Petechiae


Article Author:
Ailbhe McGrath


Article Editor:
Michael Barrett


Editors In Chief:
Jessica Snowden
Asif Noor
H Davies


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
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Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/8/2019 2:04:59 PM

Introduction

Petechiae are pinpoint non-blanching spots that measure less than 2 mm in size which affect the skin and mucous membranes. A non-blanching spot is one that does not disappear after brief pressure is applied to the area. Purpura is a non-blanching spot that measures greater than 2 mm. Petechial rashes are a common presentation to the pediatric emergency department (PED). Non-blanching rashes can be a great cause for concern for parents and physicians alike. Therefore, careful assessment and evaluation must be undertaken to formulate a sensible management plan.[1][2][3]

Etiology

There are many causes of a petechial rash in a child to be considered. Invasive meningococcal disease (IMD) caused by Neisseria meningitidis, is the priority in the differential diagnosis to consider on initial presentation. Consequently, a child with fever and a petechial rash requires urgent and comprehensive assessment. Multiple studies have shown that the rate of IMD has reduced following the introduction of meningococcal vaccines into childhood immunization schedules and that the low prevalence of IMD suggests that most children presenting with a petechial rash have less serious pathologies. However, given its associated morbidity and mortality, it should remain at the forefront of the clinician's mind when assessing the child with pyrexia and petechiae.[4][5]

Causes can be classified into the following categories:

Infective

  • Viral: Enterovirus, Parvovirus B19, Dengue
  • Bacterial: Meningococcal, scarlet fever, infective endocarditis
  • Rickettsial: Rocky Mountain Spotted fever
  • Congenital: TORCH

Trauma

  • Accidental injury
  • Non-accidental injury
  • Increased pressure following bouts of coughing, vomiting or straining

Hematological and Malignant

  • Leukaemia
  • Idiopathic thrombocytopenic purpura (ITP)
  • Thrombocytopenia with absent radius (TAR) syndrome
  • Fanconi anemia
  • Disseminated intravascular coagulation (DIC)
  • Haemolytic uraemic syndrome (HUS)
  • Splenomegaly
  • Neonatal alloimmune thrombocytopenia (NAIT)

Vasculitis and Inflammatory Conditions

  • Henoch Schonlein Purpura (HSP)
  • Systemic Lupus Erythematosus (SLE)

Connective Tissue Disorder

  • Ehlers Danlos

Congenital

  • Wiscott Aldrich
  • Glanzmann Thrombasthenia
  • Bernard Soulier

Other

  • Drug reaction
  • Vitamin K deficiency
  • Chronic liver disease

Epidemiology

One study reported that 2.5% of presentations to the pediatric emergency department were patients with a petechial rash.

Pathophysiology

Petechial rashes result from areas of hemorrhage into the dermis. Derangements in the normal hemostasis can result in petechiae along with a variety of other clinical findings. The primary pathophysiological causes of petechiae and purpura are thrombocytopenia, platelet dysfunction, disorders of coagulation, and loss of vascular integrity. Some clinical pictures result in petechial lesions from a combination of these mechanisms.(6)[6][7]

History and Physical

A detailed history and physical examination are paramount for every child presenting with petechiae. Key features in the history include time of onset, anatomical pattern and a detailed chronological account of any other symptoms, e.g., fever, coughing, vomiting, any recent URTI or gastroenteritis, and any sick contacts. A rapidly spreading rash is more concerning for IMD in an unwell child with a fever. A recent viral infection (URTI or gastroenteritis) is common in ITP, HSP, and HUS. Petechiae confined to above the nipple line are associated with bouts of vomiting or coughing. It is also important to ask about any bleeding from mucosal surfaces such as gingival bleeding, epistaxis, melena, among others. As always, vaccination status should be confirmed.

On examination, a complete set of observations and neurological status should be regularly monitored. A full systemic examination should be completed, including cardiac, respiratory, abdominal, otorhinolaryngological, and neurological (if concerns of IMD). The skin should be thoroughly examined from head to toe, and the pattern of rash should be clearly documented. Demarcating areas of petechiae with a skin marker can be helpful for monitoring progression of the rash in clinical practice.

