girl with rash

Six year old girl,previously healthy had low grade fever yesterday. As the fever subsided with paracetamol she was send to school today morning. Teacher noticed to have some odd skin lesions ,brought home. Local pediatrician was consulted ,he referred here 
At the time of admission , her vitals were stable, afebrile .These were the lesions noticed by the parents

No history of mucosal bleeds . She complains of body ache .No lymph nodes ,Joints normal 
Abdomen examination no organomegaly .
CVS and RS normal
CNS fully conscious, oriented, No focal neurological deficit 
No signs of meningeal irritation

Blood results done from outside showed , Total count of 17200 with 70 percent polymorphs . Platelet count 2.3 laksh .ESR was not done 

Possibilities considered 
Previously normal child cutaneous bluish lesions and conjuctival bleed following one day fever first possibility of some infections considered. 
Another possibility was ITP , but the platelet counts done from outside was not supporting. May be they can go wrong. Clinical features very well supporting ITP . 
As there were no pallor ,lymph node or organomegaly , possibility of malignancy was least 
Vasculitis as manifestation of connective tissue disorders at this age bit unusual . CVS examination and other features were not supporting infective endocarditis 
Out of the infections , Dengue was considered top in the list .
Conjuctival congestion , body ache was supporting.Circulatory status was normal . Main point here also was the investigation. Blood count done from outside were against .
Leptospirosis  was possible , but no jaundice , liver was just palpable soft . 
Another possibility considered was Ricketsiel infections which are increasingly reported . 

How to proceed 
Blood culture ,NS 1 antigen , PCV , LFT , Weil felix , Peripheral smear were send . Lepto not send  

Possibility of dengue was high in the list but few odd points clinically and investigations.No rash other than bleed, no cutaneous fleshing , This high count and neutrophil predomiance a bacterial infection was thought of. 
Ceftriaxone will cover possibility of menigococcemia and lepto also we decided to put here on Inj Ceftriaxone. 
Another thought was to put on Doxycycline.  

After four hours she had a generalised seizure. Neck stiffness positive. LP done showed neutrophils .gram stains showed meningococci.

Now question of chemoprophylaxis of contacts, contact tracing . 
We are getting meningococcal meningitis more often . 
Till late nintees we used to see many cases of meningococcemia then. Pyogenic meningitis as such was coming down.
Last year we had few cases of meningococal meningitis . Is it increasing ?


UPDATES 

24/03/2017
She responded very well to Inj .Ceftriaxone. Was afebrile from 48 hours of antibiotics. Antibiotics was continued for ten days 
On 9th day there was an interesting development
She developed painful swelling of right knee and right ankle joint on the same day . There was no fever, no rash , vitals were stable. System examination normal
All other joints were normal. Knee painful restriction of movement and patella tap positive 
USG knee and ankle was done , showed effusion

There was suggestion to aspirate , to put on NSAIDS , steroids. 

Antibiotics was stopped on next day , ie tenth day . No new drugs added, patient was kept on follow up. 
Logic ?
No evidence of active infection by organism . No fever no toxicity . Two joints simultaneously involved due to bacteria in a scenario where every other features support control of infection. Most likely this is immune mediated, reactive arthritis.
Ok , 
Now comes next question.
Should nt we give drugs for that. Steroids. NSAIDS. 
No need 
Swelling gradually reduced and patient discharged