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.

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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

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