Causes of Goodpasture syndrome
Goodpasture syndrome Causes: Book Excerpts
What causes Goodpasture syndrome?
Causes: Goodpasture syndrome:
No one knows why, in Goodpasture syndrome, the immune
system makes antibodies that end up attacking the lungs and kidneys. A
combination of factors has been implicated, and among these is the
presence of an inherited component.
(Source: excerpt from Goodpasture Syndrome: NIDDK)
Related information on causes of Goodpasture syndrome:
As with all medical conditions,
there may be many causal factors.
Further relevant information on causes of Goodpasture syndrome may be found in:
Causes of Goodpasture syndrome: Online Medical Books
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for more information about the causes of Goodpasture syndrome.
Hematuria:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Transient hematuria
–Urinary tract infection/pyelonephritis
–Nephrolithiasis (kidney or bladder stones)
–Exercise
–Trauma, instrumentation, catheterization, or foreign bodies
–Endometriosis
–Transient unexplained
–Henoch-Schönlein purpura/HUS
–Coagulopathy and excess anticoagulation
–Prostatitis, epididymitis
Persistent hematuria
–Sickle cell anemia
–Cancer (prostate, bladder, kidney)
–Benign prostatic hypertrophy
–Polycystic kidney disease
–Intrinsic glomerular disease Other causes of red or brown urine (pseudohematuria)
–Beeturia (14% population are susceptible after eating beets): Due to excretion of betalaine, a reddish pigment
–Myoglobinuria: Rapidly filtered and excreted; source is usually due to rhabdomyolysis; look for increased elevation of plasma CPK levels
–Hemoglobinuria: Occurs when the filtered load of unbound dimer exceeds resorptive capacity of the proximal tubules, generally at serum levels >100–150 mg/dL
Urethral carbuncle
Urethritis (e.g., Chlamydia)
Porphyria
Phenazopyridine (bladder analgesic): Produces an orange color in urine
Postinfectious glomerulonephropathy
Hereditary (Alport's syndrome)
IgA nephropathy (Berger's disease): Often see gross hematuria without positive family history of disease
Loin pain hematuria syndrome
Thin basement membrane disease (benign familial hematuria): Usually see microscopic hematuria; gross hematuria or renal failure is rare
Hypercalciuria or hyperuricuria
Arteriovenous malformation
Fistula
Others include food dyes, phenolphthalein, rifampin, and porphyrins
Excessive anticoagulation
Trauma
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Purpura:
Differential Diagnosis
(In a Page: Signs and Symptoms)
Palpable purpura (papules or nodules that are red/purple and do not blanch with pressure)
- Leukocytoclastic Vasculitis
–A necrotizing vasculitis of small vessels
–Fever, malaise, fatigue and arthralgias
–Inciting factors include drugs (e.g., NSAIDs, thaizides, and phenothiazines), infection [bacterial (e.g., RMSF, meningococcemia) or viral (e.g., hepatitis)] or, blood abnormalities (e.g., cryoglobulinemia, cryofibrinogenemia)
–Vasculitic injury to kidneys, brain, lung, heart, and GI tract may occur
-
Collagen vascular diseases
–Systemic lupus erythematosus, Sjögren's syndrome, rheumatoid arthritis
-
Granulomatous vasculitis (e.g., Wegener's, Churg-Strauss syndrome)
-
Polyarteritis nodosa
-
Internal malignancies
–Myeloma, lymphoma, or leukemia
-
Henoch-Schönlein purpura
-
Drugs
–Aspirin, NSAIDs, warfarin, heparin
-
Nonpalpable purpura (flat macules, patches
similar to ecchymoses; or petechiae that do not blanch with pressure)
-
Trauma
-
Advancing age (senile purpura)
-
Actinic changes
-
Chronic stasis
- Coagulopathies (affecting platelet number or function)
–TTP (pentad of fever, microangiopathic hemolytic anemia, thrombocytopenia, renal insufficiency, and neurologic signs)
–ITP
–Drug-induced thrombocytopenia
–Bacteremia and many viral diseases
-
Scurvy (vitamin C deficiency) can cause hemorrhage and purpura
-
TORCH infection can cause congenital purpura (“blueberry muffin baby”)
-
Many systemic diseases (e.g., Cushing's and diabetes have associated nonpalpable purpura)
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Hematuria:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Transient (fever, dehydration, exercise)
-
Urinary tract infection
–Most common cause of gross hematuria
