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Neisseria meningitides—modern day ‘black death’
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The following case history is a medico-legal case where I was requested to write a report and one of many where I experienced that gut-wrenching feeling of ‘there but for the Grace of God go I’.
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‘Sarah’, aged 3 years, attended a general practice one evening because she was unwell, lethargic, febrile, refused to eat and had developed a fine macular rash on her trunk. The examining practitioner noted that she was lying quietly, looked pale and had the pink rash on her chest and back. The only recorded vital sign was a temperature of 38.5 °C (otic).
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A diagnosis of the viral infection, roseola infantum, was made, paracetamol prescribed, and the parents were advised to return or contact him if her condition deteriorated. Sarah did deteriorate with drowsiness, floppiness, cold extremities, breathing difficulty and a change in the rash to ‘black’. Her parents took her to the nearest main hospital where she was admitted with meningococcal septicaemia. After a lengthy stay she did survive but had to have partial amputations of both arms because of severe ischaemia.
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There are many reported cases of children and adults deteriorating and dying with or without prior consultation. The court proceedings were prolonged and harrowing for all concerned. The judge was particularly critical of the GP for failing to record all the vital signs in the history—temperature, pulse rate, blood pressure and respiratory rate.
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DISCUSSION AND LESSONS LEARNED
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Acute life-threatening infections such as bacterial meningitis or septicaemia do worry us to distraction and so we should be highly suspicious of these conditions in the sick child and refer if in doubt.
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If we diagnose such a deadly infection and time reaching an emergency centre is a factor it is appropriate to give intravenous benzyl penicillin or cephalosporin (preferable if available).
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The vasculitis of meningococcal septicaemia can start as a mild maculopapular rash that resembles a mild viral exanthema prior to the classic haemorrhagic rash.
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Useful early signs include the following—an inactive disinterested child, cold skin particularly of the extremities, decreased capillary return, increased work of breathing and reduced mental state.
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Stress, angina, smokes, Viagra and angor animi
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Chuck was a 55-year-old American general practitioner who was our house guest for a few days. Arriving in Australia for a holiday, he commenced his journey to Melbourne from Cairns in a rented motor home. When he arrived he said that the long trip on unfamiliar roads was so stressful that he had resorted to chain smoking. He said that he had a history of angina pectoris and was taking glyceryl trinitrate by pump spray for any chest pain. He retired saying that he felt more relaxed and was looking forward to a good night’s sleep.
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At midnight we heard a commotion in the upstairs bathroom where we ...