The age of the child can be useful in reaching the most likely diagnosis, for example; a neonate with petechiae could have a NAIT or a TORCH infection, and HSP is more common in the 2 to 5 year age range.

Patterns of concerning symptoms and signs presenting with petechiae include but are not limited to:

  • Pyrexia, tachycardia and rapidly spreading petechiae: IMD
  • Pallor, bruising, weight loss, lymphadenopathy: Malignancy
  • Hypertension: Renal disease associated with HUS, HSP or SLE
  • Unusual patterns of petechiae with bruising, a history that is inconsistent or signs or injury or neglect: NAI

Evaluation

Investigations to diagnose the cause of a petechial rash depend on the clinical presentation and can differ from one PED to another. Adhering to the local protocol is advised. In general, investigations will depend on the location of petechiae, associated pyrexia or clinical suspicion for any of the concerning patterns of signs and symptoms. A healthy child with scattered petechiae of obvious causation, e.g., known trauma or petechiae confined to above the nipple line may not require any investigations. At the very least, the healthy child, as described, should be observed for 4 hours before discharge.

  • Complete blood count (CBC) to check platelet number, a raised or decreased white cell count or decreased hemoglobin
  • If concerns about IMD or other infection: C-reactive protein, blood culture
  • Coagulation profile, urea, electrolytes, and liver function tests may be considered in some cases (DIC, IMD, HSP, HUS). A prolonged prothrombin time can indicate factor deficiencies, Vitamin K deficiency, DIC, liver or renal disease
  • Urine dipstick and microscopy are useful when renal causes are part of the differential (HSP, HUS, SLE), to check for proteinuria in particular
  • Further tests may be later requested when a more specific diagnosis is narrowed down.

Treatment / Management

Many patients attending the PED with petechial rashes will not require any specific treatment. In fact, if a child remains well after a period of observation, with no spreading of the rash, a normal platelet count and no physical signs or signs of infection on blood tests, they may be discharged home. If IMD is likely, urgent intravenous antibiotics as per local guidelines should be administered, with close observations after admission to the ward. Some patients may be given a dose of antibiotics pre-hospital if high clinical suspicion of IMD is present. If specific diagnoses are made, for example, HSP or ITP, and there is no risk of going home, the child may be discharged with an appointment to return to the appropriate outpatient department and condition specific education. Other conditions will require admission and treatment, for example, urgent referral to oncology inpatient services for a patient with pancytopenia and a likely malignant diagnosis.[8][9]

Pearls and Other Issues

Recognizing the wide range of possible diagnoses for a child presenting with petechiae is essential for any clinician working in the PED. Public health campaigns have increased recognition of petechiae, therefore, allaying parents fears and concerns is a key role, in addition to educating them on red flag signs that should prompt return to the PED.

Enhancing Healthcare Team Outcomes

There are many causes of petechiae and the condition is best managed by a multidisciplinary team that includes hematology nurses and pharmacists. The key is to  find the primary cause. Most patients with a benign cause or drug induced petechiae have a good outcome when the offending agent is discontinued. However, when petechiae is due to heparin, paradoxical thrombosis can occur.[10]


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Petechiae - Questions

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Petechiae are most commonly observed in which of the following conditions?



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Non-blanching spots on the skin measuring less than 2 millimeters are commonly seen in the emergency department. What is the term used to refer to this sign or symptom?



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Petechiae may be a sign of decreased activity of which of the following?



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Which of the following is not a cause of petechial rashes in childhood?



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Which of the following does not cause a petechial rash?



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A 3-year-old girl presents with a scattered petechial rash over her limbs and trunk. She has obvious pallor. Complete blood count reveals hemoglobin 7.0 g/dL, platelets 15 x 10^9/L, white blood cells 2.2 x 10^9/L. What is the most likely diagnosis?



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A 3-year-old girl presents to the emergency department with a 1-day history of a petechial rash. She has had two upper respiratory chest infections in the past month, and her mother feels she has been more tired than usual. On examination, she is afebrile with normal vital signs, pale, has a scattered petechial rash over her trunk and limbs along with some bruising of her lower limbs. She has some cervical and axillary lymphadenopathy. Complete blood count shows a hemoglobin of 7g/dl, platelets of 19,000 cells/microliter, and a white cell count of 1800 cells/microliter. What is the most appropriate management plan?