-
Hypercalciuria (common)
- Primary glomerulonephritis (GN)
–Acute poststreptococcal GN: Gross hematuria ±hypertension, oliguria; 5 days to several weeks after Group A strep pharyngitis or pyoderma; can also occur after other infections
–IgA nephropathy (Berger disease): recurrent gross hematuria occurs at or near onset of a URI
–Membranoproliferative GN
-
GN associated with systemic disease
–HSP
–SLE
–Other vasculitis (rare) e.g.,Wegener
-
Other glomerular disease
–Benign familial hematuria
–Alport syndrome: Usually X linked, high-
frequency deafness, progression to renal failure
–Glomerular disease (e.g., FSGS) usually presents as nephrotic syndrome
-
Tubulointerstitial disease
–Polycystic kidney disease, interstitial
nephritis, papillary necrosis, ATN
-
Urinary pelvic junction obstruction
-
Urolithiasis/nephrolithiasis
–Painless in up to 50% of children
-
Urethrorrhagia
–Recurrent gross hematuria (spotting on the
underwear)
–Most common in peripubertal males
-
Malignancies (e.g., Wilms tumor)
-
Vascular (e.g., renal vein thrombosis)
-
Trauma
-
Non-urinary tract blood
–Menses, perineal irritation, pinworms, masturbation, STDs, sexual abuse
-
Munchausen/Munchausen by proxy (rare)
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Purpura:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Vasculitis (palpable purpura)
–HSP: Most common vasculitis, incidence: 0.01%, in 50% follows URI; other triggers are bacterial infection, drugs, vaccines, food, insect bites; lasts 1–2 weeks, age 2–8 (mean 4 years), M > F, IgA-mediated, small vessels
–Polyarteritis nodosa (PAN), Wegener granulomatosis (WG): Rare in children
- Hematologic
–ITP: Age 1–5 years; autoantibodies against platelets (platelets destroyed by splenic macrophages); usually 1–6 weeks after viral infection; 70–80% acute self-limited; 10–20% chronic recurrent; <1% associated with intracranial hemorrhage
–Other causes of thrombocytopenia: Wiscott-Aldrich syndrome, aplastic anemia, leukemia, disseminated intravascular coagulation (DIC), thrombocytopenia absent radius (TAR)
- Coagulation factor deficiencies:
–Hemophilia A/B (factors VIII/XI): A (1/7,500 male births) four times more common than B; X-linked recessive
–vWD: Prevalence 1%, autosomal dominant, vW factor deficiency or decreased function
–Liver disease: Decreased production of coagulation factors
–Hemorrhagic disease of the newborn: Decreased vitamin K-dependent coagulation factors (II, VII, IX, X)
- Infections
–Bacterial/rickettsial: Meningococcemia (MC), Group A strep (scarlet fever),
Streptococcus viridans/Staphylococcus aureus (endocarditis), Gonococcus (disseminated), Leptospirosis, Rickettsia rickettsii (Rocky Mountain spotted fever), R. prowazekii (epidemic typhus), Ehrlichiosis
–Viral: Hepatitis B, Dengue hemorrhagic fever, atypical measles
-
Drugs: Coumadin, heparin, aspirin, thiazide, corticosteroids, penicillins, sulfonamides
-
Others: Trauma/abuse, scurvy (vitamin C deficiency)
>
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
Hematuria:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Bladder cancer
A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg
Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma
Gross hematuria is characteristic in traumatic rupture or perforation of the bladder Typically, hematuria is accompanied by lower abdominal pain and, occasionally, anuria despite a strong urge to void
The patient may also develop swelling of the scrotum, buttocks, or perineum and signs of shock, such as tachycardia and hypotension.
Calculi
Bladder and renal calculi produce hematuria, which may be associated with signs of a urinary tract infection (UTI), such as dysuria and urinary frequency and urgency Bladder calculi usually cause gross hematuria, referred pain to the lower back or penile or vulvar area and, in some patients, bladder distention.
Renal calculi may produce microscopic or gross hematuria
The cardinal symptom, however, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, a fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders
Macroscopic hematuria is usually the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation
Other features include epistaxis, purpura (petechiae and ecchymoses), and signs of GI bleeding.
