In France, the incidence of
meningococcal infections is increasing. The most severe presentation, called
purpura fulminans, has a death rate of 20-25%; 5 to 20% of the survivors need skin grafts and/or
amputations. Diagnosis of invasive
meningococcal infection is very difficult when
purpura and "toxic" appearance are absent: one should take into account parents' impression of their ill child. This diagnosis must be evoked in any child presenting with febrile
purpura (like in the United Kingdom, parents should be encouraged to use the "tumbler test" to identify a vasculitic
rash); a fulminant form is to be suspected in the presence of only one
ecchymosis and signs of
infection, remembering that recognition of
shock is difficult in children. Recently, the Health Authority has recommended to administer a
third generation cephalosporin promptly (before
biological investigations) for any child with signs of
infection and a necrotic or ecchymotic
purpura (> 3 mm of diameter), and then to refer the patient to the hospital. By grouping the patients from 7 studies, it can be observed that preadmission
antibiotic administration has a protective effect on mortality (odds ratio: 0.36; 95% confidence interval: 0.23-0.56); a negative effect was observed in only one of these series. Children with
purpura fulminans should be referred to a paediatric intensive care unit. Management includes
antibiotics,
steroids, fluid
resuscitation and
catecholamines (be aware of hypoglycaemia, particularly in infants, and hypocalcaemia). Treatment of cutaneous
necrosis and distal
ischemia is difficult and still controversial:
antithrombin,
protein C,
tissue plasminogen activator and
vasodilator infusion have no proven efficacy. Cases must be rapidly notified to the Public Health Service who will institute
chemoprophylaxis for close contacts. Given the predominance of serogroup B in France, we hope that an efficient
vaccine will soon become available.