Dr Matthew Lockyer welcomes guidance on meningitis and septicaemia which helps GPs make the vital diagnosis
Few diagnoses are so feared that they colour whole areas of patient behaviour, but meningitis is certainly one, lurking – often unspoken – behind every phone call about a child with a fever or rash. Media exposure of meningitis cases has distorted perception of its incidence and created a myth that is hard to dispel, often disparaging doctors' ability to make the diagnosis.
The newly published guidelines from the Meningitis Research Foundation may help to rationalise the approach to this rare but serious infection. The involvement of GPs, both in design and feedback, is encouraging, as is the acknowledgement of difficulty in diagnosing the disease in its early stages.
The guidelines stress the importance of 'safety netting' consultations to allow urgent reassessment of the deteriorating patient. This approach shows a firm grasp of the numbers of febrile children that GPs have to see and still have a safe framework to minimise the risk of missing meningitis.
The difference between meningococcal septicaemia and meningococcal meningitis is clearly explained, and the importance of cardiovascular signs in the septicaemic form emphasised. The classic diagnostic triad of rash, headache and neck stiffness is, in reality, the exception (see Fig. 1,below).
|Figure 1: Extract from the Meningitis Research Foundation's Guidance notes on meningococcal meningitis and septicaemia: diagnosis and treatment in general practice|
Meningitis should always be included in the differential diagnosis of the febrile child, but it is the pathognomonic purpuric rash that should be sought and treated urgently. If the diagnosis is suspected, treatment with intramuscular benzylpenicillin should be given (unless there is known anaphylaxis to penicillins) before immediate transfer to hospital.
I have given intramuscular penicillin on two terrifying occasions so far: once to a baby with prolonged fitting and once to an ill toddler with a purpuric rash. Neither had meningococcal infection, but the decision to give penicillin was easy to make. The hardest part of the GP's job is dealing with the hundreds of calls from the worried parents of sick children, any one of whom could be the real thing.
Despite clear instructions, many parents are still confused about the tumbler test – I recently attended a child where the rash was being viewed through the bottom of the tumbler from several feet away, rather in the manner of a telescope! Most parents will never have seen a very sick infant, so the professional and the parent assess the situation from different standpoints.
Whether in the surgery or at home, I make it clear to parents at the consultation that I have considered the possibility of meningitis. I can then explain what changes in the child's condition should alert them to call again. I carry a clear plastic magnifier in my bag for home visits to children with rashes, and use it to demonstrate the nature of the rash, even if it is obviously not purpuric.
Some parents become abnormally worried about meningitis and consult frequently for reassurance. Although it is a serious cause of infective infant mortality, I explain that it is still comparatively uncommon; children are more at risk from poor car safety precautions than from meningitis.
Recently some parents have started to tell me that meningitis is not possible as their child is 'immunised against it', referring to the meningitis C vaccination. They need to know that the vaccination only protects against one strain of the disease.
Fear of missing a case of meningitis is a nightmare for many doctors. The new guidelines may not allow us to diagnose every case, but mhey are a realistic attempt to give doctors in primary care the best chance of making the vital diagnosis.
Copies of Meningococcal Meningitis and Septicaemia guidance notes and wall chart are available from the Meningitis Research Foundation, Midland Way, Thornbury, Bristol BS35 2BS (tel 01454 281811; 24-hour helpline freefone 080 8800 3344).
- See also 'Meningococcal disease guidelines emphasise the role of septicaemia' (Guidelines in Practice, January 2001, Vol 4(1)).