Extremity Pain and Refusal to Walk in Children With Invasive Meningococcal Disease

Abstract

ABSTRACT. Objective. Early recognition of invasive meningococcal disease in children may be difficult. Extremity pain and refusal to walk (extremity symptoms) are uncommonly mentioned as clinical findings in children who present with this disease. We sought to determine 1) the frequency of extremity symptoms as part of the clinical presentation in children with invasive meningococcal disease and 2) whether these symptoms help identify children with otherwise unsuspected meningococcal disease.Methods. We reviewed the medical records of patients who were younger than 20 years and had invasive meningococcal disease from 1985 to 1996 at 3 pediatric referral centers. Children with extremity symptoms were identified and described. We compared clinical and laboratory findings and frequency of adverse outcomes between these children and those with invasive meningococcal disease without extremity symptoms.Results. We identified 274 children with invasive meningococcal disease, 45 (16%) of whom had either history or physical examination evidence of extremity pain (31) or refusal to walk (14) as part of their clinical presentations. Five of the 45 patients had arthritis at the time of presentation. Patients with extremity symptoms at presentation were significantly older (77.9 ؎ 62.2 vs 44.0 ؎ 56.9 months), had lower temperatures (38.8 ؎ 1.2°C vs 39.2 ؎ 1.2°C), and had higher band counts (28.2 ؎ 15.2% vs 18.1 ؎ 12.4%) than did patients without extremity symptoms. There were no significant differences, however, between groups with regard to rash, white blood cell counts, coagulation parameters, prevalence of meningitis, or adverse outcomes. Seventy-three (27%) of the 274 patients had unsuspected disease, and 5 (7%) of these had extremity symptoms at the time of diagnosis.Conclusions. Sixteen percent of children with invasive meningococcal disease have extremity symptoms at the time of diagnosis. These symptoms may help to identify some patients with otherwise unsuspected invasive meningococcal disease. Pediatrics 2002;110(1). URL: http://www.pediatrics.org/cgi/content/full/110/1/e3; meningococcal infections, fever, bacteremia, myalgia, limp.ABREVIATIONS. CSF, cerebrospinal fluid; WBC, white blood cell; PT, prothrombin time; PTT, partial thromboplastin time; OR, odds ratio; CI, confidence interval; DIC, disseminated intravascular coagulation.T he clinical manifestations of invasive meningococcal disease in children typically consist of fever with toxic clinical appearance, irritability, lethargy, nuchal rigidity, hypotension, and petechial/purpuric rash. 1-6 Some children with invasive meningococcal disease, however, present in a more subtle manner with fever without clinical toxicity and other nonspecific symptoms, such as cough, rhinorrhea, vomiting, and headache, resembling an upper respiratory tract infection or other viral illness. [5][6][7] Although early recognition and treatment of meningococcal disease decreases complications, 7 neither the physical examination nor the hematologic evaluation reliably enables health ...

Which early ‘red flag’ symptoms identify children with meningococcal disease in primary care?

“…7,16 These consistently show that the pathognomonic haemorrhagic rash is only present in about half of children prior to hospital admission, that most children will have non-specific features, and that classic meningitic symptoms may not be present in the early stage of the illness. 7 Granier and colleagues' qualitative study of how GPs recognise children with meningococcal disease noted the importance of clinical features that are unusual in children with minor illnesses, such as lethargy, poor eye contact, and altered mental status, as well as pale colour.…”

Meningococcal disease associated with an acute post-streptococcal complement deficiency

“…Arthritis and a blanching maculopapular rash are two of the less common presentations of meningococcal disease. In a retrospective study of 274 children with MCD, 45 (16%) had limb symptoms at presentation, and of these 10 (22%) had arthritis [3].…”

Pediatric Emergencies Associated with Fever

“…53 Cool extremities, extremity pain, and abnormality of skin color can be early signs of meningococcal sepsis. 54,55 Extremity symptoms can range from pain to frank arthritis. Therefore, a blood culture and empiric antibiotics should be considered in any patient with fever and petechiae that extend below the level of the nipples.…”

“…58 A recent pediatric study reported mortality of 9% and nonfatal adverse outcomes in 3.6% of patients. 55 Penicillin (500,000 U/kg/d q4h), ceftriaxone (100 mg/ kg/d), or cefotaxime (200 mg/kg/d intravenously in 3 divided doses) are preferred. Chloramphenicol is an option for penicillin-allergic patients.…”