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Petechiae

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Last Update: August 10, 2020.

Introduction

Petechiae are pinpoint non-blanching spots that measure less than 2 mm in size, which affects the skin and mucous membranes. A non-blanching spot is one that does not disappear after applying brief pressure 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 are necessary 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 the initial presentation. Consequently, a child with a 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 classify 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

  • Leukemia
  • 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 syndrome

Congenital

  • Wiscott-Aldrich syndrome
  • Glanzmann thrombasthenia
  • Bernard-Soulier syndrome

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][7]

History and Physical

A detailed history and physical examination are paramount for every child presenting with petechiae. Key features in the history include the 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, the clinician should confirm vaccination status.

On examination, a complete set of observations and neurological status requires monitoring. A full systemic examination should be completed, including cardiac, respiratory, abdominal, otorhinolaryngological, and neurological (if concerns of IMD). The skin should undergo thorough examination from head to toe, and the pattern of rash requires clear documentation. Demarcating areas of petechiae with a skin marker can help monitor the 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, an inconsistent history or signs of 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 necessary 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 narrowed down to a more specific diagnosis.

Treatment / Management

Many patients attending the PED with petechial rashes will not require any specific treatment. 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 receive a dose of antibiotics pre-hospital if high clinical suspicion of IMD is present. If there are specific diagnoses, 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 probable malignant diagnosis.[8][9]

Differential Diagnosis

  • Ecchymosis
  • Palpable purpura
  • Retiform purpura

Pearls and Other Issues

Recognizing the full 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 crucial 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 condition management is optimally by an interprofessional team that includes clinicians, specialists as indicated, hematology nurses, and pharmacists. The key is to determine the primary cause. Most patients with a benign cause or drug-induced petechiae have a good outcome when discontinuing the offending agent. However, when petechiae are due to heparin, paradoxical thrombosis can occur.[10] Cross-disciplinary communication and collaboration of the entire interprofessional healthcare team will guide these cases to the optimal outcome. [Level 5]

Continuing Education / Review Questions

References

1.
Ranganathan D, John GT. Therapeutic Plasma Exchange in Renal Disorders. Indian J Nephrol. 2019 May-Jun;29(3):151-159. [PMC free article: PMC6521768] [PubMed: 31142960]
2.
Iba T, Watanabe E, Umemura Y, Wada T, Hayashida K, Kushimoto S, Japanese Surviving Sepsis Campaign Guideline Working Group for disseminated intravascular coagulation. Wada H. Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. J Intensive Care. 2019;7:32. [PMC free article: PMC6528221] [PubMed: 31139417]
3.
Clark WF, Huang SS. Introduction to therapeutic plasma exchange. Transfus Apher Sci. 2019 Jun;58(3):228-229. [PubMed: 31047822]
4.
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 Rev Clin Pharmacol. 2019 Jun;12(6):537-545. [PubMed: 30977686]
5.
Joly BS, Coppo P, Veyradier A. An update on pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol. 2019 Jun;12(6):383-395. [PubMed: 31107120]
6.
Galera P, Dulau-Florea A, Calvo KR. Inherited thrombocytopenia and platelet disorders with germline predisposition to myeloid neoplasia. Int J Lab Hematol. 2019 May;41 Suppl 1:131-141. [PubMed: 31069978]
7.
Pilania RK, Singh S. Rheumatology Panel in Pediatric Practice. Indian Pediatr. 2019 May 15;56(5):407-414. [PubMed: 31102381]
8.
Blickstein D. [TREATMENT OF IMMUNE THROMBOCYTOPENIC PURPURA IN ADULTS: UPDATE]. Harefuah. 2019 Mar;158(3):196-199. [PubMed: 30916510]
9.
Jelusic M, Sestan M, Cimaz R, Ozen S. Different histological classifications for Henoch-Schönlein purpura nephritis: which one should be used? Pediatr Rheumatol Online J. 2019 Feb 28;17(1):10. [PMC free article: PMC6393980] [PubMed: 30819179]
10.
Obara H, Matsubara K, Kitagawa Y. Acute Limb Ischemia. Ann Vasc Dis. 2018 Dec 25;11(4):443-448. [PMC free article: PMC6326052] [PubMed: 30636997]
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Bookshelf ID: NBK482331PMID: 29493956

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