Cortical necrosis (acute)
Accompanying gross hematuria in acute cortical necrosis are intense flank pain, anuria, leukocytosis, and a fever.
Cystitis
Hematuria is a telling sign in all types of cystitis
Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes grossly bloody hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Microscopic and macroscopic hematuria may occur with tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and a fever.
Diverticulitis
When diverticulitis involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia
Characteristic findings include left lower quadrant pain, abdominal tenderness, constipation or diarrhea and, at times, a palpable, firm, fixed, and tender abdominal mass The patient may also develop mild nausea, flatulence, and a low-grade fever.
Glomerulonephritis
Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and red cell casts, which may persist for months It may also produce oliguria or anuria, proteinuria, a mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure
Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial)
Typically, nephritis causes microscopic hematuria However, the patient with acute interstitial nephritis may develop gross hematuria. Other findings are a fever, a maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute — almost colorless — urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive)
Obstructive nephropathy may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease
Polycystic kidney disease is a hereditary disorder that may cause recurrent microscopic or gross hematuria
Although commonly asymptomatic before age 40, it may cause increased blood pressure, polyuria, dull flank pain, and signs of a UTI, such as dysuria and urinary frequency and urgency Later, the patient develops a swollen, tender abdomen and lumbar pain that’s aggravated by exertion and relieved by lying down
He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or stones.
Prostatitis
Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, a fever with chills, nausea, vomiting, perineal and low back pain, and a decreased libido
Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and a decreased libido.
Pyelonephritis (acute)
Acute pyelonephritis typically produces microscopic or macroscopic hematuria that progresses to grossly bloody hematuria
After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include a persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, anorexia, vomiting, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer
The classic triad of signs and symptoms includes grossly bloody hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass
Colicky pain may accompany the passage of clots Other findings include a fever, CVA tenderness, and increased blood pressure
In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction
Typically, renal infarction produces gross hematuria The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting
Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after infarction, a fever and increased blood pressure.
Renal papillary necrosis (acute)
Acute renal papillary necrosis usually produces grossly bloody hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds Arthralgia and hypertension are common.
Renal trauma
About 80% of patients with renal trauma have microscopic or gross hematuria Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymoses over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds
Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis
Gross hematuria is commonly the first sign of renal tuberculosis It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis
Grossly bloody hematuria usually occurs in renal vein thrombosis In abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness
Other features include a fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Schistosomiasis
Schistosomiasis usually causes intermittent hematuria at the end of urination It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower abdominal masses.
Sickle cell anemia
Sickle cell anemia is a hereditary disorder in which gross hematuria may result from congestion of the renal papillae Associated signs and symptoms may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice
Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus (SLE)
Gross hematuria and proteinuria may occur when SLE involves the kidneys Cardinal associated features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, a recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma
Initial hematuria may occur, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymoses.
Vasculitis
Hematuria is usually microscopic in vasculitis Associated signs and symptoms include malaise, myalgia, polyarthralgia, a fever, increased blood pressure, pallor and, occasionally, anuria
Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests
Renal biopsy is the diagnostic test most commonly associated with hematuria This sign may also result from biopsy or manipulative instrumentation of the urinary tract such as in cystoscopy.
Drugs
Drugs that commonly cause hematuria are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, phenylbutazone, oxyphenbutazone, penicillin, rifampin, and thiabendazole.
Herb alert
When taken with an anticoagulant, herbal remedies, such as garlic and ginkgo biloba, can cause adverse reactions, including excessive bleeding and hematuria.
Treatments
Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria Following a kidney transplant, a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Purpura:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Autoerythrocyte sensitivity
With autoerythrocyte sensitivity, painful ecchymoses appear either singly or in groups, usually preceded by local itching, burning, or pain. Common associated findings include epistaxis, hematuria, hematemesis, and menometrorrhagia. Abdominal pain, diarrhea, nausea, vomiting, syncope, a headache, and chest pain are also common.
Disseminated intravascular coagulation (DIC)
DIC can cause varying degrees of purpura, depending on its severity and underlying cause. Rarely, the patient develops life-threatening purpura fulminans, with symmetrical cutaneous and subcutaneous lesions on the arms and legs. Or, he may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis such as oliguria.
Dysproteinemias
With multiple myeloma, petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemia typically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and a low-grade fever may precede or accompany the purpura, which gradually fades over 1 to 2 weeks. Persistent pigmentation develops after repeated outbreaks.
