Non blanching rashes

Question 1

What terms are used to describe non-blanching rashes?

Answer 1

Petechiae: <5mm
Purpura: 5-10mm
Ecchymoses: >1cm

Question 2

List 6 common causes of non-blanching rashes

Answer 2

Meningococcal sepsis
Henoch-Schönlein purpura
Idiopathic thrombocytopaenic purpura
Haemolytic uraemic syndrome
Forceful coughing/ vomiting
Non-accidental injury

Question 3

What causes Meningococcal meningitis? Which group is it most commonly seen in?

Answer 3

Neisseria meningitides
Gram -ve diplococcus
Commensal of nasopharynx.
<5s

Question 4

List 3 symptoms of meningococcal sepsis

Answer 4

Fever
Neck stiffness
Confusion +/- seizures

Question 5

List 5 findings on examination that meningococcal sepsis can present with

Answer 5

Kernig’s sign (pain + resistance on passive knee extension with hips fully flexed)
Brudzinski’s sign (knees + hips flex on bending the head forward)
Non-blanching rash
Photophobia
Hypovolaemic shock: low BP, high HR, cap refill time >2s, skin may look mottled

Question 6

List 4 investigations for meningococcal sepsis

Answer 6

Bloods: FBC, CRP, U+E, clotting: inflammatory markers may be raised.
Blood cultures
Pharyngeal swab: to screen for Neisseria meningitides in the pharynx.
Lumbar puncture: definitive dx

Question 7

What is the immediate management of meningococcal sepsis?

Answer 7

Transfer to hospital

IM Benzyl penicillin if in primary care

Question 8

What is the empirical treatment for meningococcal sepsis?

Answer 8

in <3 months: IV cefotaxime + amoxicillin

in >3 months: IV ceftriaxone + IV dexamethasone

Question 9

List 3 complications of meningococcal sepsis

Answer 9

Seizures
Raised ICP + hydrocephalus
Disseminated intravascular coagulation leading to multi-organ failure

Question 10

Describe the aetiology of Henoch-Schönlein purpura

Answer 10

IgA mediated vasculitis of unknown aetiology.

Often occurs post-infection with most common trigger being group A strep.

Question 11

Give 2 risk factors for Henoch-Schönlein purpura

Answer 11

Age: <10s -peak of cases 4-6 years old.
Season: autumn/winter months.

Question 12

List 5 symptoms of Henoch-Schönlein purpura

Answer 12

A prodromal mild URT illness or GI infection
Generalised abdo pain
Bloody diarrhoea
N+V
Joint pain

Question 13

Give 2 clinical findings in Henoch-Schönlein purpura

Answer 13

Low-grade fever

Symmetrical rash on back of the legs, buttocks + arms

Question 14

List 4 complications of Henoch-Schönlein purpura

Answer 14

Recurrence (1/3)
Nephrotic or nephritic syndrome
Renal failure
Intussusception

Question 15

List 4 complications of Henoch-Schönlein purpura

Answer 15

Recurrence (1/3)
Nephrotic or nephritic syndrome
Renal failure
Intussusception

Question 16

Describe the rash in HSP

Answer 16

Macular rash begins as erythematous

then becomes purpuric + raised

Question 17

What does Immune thrombocytopenic purpura involve?

Answer 17

development of a purpuric rash in those with low circulating platelets (<100 x 10⁹/L) in the absence of any clear cause.

Question 18

Describe the risk factors for Immune thrombocytopenic purpura

Answer 18

ITP usually follows a viral illness in children

No known specific risk factors in adults.

Question 19

Give 2 symptoms of Immune thrombocytopenic purpura

Answer 19

Prodromal viral illness in children
Epistaxis
(Many asymptomatic)

Question 20

Give the signs of Immune thrombocytopenic purpura

Answer 20

Petechiae +/- bruising

Question 21

Give 5 differentials for Immune thrombocytopenic purpura

Answer 21

Meningococcal sepsis
Aplastic anaemia
Leukaemia
Non-accidental injury
Disseminated intravascular coagulation

Question 22

What 3 investigations would you order for Immune thrombocytopenic purpura ?

Answer 22

Bloods (FBC) + blood film: will show thrombocytopenia.
Bloodborne virus screen (HIV, hepatitis C): to exclude secondary cause of ITP.
Bone marrow biopsy: if dx uncertain.

Question 23

Describe the approach to management of Immune thrombocytopenic purpura

Answer 23

In children, ITP is usually self-limiting.
Tx based on Sx, rather than absolute platelet count.
Active tx is rarely needed for platelet counts of >50×10⁹/L.

Refer to haematology.

Question 24

Describe the management of Immune thrombocytopenic purpura

Answer 24

Stopping any meds which may affect platelets e.g. NSAIDS
Oral prednisolone = 1st-line
Possibly IV immunoglobulins (IVIG) or monoclonal antibodies e.g. rituximab.
Splenectomy considered once all medical tx options exhausted

Question 25

Describe the management of Immune thrombocytopenic purpura

Answer 25

Stopping any meds which may affect platelets e.g. NSAIDS
Oral prednisolone = 1st-line
Possibly IV immunoglobulins (IVIG) or monoclonal antibodies e.g. rituximab.
Splenectomy considered once all medical tx options exhausted

Question 26

What triad defines Haemolytic uraemic syndrome?

Answer 26

Microangiopathic haemolytic uraemia
Acute kidney injury
Thrombocytopaenia

Question 27

Describe the aetiology of Haemolytic uraemic syndrome

Answer 27

Post infection with Escherichia coli O157.

Commonly found in faeces of sheep, cows + goats (petting zoos + improper hand hygiene)

Question 28

List 3 risk factors for Haemolytic uraemic syndrome

Answer 28

Age: young children esp. 6 months - 5 years. + elderly Immunocompromised adults
Season: peak in summer.

Question 29

List 4 symptoms of Haemolytic uraemic syndrome

Answer 29

Diarrhoea, typically turns bloody ~day 3
Abdo pain
Fever
Vomiting

Question 30

List 3 signs of Haemolytic uraemic syndrome

Answer 30

Abdo tenderness
HTN secondary to AKI
Small petechiae on skin can occur due to low platelets

Question 31

Give 3 differentials for Haemolytic uraemic syndrome

Answer 31

Acute gastroenteritis
Intussusception
Disseminated intravascular coagulation

Question 32

Give 3 investigations for Haemolytic uraemic syndrome

Answer 32

Bloods: FBC, U+E, CRP, clotting: may show thrombocytopenia, raised WCC, anaemia + AKI
Urinalysis: screen for haematuria + proteinuria.
Stool cultures: screen for E.Coli O157.

Question 33

Describe management for Haemolytic uraemic syndrome

Answer 33

Supportive; maintenance of fluid balance + correction of electrolyte abnormalities.
Severe cases may lead to development of renal failure requiring dialysis.
Notifiable disease to PHE

Question 34

What should you ask about in the history when suspecting HUS?

Answer 34

Recent exposure to farm animals + if child attends school or playgroup.