Derm Cases · Dermatology / Emergency Medicine / Infectious Diseases / Paediatrics
OSCE — fever and non-blanching rash: meningococcaemia and purpura fulminans
An 8-minute OSCE station on early recognition of meningococcal sepsis, glass-test counselling, do-not-delay antibiotics, purpura fulminans management principles, and public-health/contact prophylaxis.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on early recognition of meningococcal sepsis, glass-test counselling, do-not-delay antibiotics, purpura fulminans management principles, and public-health/contact prophylaxis.
Brief (to candidate)
A 16-year-old is brought from a boarding school with 8 hours of fever, myalgia and a spreading petechial–purpuric rash on the limbs and trunk. Some lesions do not blanch with a glass tumbler. He is cold, tachycardic and drowsy. You have 8 minutes to recognise meningococcaemia, start emergency care, and plan public-health actions.
Candidate instructions
- Recognise invasive meningococcal disease and evolving rash patterns.
- Prioritise immediate antibiotics and resuscitation over investigations.
- Identify purpura fulminans and coagulopathy red flags.
- Plan cultures/LP only when safe; never delay the first dose.
- Address contact prophylaxis, notification and vaccination.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Recognition | Fever + non-blanching petechiae/purpura ± shock/meningism; glass test positive; early rash may be sparse or still blanching — do not wait for classical purpura[1][2] |
| Pathophysiology brief | Endotoxin-driven DIC and dermal vessel thrombosis → purpura fulminans in severe disease[3][7] |
| Immediate Rx | Give parenteral antibiotic ASAP (e.g. ceftriaxone/cefotaxime per protocol) before transfer/LP if delayed; ABC, fluids, senior/ICU support; blood cultures if no delay |
| Investigations | Do not delay antibiotics for CT/LP; avoid LP if coagulopathy, raised ICP features, or unstable shock |
| Purpura fulminans | Rapidly progressive purpura, acral ischaemia, DIC — aggressive sepsis care, haematology/ICU input; treat cause, support organ failure[7] |
| Public health | Notify public health; chemoprophylaxis for close contacts; check vaccination history (MenACWY/MenB as per schedule)[4] |
| Communication | Explain time-critical illness to family; advise other household members on early fever/rash presentation |
Model key actions
- Treat as suspected meningococcal sepsis immediately on fever + non-blanching rash ± shock.[1][2]
- First antibiotic dose without delay; resuscitate; escalate to critical care.[1]
- Notify public health and arrange contact prophylaxis; document purpura fulminans features if present.[4][7]
Common errors
- Waiting for LP/CT before the first antibiotic.
- Reassuring because early rash is still blanching or sparse.
- Missing shock / DIC / limb ischaemia while focusing only on the rash.
- Forgetting household/school contact prophylaxis and notification.
- Performing LP in coagulopathy or unstable shock.
References5ShowHide
- [1]Rajapaksa S, Starr M. Meningococcal sepsis. Australian family physician, 2010.PMID 20485712
- [2]Vaz LE. Meningococcal Disease. Pediatrics in Review, 2017.PMID 28364047
- [3]Lécuyer H, Borgel D, Nassif X, et al. Pathogenesis of meningococcal purpura fulminans. Pathogens and disease, 2017.PMID 28334263
- [4]Parikh SR, Campbell H, Bettinger JA, et al. The everchanging epidemiology of meningococcal disease worldwide and the potential for prevention through vaccination. The Journal of infection, 2020.PMID 32504737
- [7]Bendapudi PK, Losman JA. How I diagnose and treat acute infection-associated purpura fulminans. Blood, 2025.PMID 39786416