Healthy Baby Practical advice for treating newborns and toddlers. Petechiae and Purpura: The Ominous and the Not-So-Obvious? Stan L. Block, MD, FAAP Abstract tient does not appear to be acutely ill or The next considerations will be three Petechiae and purpura are among the prostrate or to have meningismus. If you other sometimes not-so-obvious blood/ most alarming findings a pediatrician will are observing this scenario, you will then vasculitic disorders: autoimmune throm- commonly observe in the office. Severity of be making immediate arrangements for bocytopenias (eg, idiopathic thrombo- illness can range from a temper tantrum, to blood culture, intravenous access, pos- cytopenia [ITP], systemic lupus ery- common viral infections, to the most dead- sibly an in-office parenteral dose of cef- thematosus [SLE]), and the not-so-rare ly infections and diseases. To avoid many triaxone (which is available in nearly all Henoch-Schoenlein purpura (HSP). of the pitfalls in diagnosis, practitioners pediatric offices), and emergency trans- But the most common pathogens as- will need to be thorough in history taking, port to your nearest capable emergency sociated with petechiae/purpura will assessing fever and immunization status, department. However, this highly urgent usually be the more innocuous infec- and physical examination. In addition, a scenario is, fortunately, exceedingly rare tious agents, such as viral infections you few simple laboratory tests will usually be in most of our lifetimes. commonly see in your practice, includ- needed and possibly a manual differential. Instead, typically, you will be encoun- ing mononucleosis, enterovirus, and [Pediatr Ann. 2014;43(8):297-303.] tering a young patient who is non-toxic, parvovirus infections.2 Schneider and who may or may not be febrile, who is colleagues3 reported that most cases of hether the child is febrile, alert, is speaking normally, and has nor- petechiae seen in a hospitalized popula- well, or ill, whenever you mal vital signs. You should first attempt to tion of German children (average age, Wsee a patient with petechiae ensure that you are not seeing a case of 3.8 years) were viral in origin (39 of 58), and/or purpura in your office, you should low-grade early meningococcemia, which with a positive blood culture in only one first take a deep breath. Then your index could evolve extremely rapidly into full- child. However, as a major limitation of of suspicion and your pediatric instincts blown shock. The good news: The former the study, they excluded from the report should override everything else in your disease has become an increasingly un- children who had any purpuric lesions. life or office. You should obtain a full set common encounter, with apparently only Also, fewer than 10 petechiae were re- of vital signs, including blood pressure about 1,000 cases of invasive meningo- ported in 23% of children in the series as and oximeter, and make sure your pa- coccal disease (IMD) occurring annually well. Be forewarned, as I have person- in the United States in recent years.1 But ally seen merely four petechiae, fever, when you practice in rural Kentucky, any and arthralgia as the initial presenting Stan L. Block, MD, FAAP, is Professor of Clinical esoteric disease may be lurking. signs of IMD.4 Pediatrics, University of Louisville, and University Next on your list of urgent and poten- of Kentucky; President, Kentucky Pediatric and tially devastating diseases are what I term APPROACH TO PETECHIAE/ Adult Research Inc.; and General Pediatrician, the “big 3” group of very ominous pete- PURPURA Bardstown, Kentucky. chial illnesses: 1) renal group: hemolytic Upper Body Location of Petechiae Address correspondence to Stan L. Block, MD, uremic syndrome (HUS), 2) cancer/hema- Although still ripe with diagnostic FAAP, via e-mail at [email protected]. tology group: leukemia/lymphoma/neuro- pitfalls, a much easier presumptive diag- Disclosure: Dr. Block has no relevant financial blastoma/aplastic anemia, and 3) Rocky nosis for you will occur when the pete- relationships to disclose. Mountain spotted fever (RMSF) group, chiae are relegated above the nipple line doi: 10.3928/00904481-20140723-03 including ehrlichiosis and anaplasmosis. on physical examination. The diagnoses PEDIATRIC ANNALS • Vol. 43, No. 8, 2014 297 Healthy Baby A B eliminate the diagnosis of HSP. l Urine analysis (UA). Certain abnor- malities suggest HUS, rarely RMSF group or HSP In the more ill or febrile child con- sider: l Complete metabolic panel (CMP; ie, electrolytes, renal and liver func- Images courtesy of Stan L. Block, MD, FAAP. MD, Block, Images courtesy L. of Stan tions). Certain abnormalities suggest the RMSF group, mononucleosis, C HUS, or meningococcemia. l Blood culture. l Lumbar puncture. Primarily per- formed for any stable child with nu- chal rigidity or altered mental status; however, it will likely be too difficult to obtain in the office setting for all but infants and toddlers. Then make