borne diseases
• Hematologic Causes:
  • Immune thrombocytopenic purpura (ITP)
  • Leukaemia or other hematologic malignancies
  • Disseminated intravascular coagulation (DIC)
  • Aplastic anaemia
• Autoimmune Causes:
  • Henoch-Schönlein purpura (HSP)
  • Systemic lupus erythematosus (SLE)
• Vasculitis: Small vessel vasculitis, often presenting with petechiae, purpura, and systemic symptoms.
• Drug-Induced Causes: Medications that may induce thrombocytopenia or vasculitis, such as certain antibiotics.
• Nutritional Deficiency: Vitamin C deficiency (scurvy) leading to fragile capillaries and petechial rash.
• Mechanical Causes: Increased intrathoracic pressure from coughing, vomiting, or physical exertion can cause petechiae, especially on the face and neck.

5. Management

1. Immediate Stabilization:
   • If sepsis is suspected, initiate broad-spectrum antibiotics promptly.
   • Manage airway, breathing, and circulation in critically ill patients.
2. Treat Underlying Cause:
   • Antibiotics for bacterial infections (e.g., meningococcal or streptococcal infections).
   • Antivirals if viral infection is confirmed and specific treatment is available.
   • Immune modulation (e.g., IVIG or steroids) for immune-mediated conditions such as ITP.
3. Symptomatic Management: Pain and fever control with appropriate analgesics and antipyretics.
4. Follow-Up: Regular monitoring of CBC, platelet counts, and other relevant tests, especially in cases with hematologic or autoimmune causes.
5. Referral to Specialists: Consider referral to haematology, infectious disease, or rheumatology based on underlying cause.

Meningococcal septicaemia is always the major worry in any child or young adult