What is the most important management for a child with a history of fever and rash for 5 days, presenting with a generalized tonic-clonic seizure (GTC), drowsiness, generalized non-blanching maculopapular rash, fever, hypotension, tachycardia, and a positive Dengue IgM test?

Most Important Management: IV Ceftriaxone

The most important immediate management is IV Ceftriaxone (Option C) to empirically treat possible bacterial meningitis or co-infection, as this child presents with fever, seizure, altered mental status (drowsiness), and a non-blanching rash—a constellation that cannot exclude life-threatening bacterial infection despite positive dengue serology.

Clinical Reasoning

Why Antibiotics Take Priority

This clinical scenario presents several red flags that mandate immediate empiric antimicrobial therapy:

• Non-blanching rash with fever and altered consciousness represents a medical emergency requiring immediate antibiotics before any diagnostic procedures 1
• Drowsiness post-seizure could represent post-ictal state, but in the context of fever and non-blanching rash, bacterial meningitis or meningococcemia must be excluded
• Dengue positivity does NOT exclude bacterial co-infection, and dengue itself can present with CNS complications requiring different management considerations
• The blood pressure (90/50) is at the 50th centile but warrants close monitoring for dengue shock syndrome

Why Other Options Are Inappropriate Now

CT Brain (Option A):

• Not indicated before lumbar puncture in this case—no papilloedema, no focal neurological signs, normal muscle tone 1
• Would delay life-saving antibiotics
• The seizure was brief (5 minutes), self-limited, and likely febrile in nature 1

Lumbar Puncture (Option B):

• Should be performed, but AFTER antibiotics are administered
• The clinical signs (negative Kernig's and Brudzinski's, no papilloedema, brisk reflexes) make raised intracranial pressure less likely, but antibiotics should never be delayed for LP 1
• In suspected bacterial meningitis with non-blanching rash, blood cultures and antibiotics precede LP

IV Phenytoin (Option D):

• Not indicated for this single, self-limited seizure that resolved spontaneously 1, 2
• Simple febrile seizures lasting <15 minutes, generalized, occurring once in 24 hours do not require anticonvulsant prophylaxis 1, 2
• Continuous anticonvulsant therapy is specifically NOT recommended for simple febrile seizures due to adverse effects outweighing benefits 1, 2
• Prophylactic phenobarbital has even been shown to increase mortality in some settings 1

Management Algorithm

Immediate actions (within minutes):

1. Secure IV access and obtain blood cultures
2. Administer IV Ceftriaxone immediately (do not wait for LP or imaging)
3. Monitor vital signs closely for dengue shock syndrome (hypotension, tachycardia)

Subsequent actions (within 1-2 hours): 4. Perform lumbar puncture once antibiotics are on board (no contraindications present) 5. Monitor for seizure recurrence—if occurs, follow standard seizure management protocol 1 6. Assess for dengue complications (plasma leakage, hemorrhage, organ impairment)

Critical Pitfalls to Avoid

• Never delay antibiotics for diagnostic procedures when bacterial meningitis/sepsis is in the differential with a non-blanching rash 1
• Do not assume dengue explains everything—co-infections occur, and bacterial meningitis is immediately life-threatening
• Do not start anticonvulsant prophylaxis for a single, brief, self-limited febrile seizure 1, 2
• Do not perform CT before LP unless there are clear signs of raised intracranial pressure (focal signs, papilloedema, declining consciousness beyond post-ictal state) 1