Easy bruising syndrome
Easy bruising syndrome is characterized by recurrent bruising on the legs, arms, and trunk, either spontaneously or following minor trauma. Bruising may be preceded by pain and is more common in women than in men, especially during menses.
Ehlers-Danlos syndrome (EDS)
Besides petechiae, EDS is marked by easy bruising, epistaxis, gum bleeding, hematuria, melena, menorrhagia, and excessive bleeding after surgery. EDS characteristically produces soft, velvety, hyperelastic skin; hyperextensible joints; increased skin and blood vessel fragility; and repeated dislocations of the temporomandibular joint.
Idiopathic thrombocytopenic purpura (ITP)
Chronic ITP typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.
Leukemia
Leukemia produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. Confluent ecchymoses are uncommon. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.
Acute leukemias also produce severe prostration and a high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, a headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemias begin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, a low-grade fever, anorexia, and weight loss.
Myeloproliferative disorders
Myeloproliferative disorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of a headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.
Systemic lupus erythematosus (SLE)
SLE is a chronic inflammatory disorder that may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic butterfly rash appears in the disorder’s acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud’s phenomenon, seizures, psychotic behavior, photosensitivity, a fever, anorexia, weight loss, and lymphadenopathy.
Thrombotic thrombocytopenic purpura
Generalized purpura, hematuria, vaginal bleeding, jaundice, and pallor are among the usual presenting signs and symptoms in thrombotic thrombocytopenic purpura. Most patients have a fever, and some also experience fatigue, weakness, a headache, nausea, abdominal pain, arthralgia, and hepatosplenomegaly. Possible neurologic effects include seizures, paresthesia, cranial nerve palsies, vertigo, and an altered level of consciousness. Renal failure may also occur.
Trauma
Traumatic injury can cause local or widespread purpura.
Other causes
Diagnostic tests
Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas due to extravasated blood.
Drugs
The anticoagulants heparin and warfarin can produce purpura. Administration of warfarin can result in painful areas of erythema that become purpuric and then necrotic with an adherent black eschar. The lesions develop between the 3rd and 10th day of drug administration.
Surgery and other procedures
Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. These include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and the use of plasma expanders such as dextran.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Goodpasture's syndrome:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
The cause of Goodpasture’s syndrome is unknown. Although some cases have been associated with exposure to hydrocarbons or type 2 influenza, many have no precipitating events. The high incidence of human leukocyte antigen DRW2 in these patients suggests a genetic predisposition. Abnormal production and deposition of antibody against GBM and alveolar basement membrane activate the complement and inflammatory responses, resulting in glomerular and alveolar tissue damage.
This syndrome may occur at any age but is most common in males between ages 20 and 30. A second peak incidence occurs between ages 50 and 70, with males and females in this age group affected equally.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Allergic purpuras:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
The most common identifiable cause of allergic purpura is probably an autoimmune reaction directed against vascular walls, triggered by a bacterial infection (particularly streptococcal infection). Typically, upper respiratory tract infection occurs 1 to 3 weeks before the onset of symptoms. Other possible causes include allergic reactions to some drugs and vaccines, to insect bites, and to some foods (such as wheat, eggs, milk, and chocolate).
Allergic purpura affects more males than females and is most prevalent in children ages 3 to 7. The prognosis is more favorable for children than adults.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Idiopathic thrombocytopenic purpura:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
ITP may be an autoimmune disorder, because antibodies that reduce the life span of platelets have been found in nearly all patients. The spleen probably helps to remove platelets modified by the antibody. Acute ITP usually follows a viral infection, such as rubella or chickenpox, and can follow immunization with a live virus vaccine. Chronic ITP seldom follows infection and is commonly linked to immunologic disorders such as systemic lupus erythematosus. It’s also linked to drug reactions. ITP frequently occurs in patients who have abused alcohol, heroin, or morphine, and in patients with acquired immunodeficiency syndrome who are exposed to the rubella virus.
Acute ITP usually affects children between ages 2 and 6; chronic ITP mainly affects adults younger than age 50, especially women between ages 20 and 40.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Premature rupture of membranes:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Although the cause of PROM is unknown, malpresentation and contracted pelvis commonly accompany the rupture. Predisposing factors may include:
❑ poor nutrition and hygiene, and lack of proper prenatal care
❑ incompetent cervix (perhaps as a result of abortions)
❑ increased intrauterine tension due to hydramnios or multiple pregnancies
❑ defects in the amniochorial membranes’ tensile strength
❑ uterine infection.
