Case 27 A febrile baby
Emma had an uneventful birth. At the age of six months she was taken to the doctor by her mother, Susan. Susan was worried because Emma was ‘burning up’ and snuffly. She said that Emma was not feeding well, was making funny noises when she breathed and had a rash.
Dr Moore saw Emma. His clinical note detailed that the baby was unwell and had been tachypnoeic that day. He noted that Emma was drinking but not taking solids.
What features would you have specifically noted?
On examination he recorded that Emma felt hot but was alert. He made a tick after fontanelle, throat, ears, chest and abdomen and indicated that there was no photophobia or neck stiffness. He diagnosed a viral illness, advised calpol and fluids and that Emma should be seen again if she got worse.
Would you have done anything differently?
Early the next morning Susan contacted the Out of Hours (OOH) service because Emma has been irritable during the night. Susan had gone to check on Emma and found that she was drowsy and had a purple rash. The OOH Service advised Susan to call an ambulance. A visiting doctor also went but by the time they arrived Emma had already been taken to hospital. On admission a diagnosis of meningococcal septicaemia was made. Unfortunately Emma suffered brain damage and was severely handicapped as a result of her illness.
Susan felt that Dr Moore should have referred Emma to hospital as an emergency. Dr Moore was sued for alleged negligence.
Do you think his claim will succeed?
Expert comment
The suspicion of meningococcal meningitis or septicaemia is a challenge for general practitioners for several reasons:
- The condition is rare. A full time general practitioner is only likely to see one or two cases in their career. The diagnosis is suspected from text book descriptions and the recognition that the patient is generally unwell.
- The early features are the same as those of minor viral illness. A 2006 paper in The Lancet showed that by 20–22 hours after the onset of the illness only 50% of children under the age of one had developed features of septicaemia, only 30% had a haemorrhagic rash and only 20% had impaired consciousness (Thompson et al., 2006).
- The condition may get rapidly worse. It is not uncommon for a doctor to have seen a patient a few hours before and not realized the severity of the illness. In one study the researchers examined 177 cases of meningococcal disease retrospectively (Toft Sorenson et al., 1992). Of these 92 (52%) had seen a doctor who had not recognized the likelihood of serious disease in the period immediately prior to admission.
The Meningitis Trust was established in 1986 following a prolonged outbreak of meningococcal disease in Stroud and Stonehouse, Gloucestershire. This helped to improve both public and medical awareness of the disease. Information leaflets were distributed throughout the county highlighting features of the condition: a distinctive haemorrhagic rash (which could be recognized as nonblanching by the ‘tumbler test’), impaired consciousness, a stiff neck and, in infants, a bulging fontanelle and a high-pitched scream. Thompson et al. (2006) highlighted the fact that the ‘classical’ features of the disease occur very late. They advocated looking for certain earlier features of the disease (such as cold peripheries, a mottled discolouration of the skin and limb pains).
In the past many general practitioners would have made an assessment like that made by Dr Williams. This gave a general impression of the clinical condition of a child. However he has omitted some details that would have given a clearer picture not only at the time but subsequently when the case was being scrutinized.
NICE (2007) published guidance on the assessment and initial management of feverish illness in children under 5 years. This gives a traffic light system for assessing the severity of illness. Children with ‘Red’ features should be admitted urgently, children with ‘amber’ features can either be managed at home with suitable ‘safety netting’ or admitted to hospital. These features provide a minimum data set that it would be helpful to record.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
