Septic shock at the time of its height represents a difficult picture: cyanotic or ash-gray skin, cold limbs, grunting breath, stupor or coma, hypotension, and in the final blood pressure is not definable. Septic shock may also be accompanied by pallor, jaundice, hepatomegaly, shortness of breath, tachypnea and tachycardia.
A rash of purpura or ecchymosis usually indicates the development of disseminated intravascular coagulation syndrome. Fortunately, such a pronounced picture is not as common as less severe or even “hidden” bacteremia, when the child looks pretty good.
Skin manifestations of bacteremia include petechiae and purpura. Petechiae are small reddish-purple spots that do not disappear when pressed. Their diameter is usually up to 1 mm; they occur with embolism or vascular damage. Petechiae most often develops at meningococcemia, but can also be observed in other types of bacteremia and in diseases that occur without bacteremia.
In the study of patients with meningococcemia or meningococcal meningitis in 75% of 151 patients, a generalized maculopapular or petechial rash was observed. Purple – this is a larger hemorrhagic rash on the skin. It usually occurs in severe diseases, often occurring with shock and deficiency of coagulation factors.
According to some authors, “febrile seizures” should be alarming in relation to possible bacteremia. In fact, it is difficult to be sure that, between bacteremia and febrile seizures, there is something more than a casual connection. Both conditions are characteristic of one age group (from 6 months to 2-3 years) and both are associated with high fever.
Hamrick showed that 5 of 28 children with bacteremia had convulsions at the time of the development of bacteremia, classified as febrile. Since the author did not provide information on the total number of patients with fever under observation, or on the number of blood cultures performed, it is impossible to statistically analyze his data. In addition, blood cultures were not performed in all patients, but only according to “clinical indications.” One of such indications was febrile seizures, and this can explain their high frequency in patients with bacteremia.
In the work of Myers of 7 children with latent pneumococcal bacteremia, 3 had febrile seizures. Two of them did not have meningitis either during convulsions or later. In the third child, the first spinal puncture was regarded as “non-diagnostic”, but after 3 days, the puncture results clearly indicated meningitis. In a retrospective study, Torphy also showed that 5 out of 12 children with latent pneumococcal bacteremia suffered convulsions during bacteremia. Only one of them later developed purulent meningitis.
On the other hand, according to McCarthy, only 2 out of 150 febrile children had convulsions, but without meningitis, bacteremia was detected! The lack of statistical analysis, the small number of patients examined and the selective, retrospective nature of the studies make it impossible to draw a definite conclusion about the relationship of febrile seizures with bacteremia.
Burech et al. reported 5 infants with pneumococcal bacteremia who were admitted to hospital for fever and inflammatory cystic lesion of the gums.
The authors described the course of this disease as follows: after swelling of the gums, soft, fluid-filled erythematous patches appear and, finally, ulcerations. Redness and swelling of the outer surface of the cheek were also noted in 4 of 5 patients. The authors believe that children admitted with such symptoms should be considered as being at risk of developing pneumococcal bacteremia. An identical case leads Yeager. However, in another paper, such changes were described as localized pyogenic cysts without bacteremia.
As Prahara emphasizes, bacteremia can manifest as arthralgia and arthritis without direct infection of the bones or joints. He described 9 children with bacteremia (7 – staphylococcal and 2 – pneumococcal etiology), the first manifestations of which were fever and arthritis or arthralgia. Initially, they were diagnosed with acute rheumatic fever or rheumatoid arthritis. In fact, none of these patients suffered from any connective tissue disease. One child had osteomyelitis, and another had a pelvic abscess. The remaining 7 children were diagnosed with bacteremia without a clear focus of infection.
Characteristically, they did not have septic arthritis or osteomyelitis. Arthralgia was observed in both acute and chronic meningococcemia. According to McCarthy, blood cultures in febrile children with arthritis or arthralgia were positive in 11% of cases; but at the same time, the author does not provide information about how many children suffered from septic arthritis. Carefully collected history in the diagnosis of bacteremia is as important as physicalinvestigation Bacteremia can result from invasive studies and procedures. Any chronic diseases, especially those in the treatment of which immunosuppressants are used, significantly increase the risk of developing not only bacteremia, but also severe sepsis.