PROM occurs in nearly 10% of all pregnancies over 20 weeks’ gestation.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hematuria:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Appendicitis
About 15% of patients with appendicitis have either microscopic or macroscopic hematuria accompanied by bladder tenderness, dysuria, and urinary urgency. More typical findings include constant right-lower-quadrant pain (especially over McBurney’s point), nausea and vomiting, anorexia, abdominal rigidity, rebound tenderness, constipation, tachycardia, and low-grade fever.
Bladder cancer
A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma
A characteristic finding in traumatic rupture or perforation of the bladder, gross hematuria is typically accompanied by lower abdominal pain. The patient may also develop anuria despite a strong urge to void; swelling of the scrotum, buttocks, or perineum; and signs of shock, such as tachycardia and hypotension.
Calculi
Both bladder and renal calculi produce hematuria, which may be associated with signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Bladder calculi may also cause gross hematuria, referred pain to the lower back or penile or vulvar area and, occasionally, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, though, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders
Macroscopic hematuria is commonly the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Among other features are epistaxis, purpura (petechiae and ecchymosis), and signs of GI bleeding.
Cortical necrosis (acute)
Accompanying gross hematuria in this renal disorder are intense flank pain, anuria, leukocytosis, and fever.
Cystitis
Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes gross hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Both microscopic and macroscopic hematuria may occur in tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and fever.
Diverticulitis
When this disorder involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left-lower-quadrant pain, abdominal tenderness, constipation or diarrhea and, occasionally, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Endocarditis (subacute infective)
Occasionally, this disorder produces embolization, resulting in renal infarction and microscopic or gross hematuria. Common related findings are constant fever, chills, night sweats, fatigue, pallor, anorexia, weight loss, polyarthralgia, petechiae, flank pain, severe back pain, stiff neck, cardiac murmurs, tachycardia, and splenomegaly.
Glomerulonephritis
Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and RBC casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial)
Typically, this infection causes microscopic hematuria. However, some patients with acute interstitial nephritis may develop gross hematuria. Other findings are fever, maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute—almost colorless—urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive)
This disorder may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease
This hereditary disorder may cause recurrent microscopic or gross hematuria. It commonly produces no symptoms before age 40 but may cause increased blood pressure, polyuria, dull flank pain, and signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that’s aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or calculi.
Prostatic hyperplasia (benign)
About 20% of patients with an enlarged prostate have macroscopic hematuria, usually when a significant obstruction is present. The hematuria is usually preceded by diminished urinary stream, tenesmus, and a feeling of incomplete voiding. It may be accompanied by urinary hesitancy, frequency, and incontinence; nocturia; perineal pain; and constipation. Inspection reveals a midline mass representing the distended bladder; rectal palpation reveals an enlarged prostate.
Prostatitis
Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, fever with chills, nausea, vomiting, perineal and low back pain, and decreased libido. Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and decreased libido.
Pyelonephritis (acute)
This infection typically produces microscopic or macroscopic hematuria that progresses to gross hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, vomiting, anorexia, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer
The classic triad of signs and symptoms includes gross hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction
Typically, this disorder produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after the infarction, fever and increased blood pressure.
Renal papillary necrosis (acute)
This disorder usually produces gross hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma
About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymosis over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis
Gross hematuria is often the first sign of this disorder. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis
Gross hematuria usually occurs in this type of thrombosis. In an abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Schistosomiasis
This infection usually causes intermittent hematuria at the end of urination. It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower abdominal masses.
Sickle cell anemia
In this hereditary disorder, gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus
Gross hematuria and proteinuria may occur when this disorder involves the kidneys. Cardinal features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma
Hematuria may occur initially, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymosis.
Vaginitis
When this infection spreads to the urinary tract, it may produce macroscopic hematuria. Related signs and symptoms may include urinary frequency and urgency, dysuria, nocturia, perineal pain, pruritus, and a malodorous vaginal discharge.
Vasculitis
Hematuria is usually microscopic in this disorder. Associated signs and symptoms include malaise, myalgia, polyarthralgia, fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests
Renal biopsy is the diagnostic test most often associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract, as in cystoscopy.
