Shahid Jamil  ( Medical Unit A, lady Reading Hospital, Postgraduate Medical Institute, Peshawar. )

During a meningococcal outbreak, 221 patients were studied. A skin rash was present in 78 (35.3%) patients. Twenty one (11.3%) patients had a frankly purpuric rash, involving mainly the extremities and the remaining had a generalised macular or petechial lesions. Extensive purpuric lesions, involving mainly the extremities were associated with disseminated intravascular coagulation (DIC), shock and a fatal outcome. This peripherally distributed rash may be used as a clinical substitute for the laboratory tests that confirm DIG (JPMA 39: 239,1989).

About 60% of patients with meningococcal disease have a skin rash¹. During the early course of the disease the rash may be macular and may blanch with the application of pressure, but be­comes petechial and/or ecchymotic later. This rash is very suggestive of meningococcal disease^2,3. The diagnostic specificity of petechial rash in a patient of purulent meningitis is quite high in adults, rang­ing from 87-100%⁴. The purpuric rash of menin­gococcal disease has been associated with a bad prognosis, specially, when it predominantly affects the extremities. ^5-7 Because of shock, and its accompanying redistribution of the blood, the areas of reduced perfusion often have the most extensive purpura. This is mainly evident on the extremities, though it does not follow an anatomic vascular pattern. ⁸ In some of the patients the rash may not become purpuric and would remain as erythematous mactiles. The rash may be misdiagnosed as anaphylactoid purpura⁹, viral¹⁰ or drug rash¹¹. This paper reports the types of skin lesion observed during an outbreak of Group A meningococcal disease in Peshawar from December 1987 to May 1988.

Two hundred and twenty one patients with meningococcal disease were admitted to Lady Reading Hospital, Peshawar, during an outbreak of this disease. The age of patients ranged from 12 to 65 years. Diagnosis was confirmed by positive cul­ture in 132 (60%) cases, while rest of the patients had gram negative, intracellular diplococci on stained smears of the cerebrospinal fluid (C.S.F.). Slide agglutination of all the positive cultures yielded group A organisms. Besides the routine blood and CSF tests, platelet count, prothrombin time, partial throm­boplastin time and flbrin degradation products were done in all patients with peripherally dis­tributed pürpuric rash and in a similar number of patients without a rash or with only a generalised macular rash. Blood pressure was recorded three hourly. Patients with a systolic blood pressure below9Omm Hg were labelled to have hypotension.

Of 221 patients, 78(35.3%) presented with a rash. Fifty seven (73%) had generalized rash main­ly involving the trunk and 21 (26.9%) had peri­pheral purpuric rash. Fifteen (71.4%) patients with peripheral pur­puric rash had hypotension and 4(19%) died. The occurrence of hypotension and mortality in pat­ients with generalized mainly macular rash was lower and no different from patients without skin lesions. All patients with extensive peripheral pur­pura and only one without skin lesions had dissemi­nated intravascular coagulation (P< 0.01).

In some patients suffering from meningococ­caemia a rash develops which blanches earlier and later becomes petechial and/or ecchymotic; it is very suggestive of the disease in adults, along with other symptoms¹². The distribution of the rash is variable²⁰. All patients with an acute fever, rash and vomiting during this study (extending over five months) had meningococcal infection. Other cases of such a rash include purulent meningitis with pneumococcal infection, ² hemo­philus influenzae^1,12 and staphylococcus aureus¹³ infections. Aseptic meningitis due to ECHO virus has also been reported to mimic meningococ­caemia¹⁴. The rash is present in 60% of the patients suffering from meningococcal disease,1 whereas in this study only 35.3% of the patients develop a rash. When petechiae and ecchymosis develop DIC, must be suspected and investigation should be carried out immediately. Hypotension is a feature of acute menin­gococcaemia and it has been noted that almost all patients with bypotension have DIC. It is certain whether DIC occurs first or hypotension contribu­tes to the development of DIC¹⁵. Probably, en­dotoxic damage of thevascular endothelium occurs initially¹⁶, leading to DIC, Sanarelli Schwartzman phenomenon and shock⁶. In the present study 15(71.4%) patients with peripheral lesions and DIC had hypotension and 4 (19%) died. Patients without a rash and those with a generalised rash did not have hypotension and only 4(4.7%) patients died in this group. Thus patients without a rash and those with a generalised rash, rarely have DIC, hypotension and a bad outcome. On the other hand, patients with predominantly peripheral lesions have a higher chance of having DIC, shock and a bad outcome. This study concludes that all patients of meningococcal disease with peripherally distribu­ted eccbymosis have DIC and DIC without rash is unusual.

I thank Dr. Farhat Rizwi, Incharge Micro­biologySection and Dr. FazleRaziq, InchargeHae­matology Section, at our Institute, for helping me in carrying out all relevant laboratory tests.

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