a calculated guess Figure 1. An 18-year-old female with history of “possible spider bite” punctum on right lower rib area whether to: (A, blue arrow). Forty-eight hours after the initial bite, she has developed marked confluent erythroder- l Initiate empiric antibiotics (orally or ma on the lateral trunk, in contrast with the more maculo-papular pinpoint rash on the abdomen, as parenterally). well as a thick, scarlet fever–like rash on the abdomen, neck, and elbow creases (B). At 96 hours, the rash has progressed. It is more petechial and pruritic on the knees (C), despite 48 hours of oral clindamycin l Use doxycycline to cover for the and 24 hours of doxycycline therapy to cover for potential methicillin-resistant Staphylococcus aureus- RMSF group and/or ceftriaxone to related surgical scarlet fever and Rocky Mountain spotted fever, respectively, from the insect bite. Are you more concerned that the bite may have initially been from a tick instead? cover for meningococcemia. l Hospitalize your patient. l Send home with careful follow-up. are more likely to be benign: streptococ- with oximetry. You should inspect the You must be keenly aware that the cal pharyngitis, forceful vomiting, se- skin carefully for distribution of pete- earliest finding and only good clue for vere cough.5 But still be very cautious chiae and purpura and other types of IMD in nearly one third of infected pa- when making this assumption in any rashes—especially for lesions below tients was an elevated band count on the febrile child. For these patients, I would the nipple line, any elevation and non- manual differential of the CBC.6 Regard- still consider obtaining a complete blood blanching of lesions, and sclera icterus. ing the “RMSF triad,” as I discussed in count (CBC), possibly with a manual The patient’s general demeanor and level my July 2014 article,7 most patients with differential, along with close follow-up of alertness and toxicity are important to RMSF will, initially or over a few days, within the next 24 hours by phone and/ note. A thorough physical examination have at least one or more of the three fol- or in the office the next day.6 is essential, including at minimum: most lowing laboratory manifestations: low node regions, neck suppleness, pharynx, leukocyte count with a high band count, History heart, lungs, liver, spleen, abdomen, and thrombocytopenia, and/or hyponatre- You will want to ascertain most of the joints. mia.8 In addition, those with Ehrlichio- following factors in your history: level sis will usually have elevated hepatic of fever, tick bites in the last 3 weeks, Laboratory Assessments transaminases. An empiric course of recent travel, recent camping trips, con- I suggest the following basic and sim- doxycycline should be considered. stitutional symptoms such as weight loss ple laboratory assessments for patients These medical decisions are among and fatigue, urine output and color, vac- with petechiae and/or purpura: the most difficult for both experienced cination status, sore throat, headaches, l CBC with a manual differential (can and novice practitioners. Remember that and joint aches. be performed by capillary stick). Cer- almost no in-office hematology machine tain abnormalities suggest meningo- and leukocyte counter can perform a Physical Examination coccemia, RMSF, ehrlichiosis, HUS, band count or examine a peripheral Vital signs should be assessed, along and cancer group, and will usually blood smear for “blasts” or hemolysis. 298 Copyright © SLACK Incorporated Healthy Baby CASE 1 venously. Within 48 hours, the patient is A At 48 hours after a possible “spider feeling much better, and her rash is fad- bite,” an 18-year-old female presents ing rapidly. The RMSF and ehrlichiosis with a fulminant erythroderma (Figure titers that you obtained earlier were neg- 1A) mixed with a scarlet fever–like rash ative. She recovers uneventfully. (Figure 1B) on her lateral torso and ab- Diagnosis: Petechiae/purpura sec- domen, respectively. Unlike most cases ondary to brown recluse spider bite. of alleged spider bites seen in the of- fice, which are usually staphylococcal Discussion pyodermas not associated with a bite, a Brown recluse spider bites can cause small bite punctum is actually present on systemic toxicity, including fever, chills, her side (Figure 1A, arrow). She is afe- nausea, malaise, and a diffuse macular brile, affable, and feels fine. Her physi- rash with petechiae.9,10 Hemolysis, co- cal examination and vital signs are nor- agulopathy, and renal failure have also mal. Because you are concerned that this been reported in children. In one series may be a Staphylococcus aureus “surgi- of adult patients, 5% were hospitalized, B cal scarlet fever” reaction, you initiate 3% required surgical debridement, and oral clindamycin therapy. When seen 24 9% received Dapsone antibiotic (not for hours later, the rash is still spreading, so children).10 you initiate doxycycline therapy for pos- sible tick-borne illnesses.