Drugs
Drugs that commonly cause hematuria are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, penicillin, rifampin, and thiabendazole.
Herb Alert
When taken with an anticoagulant, herbal medicines such as garlic and ginkgo biloba can cause excessive bleeding and hematuria.
Treatments
Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. After a kidney transplant, a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Purpura:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Amyloidosis
This disorder produces purpura that appears either spontaneously on dependent areas of the skin or following minor trauma, coughing, or straining. The eyelids and mucous membranes are commonly affected.
Autoerythrocyte sensitivity
With this syndrome, painful ecchymoses appear either singly or in groups, usually preceded by local itching, burning, or pain. Common associated findings include epistaxis, hematuria, hematemesis, and menometrorrhagia. Abdominal pain, diarrhea, nausea, vomiting, syncope, headache, and chest pain are also common.
Cholesterol emboli
Purpura due to cholesterol emboli are most commonly found in the lower extremities of patient with atherosclerotic vascular disease and usually occur after anticoagulation therapy or an invasive arterial procedure such as angiogram or cardiac catheterization but may occur spontaneously. Associated findings include livedo reticularis, cyanosis, gangrene, nodules and ulceration of the skin.
Dermatoses (pigmented)
This group of disorders, thought to result from chronic stasis, produces benign, chronic purpura, mainly on dependent areas.
Disseminated intravascular coagulation
This disorder can cause varying degrees of purpura, depending on its severity and underlying cause. Rarely, the patient develops life-threatening purpura fulminans, with symmetrical cutaneous and subcutaneous lesions on the arms and legs, or he may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis, such as oliguria.
Dysproteinemias
With multiple myeloma, petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemia typically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and low-grade fever may precede or accompany the purpura, which gradually fades over 1 to 2 weeks. Persistent pigmentation develops after repeated outbreaks.
Easy bruising syndrome
This syndrome is characterized by recurrent bruising on the legs, arms, and trunk, either spontaneously or following minor trauma. Bruising may be preceded by pain and is more common in women than in men, especially during menses.
Ehlers-Danlos syndrome (EDS)
Besides petechiae, this syndrome is marked by easy bruising, epistaxis, gum bleeding, hematuria, melena, menorrhagia, and excessive bleeding after surgery. EDS characteristically produces soft, velvety, hyperelastic skin; hyperextensible joints; increased skin and blood vessel fragility; and repeated dislocations of the temporomandibular joint.
Fat emboli
Petechiae that occur on the upper body a few days after a major injury are caused by fat emboli.
Idiopathic thrombocytopenic purpura (ITP)
Chronic ITP typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.
Leukemia
This disease produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. Confluent ecchymoses are uncommon. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.
Acute leukemias also produce severe prostration and high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemias begin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, low-grade fever, anorexia, and weight loss.
Liver disease
Liver disease may cause purpura, particularly ecchymoses, and other bleeding tendencies. Associated findings include hepatomegaly, ascites, right-upper-quadrant pain, jaundice, nausea, vomiting, and anorexia.
Lymphomas
T-cell (Hodgkin’s) lymphomas initially may produce erythematous patches with some scaling. These lesions, which may be psoriasiform or parapsoriasiform, then become interspersed with nodules. Pruritus and discomfort are common. Later, tumors and ulcerations form, and nontender lymphadenopathy develops.
B-cell (non-Hodgkin’s) lymphoma may produce a scaling dermatitis with pruritus, which usually begins on the legs and then affects the entire body. Small pink-to-brown nodules and diffuse pigmentation also occur. B-cell lymphomas typically produce painless peripheral lymphadenopathy, usually affecting the cervical nodes first. Other findings in both types of lymphoma include fever, fatigue, malaise, weight loss, and hepatosplenomegaly.
Meningococcemia
Transmitted by droplet inhalation, it’s most common in children and caused by Neisseria meningitidis. Cutaneous and oropharyngeal petechia and purpura are initially discrete but become confluent, developing into hemorrhagic bullae and ulcerations. Fulminant infection results in extensive purpura and ecchymosis with irregular borders (purpura fulminans) most notably on the extremities. These lesions may develop necrotic centers. This disease is usually fatal if not recognized and treated early. Prognosis is poor when purpura or ecchymosis is present at the time of diagnosis. Associated symptoms include spiking fevers, chills, myalgia and arthralgia, and recent upper respiratory tract infection. Rapid progression of symptoms leads to headache, neck stiffness and nuchal rigidity. Septic shock ensues within hours on onset of symptoms with altered mental status and hypotension.