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A 9-month-old boy is brought in by his mother to the emergency department with a rash that she first noticed 5 hours ago. He is feeding less than usual, and she has given him ibuprofen before bringing him in. She does not report any other symptoms. He is unvaccinated. On examination, his temperature is 39.2 C, heart rate 170/min, respiratory rate 40/min, SaO2 97% on room air. He is pink with a central capillary refill of 3 seconds and cold peripheries. He is irritable and difficult to settle. Ear, nose, throat, and respiratory examinations are unremarkable. He has a petechial rash over his trunk which is spreading to his arms and face. Which of the following is the most appropriate next step in the management of this patient?



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A 9-year-old girl presents to the emergency department with a rash. She has a dry cough for one week and was started on an oral antibiotic three days ago. Yesterday she noticed a rash around her eyes and on her chest. On examination, she is alert and oriented, with a temperature of 36.8 C, heart rate of 88/min, respiratory rate of 20/min, SaO2 98% on room air. She has an erythematous pharynx. There is a flat non-blanching pinpoint rash around her eyes bilaterally and scattered across her upper chest and shoulders. The rest of her skin is clear, and her mother states that it looks the same as yesterday morning. What is the next step in the management of this patient?



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A 4-year-old girl presents to the emergency department with a rash. She is otherwise asymptomatic but had a cough and coryzal illness a few weeks ago. Vital signs include a temperature of 36.8 C, heart rate of 108/min, respiratory rate of 30/min, SaO2 of 99%. She is well perfused and warm to touch, with a flat, non-blanching, small rashes scattered over her trunk and limbs. The rest of her systemic examination is normal. Complete blood count shows a hemoglobin of 11.3 g/dL, white cell count of 6,200 cells/microliter and platelets of 9,000 cells/microliter. Which of the following is the most likely diagnosis; and the management plan?



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A 6-year-old girl presents to the emergency department with a non-blanching rash on her trunk. She has a 2-day history of cough and coryza. She is alert and oriented. She is flushed and coryzal with warm perfused peripheries. Her vitals include a temperature of 38.0 C, heart rate of 115/min, respiratory rate of 26/min, SaO2 of 99%. Systemic examination reveals an erythematous pharynx and erythematous tympanic membranes bilaterally. Her mother had only noticed the rash a few hours ago. What is the most appropriate management plan for this girl?



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Petechiae - References

References

Ranganathan D,John GT, Therapeutic Plasma Exchange in Renal Disorders. Indian journal of nephrology. 2019 May-Jun;     [PubMed]
Iba T,Watanabe E,Umemura Y,Wada T,Hayashida K,Kushimoto S,Wada H, Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. Journal of intensive care. 2019;     [PubMed]
Clark WF,Huang SS, Introduction to therapeutic plasma exchange. Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis. 2019 Apr 26;     [PubMed]
Sargentini-Maier ML,De Decker P,Tersteeg C,Canvin J,Callewaert F,De Winter H, Clinical pharmacology of caplacizumab for the treatment of patients with acquired thrombotic thrombocytopenic purpura. Expert review of clinical pharmacology. 2019 Jun;     [PubMed]
Joly BS,Coppo P,Veyradier A, An update on pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert review of hematology. 2019 Jun;     [PubMed]
Galera P,Dulau-Florea A,Calvo KR, Inherited thrombocytopenia and platelet disorders with germline predisposition to myeloid neoplasia. International journal of laboratory hematology. 2019 May;     [PubMed]
Pilania RK,Singh S, Rheumatology Panel in Pediatric Practice. Indian pediatrics. 2019 May 15;     [PubMed]
Blickstein D, [TREATMENT OF IMMUNE THROMBOCYTOPENIC PURPURA IN ADULTS: UPDATE]. Harefuah. 2019 Mar;     [PubMed]
Jelusic M,Sestan M,Cimaz R,Ozen S, Different histological classifications for Henoch-Schönlein purpura nephritis: which one should be used? Pediatric rheumatology online journal. 2019 Feb 28;     [PubMed]
Obara H,Matsubara K,Kitagawa Y, Acute Limb Ischemia. Annals of vascular diseases. 2018 Dec 25;     [PubMed]

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