A concerned mother brought in her seven-year-old son. On collecting the boy from school, she had noticed a rash of fine red dots that was most prominent behind his ears but extended to the face and forehead. The patient was well, with no other symptoms. He had not been coughing, vomiting or straining to open his bowels.
Examination revealed an impressive rash of densely packed fine petechiae mainly distributed on the face. There were a few spots on the neck and chest, above the nipple line. The boy was active, with no fever.
The location of the rash within the distribution of the superior vena cava suggested a mechanical cause, but the history failed to reveal a precipitant. He was too well for this to be meningococcal disease or a manifestation of acute leukaemia. In the absence of an obvious cause, immune thrombocytopaenic purpura needed to be excluded.
The boy and his mother were chatting while I was waiting on hold for the paediatric registrar, when the diagnosis revealed itself. The boy told his mother he had been having a competition with his friends to see who could make their face look the most red. He then demonstrated a dramatic forced Valsalva manoeuvre, turning his face a brilliant red and probably producing yet more petechiae.
Rashes confined to the superior vena cava distribution are unlikely to represent meningococcal disease.1 The phenomenon can occur following a rise in venous and capillary pressure as a result of coughing or vomiting. If the patient is well, reassurance is all that is required. In this instance, the florid rash was the outcome of a childhood game. It was the fortuitous extension of the time taken to listen to the patient story that confirmed the diagnosis and prevented a hospital admission.
- Dr Brodie is a GP in Worcestershire
1. Wells LC, Smith JC, Weston V et al. The child with a non-blanching rash: how likely is meningococcal disease? Arch Dis Child 2001; 85: 218-22.