Paediatric Clinical Practice Guideline

Petechiae and Purpura

Author: D. Paradise / M. Lazner Publication date: April 2015 (updated from July 2012) Review date: April 2017

Background  Fever and petechiae = meningococcal disease until proven otherwise  All children with fever or history of fever and petechiae should be reviewed by a Senior Clinician

Definitions Petechiae and purpura are small flat dark red/purple spots resulting from bleeding into skin or under mucosal membranes. Petechiae – Non blanching spots < 2mm Purpura – Non blanching spots > 2mm

Meningococcal disease is easily missed and the overall mortality is 10% - if the child is unwell, treatment must take priority.

Indicators of an unwell child* may be:  Clinician instinct – the child that subjectively looks unwell  Parental concern  Tachycardia and tachypnoea +/- desaturation  Signs of poor peripheral perfusion o Cool peripheries, pallor o Prolonged capillary refill time > 2 secs  Fever > 38.5C or > 38 in child < 3 months  Altered conscious level

Differential Diagnosis  Meningococcal/streptococcal infection – fever, shock and meningitic signs may not be present. Have a low threshold for antibiotic treatment or prolonged observation, especially if pre-treated with antibiotics. See meningococcal septicaemia guideline.  Viral exanthema – influenza, enterovirus. If child is unwell, do not assume it is viral. Treat first and diagnose on viral throat swab later.  Henoch Schönlein purpura (HSP) – child usually well. Classical rash distribution over buttocks and legs with accompanying joint or abdominal pain – see HSP guideline.  Haematological – examine for hepatomegaly, splenomegaly and lymphadenopathy – the child may have acute leukaemia or aplastic anaemia. If history of mucosal bleeding check clotting screen. Isolated thrombocytopenia – see ITP guideline.  Mechanical – pressure and trauma can cause petechiae (be aware of NAI). Forceful coughing and vomiting can result in petechial rash in the SVC distribution.

BSUH Clinical Practice Guideline – Petechiae and purpura Page 1 of 2

Child presents to CED with petechial or purpuric rash

 Transfer to resus Treat as per  Assess for signs of Is child well or unwell? UNWELL meningococcal shock - see indicators of an disease  Fluid resuscitate unwell child* guideline  IV Ceftriaxone 80mg/kg WELL Consultant or Registrar review ASAP Is there a history of

fever or pre- YES treatment with antibiotics?

FBC and blood film High or low WCC No CRP +/- clotting or Raised CRP Yes +/- blood cultures

Purpura > 2mm? Senior review Muscosal bleeding? Treat as per meningococcal Thrombocytopenia disease No Normal Hb, WCC and guideline blood film No hepatosplenomegaly Consider other diagnoses  mechanical causes – Bloods normal esp if SVC distribution Rash over buttock  If mechanical consider Treat as per and legs NAI ITP guideline +/- joint pain +/- abdominal pain

Bloods normal Senior review Treat as per Consider CRP, FBC and HSP guideline blood film

Observe for ≥ 4 hours or admit for Observe for 2 hours observation > 8 hours (particularly if pre-treated with antibiotics) Home with safety-net advice if: Home with safety-net advice if:

 Remains well  Remains well  Afebrile  Afebrile  Rash has not spread  Rash has not spread  Bloods are normal (if done)  No Clinician / parent concern  No Clinician / parent concern BSUH Clinical Practice Guideline – Petechiae and purpura Page 2 of 2