Petechiae are common in benign viralillnesses but can be a sign of more serious conditions, such as meningococcemia andthrombocytopenia
Petechiae are common in benign viralillnesses but can be a sign of more serious conditions, such as meningococcemia andthrombocytopenia: Excerpt from Avoiding Common Pediatric Errors
Author:
Johann Peterson, MD
What to Do - Interpret the Data
Petechiae are nonblanching, usually red, macules <1 mm in diameter. They
are a form of purpura, which as a general term refers to rashes caused by the
extravasation of red blood cells into the skin. Other purpuric lesions are ecchymoses (nonblanching macules >1 cm), and purpura (macules from 1 mm
to 1 cm in diameter). Thus, the term purpura (somewhat confusingly) can be
used either to refer to all of these purpuric rashes as a group, or specifically
to mean purpura per se. Purpura fulminans refers to large, confluent "lakes"
of ecchymoses, which become necrotic. Broadly, purpuric rashes are caused
by disorders of coagulation, platelet disorders, or disorders affecting the
walls of blood vessels. Thus, the process leading to purpura may be thrombocytopenia (immune-mediated, infectious, malignant, Kasabach-Merritt
syndrome) or platelet dysfunction, coagulopathy (inherited [e.g., protein C
or S deficiency or other factor deficiency] or acquired [e.g., hemorrhagic
disease of the newborn, disseminated intravascular coagulation]), vasculitis,
or connective tissue disease (scurvy, Ehlers-Danlos). Petechiae are most often the result of platelet dysfunction or thrombocytopenia. The differential
diagnosis of purpura is enormous and includes everyone's favorite suspect,
meningococcemia, as well as many other infections, noninfectious acquired
diseases, congenital disorders, and trauma.
In neonates, a common cause of petechia is immune-mediated thrombocytopenia, due either to maternal alloimmunization against fetal platelets
or to transplacental passage of maternal autoantibodies (e.g., idiopathic
thrombocytopenic purpura, lupus, or drug reactions). Kasabach-Merritt
syndrome refers to thrombocytopenia from the sequestration or coagulative consumption of platelets within a hemangioma or similar vascular anomaly. Other causes of thrombocytopenia in infants are congenital
disordersof plateletnumber (Wiskott-Aldrich,Fanconi,thrombocytopeniaabsent radii syndromes) or function (Bernard-Soulier, Glanzmann thrombasthenia), and heparin-induced thrombocytopenia. Infectious possibilities
include TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus,
herpessimplexvirus)infections,humanimmunodeficiencyvirus,parvovirus
B19, and bacterial sepsis.
For children, the most worrisome (but uncommon) cause of petechia
and fever is bacteremia, and most children with these signs typically undergo
sepsis "rule-out," including culture of at least blood and urine plus empiric
antibiotics for 48 hours. However, in several published series, other causes
are far more common, including presumed viral urinary tract infection,
Group A streptococcal pharyngitis, respiratory syncytial virus, and otitis
media. In these series, only 8% to 20% of children with fever and petechiae
had documented invasive bacterial disease. Neisseria meningitidis was the
most common organism causing bacteremia among children with fever and
petechiae, but Streptococcus pneumoniae, group-B Streptococcus, Haemophilus
influenzae, Staphylococcus aureus, and Escherichia coli were also identified in
blood cultures. Other ostensible causes were urinary tract infections, aseptic
meningitis; Henoch-Schönlein purpura; acute leukemia Rocky Mountain
spotted fever; idiopathic thrombocytopenic purpura; roseola; Mycoplasma
pneumonia; rotavirus; and reaction to the measles, mumps, rubella (MMR)
vaccine.
In some of these series, several criteria were found to completely excludeseriousbacterial infection: well-appearance (although thiswasvariably
defined), absence of petechiae below the nipples, and a normal C-reactive
protein. However, there does not seem to be consensus regarding safe criteria, which, in the presence of fever and petechiae, will identify seriously ill
children with acceptable sensitivity. The list of possible infections in a child
with fever and a purpuric rash is long, and in fact it is common for no agent
to be identified.
A number of features may provide clues to the diagnosis. Meningococcemia is classically associated with generalized petechiae that are often
stellate, and that progress rapidly, eventually into ecchymoses and necrosis.
A petechial rash is a common presenting symptom, but some children will
have a nonspecific maculopapular rash, or none at all. The rash of Rocky
Mountain spotted fever begins with petechiae on the palms and soles and
spreads centrally, and the child will typically appear quite ill. Epidemic typhus causespetechiaeorpurpurabeginning on thetrunk.Botharecausedby
Rickettsiae, which directly invade endothelial cells. A number of viruses, especially parvovirus B19, have been associated with "papular purpuric gloves
and socks syndrome," which consists of symmetric erythema and edema of
the hands and feet, which is sharply demarcated and usually painful, or pruritic. An associated petechial body rash, fever, and oral erosions are common.
Henoch-Schönlein purpura is an immunoglobulin (Ig)A-mediated vasculitis that is common in children and classically presents with a symmetric
palpable purpuric rash on the legs and buttocks, but petechiae and/or ecchymoses may coexist or be the only rash. Other common features include
fever, abdominal pain, arthralgias, and hematuria with or without proteinuria. Localized petechiae, or petechiae in an unusual distribution, may be
due to minor trauma (e.g., from a blood pressure cuff) and should also alert
to the possibility of child abuse. Vigorous coughing may cause petechiae in
the distribution of the superior vena cava, including scleral hemorrhage.
Suggested Readings
Baker RC, Seguin JH, Leslie N, et al. Fever and petechiae in children. Pediatrics. 1989;84(6):
1051–1055.
Baselga E, Drolet BA, Esterly NB. Purpura in infants and children. J Am Acad Dermatol.
1997;37(5 Pt 1):673–705.
Brogan PA, Raffles A. The management of fever and petechiae: making sense of rash decisions.
Arch Dis Child. 2000;83(6):506–507.
Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever
and petechiae. J Pediatr. 1997;131(3):398–404.
Van Nguyen Q , Nguyen EA, Weiner LB. Incidence of invasive bacterial disease in children
with fever and petechiae. Pediatrics. 1984;74(1):77–80.
'>
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Bullous Pemphigoid
More Medical Textbooks Online about Bullous Pemphigoid
Review other book chapters online related to Bullous Pemphigoid:
Medical Books Excerpts
- Dermatitis
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
|
|
» Next page: Surveys relating to Bullous Pemphigoid
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
