Non-blanching rash in an infant with bronchiolitis
Diagnosing the cause of a non-blanching rash in children presents a challenge. Careful attention must be given to associated signs, symptoms and blood results to ensure an accurate diagnosis
Siba Prosad Paul is ST5 in paediatrics; Sarah Hicks is ST1 in paediatrics; Kaylea Tomlin is staff nurse in Paediatrics; all at Great Western Hospital, Swindon.
5 key points
- Non-blanching petechial rashes have been known to be associated with RSV bronchiolitis
- One in ten cases of non-blanching rashes are associated with a meningococcal infection
- The treatment of bronchiolitis is mainly supportive care
- Blood investigations need to be done to rule out serious bacterial infections
- Knowledge about the link between petechiae and bronchiolitis helps nurses reassure parents
Bronchiolitis is an illness that begins with an upper respiratory tract infection followed by signs of lower respiratory tract infection in the form of respiratory distress, hacking cough, bilateral crepitations, air trapping and wheezing (Paul et al, 2011). This is commonly seen in infants and young children; respiratory syncitial virus (RSV) is responsible in up to 90% of the cases.
Bronchiolitis accounts for about 20,000 hospital admissions per year in the UK (Paul et al, 2011). However, an infant presenting with a fever and rash from bronchiolitis illness can sometimes present a diagnostic challenge to the paediatric team due to the fear of meningococcal disease.
In a study of 233 infants and children presenting with a non-blanching rash, only 11% of the children had a proven meningococcal infection (Wells et al, 2001).
A 3-month-old boy, born at full term, previously healthy and fully immunised presented with a three-day history of cough, cold, mild fever and decreased feeding. The risk factors for bronchiolitis illness in an infant include prematurity, congenital cardiac defects, exposure to tobacco smoke, absence of breastfeeding and age less than 3 months (Paul et al, 2011; Bracht et al, 2011).
Initial observations showed a temperature of 36°C, a pulse rate of 152 beats per minute (bpm), a respiratory rate of 36 bpm, oxygen saturations of 98% in air and a central capillary refill time of 2 seconds. He was settled during the examination with mild respiratory distress.
A few non-blanching petechial rashes were noted over the right upper limb and parents reported evolving new rashes. The baby was admitted and, because of the fever and petechial rash, blood investigations were conducted.
Inflammatory markers were mildly abnormal suggesting infection. In view of the clinical condition and blood results, the child was given a dose of intravenous ceftriaxone.
The treatment of bronchiolitis is mainly supportive care, which includes administration of supplemental oxygen, maintenance of fluid balance and supporting nutrition via nasogastric tube feeding or intravenous fluids; none was needed in this case (Bracht et al, 2011). He remained well over the next 12 hours and no further spread of non-blanching rashes were noted. A nasopharyngeal aspirate confirmed the presence of RSV.
As the baby continued to improve, the antibiotics were stopped and he was discharged home. The parents were reassured that their child had a bronchiolitis illness and about the known association of RSV with petechial rashes in infants (Colin et al, 1993). The blood culture results confirmed no bacterial growth after 5 days. A telephone follow-up revealed that the baby has completely recovered and that he was growing and developing well.
This case illustrates the importance of being aware of the difficulties when faced with a child with a non-blanching rash. It is important that blood investigations are carried out to rule out serious bacterial infections. If a clinical suspicion of meningococcal disease arises, it is advisable to start antibiotics.
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Bracht M et al (2011) Impact of respiratory syncytial virus: the nurse’s perspective. Drugs in R&D; 11: 3, 215-226.
Colin SE et al (1993) Respiratory syncytial virus as a cause of fever and petechiae in infants. Clinical Pediatrics (Phila); 32: 6, 355-356.
Paul SP et al (2011) Effective management of lower respiratory tract infections in childhood. Nursing Children and Young People; 23: 9, 28-35.
Wells LC et al (2001) The child with a non-blanching rash: how likely is meningococcal disease? Archives of Diseases in Childhood; 85: 218–222.