BMJ 2017;358:j3148 doi: 10.1136/bmj.j3148 (Published 2017 July 13) Page 1 of 2

Endgames

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SPOT DIAGNOSIS A rash localised around the eyes

Mitsuhito Ota dermatologist and director

Department of Dermatology, Chitose City Hospital Hokkou 2, Chitose, Japan

A 26 year old woman presented with a sudden rash on the face purpura on the body can help determine its cause.1 For example, (fig 1). The previous day, she had had severe vomiting, cutaneous vasculitis tends to develop on the lower limbs. Nail diarrhoea, and fever, and had been diagnosed with acute viral fold petechiae are characteristic of systemic sclerosis or gastroenteritis. The rash was localised around the eyes. What dermatomyositis. is the cause of rash? Facial petechiae result from elevated intravascular pressure after severe straining, such as from vomiting, prolonged coughing, crying, infant delivery, or any effort implying Valsalva manoeuvre. They have also been reported as a complication of endoscopic procedures.2 3 The condition is related to rich vascular supply to the face and tends to occur at particular sites of loose tissue, such as the eyelids.4 These purpuric areas are asymptomatic and might go unnoticed by the patient; however, their appearance can cause concern.5 Laboratory evaluations and skin biopsies are not needed. The lesion typically subsides in a few days without treatment.2-4 The differential diagnoses of purpura locally on the eyelids include amyloidosis associated purpura (panda sign) and purpura related to neuroblastoma.

Fig 1 Localised peri-orbital pinpoint rash Learning points 1. Purpura can indicate a range of conditions, from minor to Answer very serious. The size, palpability, and distribution of purpura, and taking a detailed history can help to determine The diagnosis is facial purpura caused by emesis. The cause is subsequent investigations. rupture of capillaries in the upper dermis resulting from elevated 2. Most cases of petechiae are benign, therefore it is usually intravascular pressure during vomiting. unnecessary to order extra tests. Discussion I have read and understood BMJ policy on declaration of interests and Purpura is caused by extravasation of blood into the skin and/or declare no competing interests. subcutaneous tissue. Small purpural lesions of 2 mm or less in diameter are called petechia; larger purpuric lesions of more Patient consent obtained. than 10 mm in diameter are called ecchymosis. Erythema and Provenance and peer review: not commissioned; externally peer telangiectatic vessels blanch under the direct pressure of a glass reviewed. slide (diascopy), but purpura does not. Assessing the palpability 1 Cox NH, Piette WW. Purpura and microvascular occlusion. In: of purpura is the first step in evaluating the purpuric lesion. Burns S, Breathnach S, Cox N, Griffiths C, eds. Rook’s text book of dermatology. 8th ed. Palpable purpura is most likely the result of extensive cellular Blackwell Publishing Ltd, 2010: 49doi:10.1002/9781444317633.ch49. infiltration and extravascular fibrin deposition secondary to an 2 Ozaslan E, Purnak T, Senel E. Facial petechiae as a complication of diagnostic endoscopy. Acta Dermatovenerol Alp Pannonica Adriat 2010;358:21-2.pmid:21390476. inflammatory process, such as vasculitis. Simple haemorrhages 3 Yüksel İ, Ekiz Ö, Ekiz F, Başar Ö, Yüksel O. Facial purpura in an elderly patient after due to thrombocytopenia, platelet dysfunction, abnormal vessel upper gastrointestinal endoscopy. Chin Med J (Engl) 2012;358:1520.pmid:22715517. 4 Balta I, Ekiz O, Ekiz F, Balta S. Facial purpura as a complication of upper gastrointestinal fragility, or elevated intravascular pressure present as endoscopy. Int J Dermatol 2014;358:e134. doi:10.1111/j.1365-4632.2012.05626.x pmid: non-palpable purpuric lesions. Additionally, the location of 23556987.

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5 Rasmussen JE. Puzzling purpuras in children and young adults. J Am Acad Dermatol Published by the BMJ Publishing Group Limited. For permission to use (where not already 1982;358:67-72. doi:10.1016/S0190-9622(82)80202-8 pmid:7085958. granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions

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