Myeloproliferative disorders
These disorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.
Nutritional deficiencies
With vitamin C deficiency (scurvy), the characteristic pattern of purpura is perifollicular petechiae, which coalesce to form ecchymoses, in the “saddle area” of the thighs and buttocks. Additional hemorrhaging occurs in arm and leg muscles (with phlebothrombosis), viscera, joints (with limb and joint pain), and nail beds. Related findings include scaly dermatitis; pallor; tender, swollen, bleeding gums and loosened teeth; dry mouth; and poor wound healing. Nonspecific symptoms include weakness, lethargy, and anorexia. Irritability, depression, insomnia, and hysteria may also develop.
Vitamin K deficiency produces abnormal bleeding tendencies, such as ecchymosis, gum bleeding, epistaxis, hematuria, and GI and intracranial bleeding.
Vitamin B12 deficiency can cause varying degrees of purpura. GI findings include anorexia, nausea, vomiting, weight loss, abdominal discomfort, and jaundice. Dyspnea, peripheral neuropathies, ataxia, glossitis and, occasionally, depression also occur.
Folic acid deficiency also can cause varying degrees of purpura. The patient may be irritable and forgetful and complain of fatigue, weakness, dyspnea, palpitations, nausea, anorexia, headaches, and fainting spells. Additional findings include pallor, slight jaundice, and glossitis.
Rocky Mountain spotted fever
This illness is contracted through the bite of an infected tick and is most common among children between ages 5 and 10. Initial skin lesions are small pink macules that evolve into blatant petechia and palpable purpura. Hemorrhagic macules may develop. The palms and soles are particularly affected. Extensive cutaneous necrosis occurs due to disseminated intravascular coagulation in a small percentage of patients experiencing gangrene of the extremities, necessitating amputation. Associated signs and symptoms include fever, severe headache, generalized myalgia, photophobia, nausea and vomiting. Late in the course of the illness, shock and death may occur.
Septicemia
Thrombocytopenia or the effects of toxins in acute infection can lead to purpura, especially in the form of petechiae. Associated findings include fever, chills, headache, tachycardia, lethargy, diaphoresis, and anorexia. Signs and symptoms specific to the area of infection—for example, cough, wound drainage, and urinary burning—also occur.
Stasis
Chronic stasis usually affects the elderly, producing dusky reddish purpura on the legs after prolonged standing.
Systemic lupus erythematosus
This chronic inflammatory disorder may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic butterfly rash appears in the disorder’s acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud’s phenomenon, seizures, psychotic behavior, photosensitivity, fever, anorexia, weight loss, and lymphadenopathy.
Thrombotic thrombocytopenic purpura
Generalized purpura, hematuria, vaginal bleeding, jaundice, and pallor are among the usual presenting signs and symptoms in this disorder. Most patients have fever, and some also experience fatigue, weakness, headache, nausea, abdominal pain, arthralgias, and hepatosplenomegaly. Possible neurologic effects include seizures, paresthesia, cranial nerve palsies, vertigo, and altered level
of consciousness. Renal failure may also occur.
Trauma
Traumatic injury can cause local or widespread purpura.
Vasculitis
Palpable purpura is commonly caused by allergic vasculitis (leukocytoclastic vasculitis) of which Henoch-Schönlein purpura is one subtype. Most common in adolescents and children, lesions can be found anywhere on the body but are most prevalent on the lower extremities and buttocks. The purpura tends to be smooth, bordered, and circular in nature. Systemic signs and symptoms include fever, arthralgias, abdominal pain, GI bleeding and nephritis.
Other causes
Diagnostic tests
Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas due to extravasated blood.
Drugs
The anticoagulants heparin and warfarin can produce purpura. Administration of warfarin can result in painful areas of erythema that become purpuric then necrotic with an adherent black eschar. The lesions develop between the 3rd and 10th day of drug administration.
Surgery and other procedures
Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. These include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and use of plasma expanders such as dextran.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hematuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Urinary tract infection
❑ Nephrolithiasis
❑ Anticoagulation
❑ Long distance running
❑ Renal trauma
❑ Bladder cancer
❑ Renal cell cancer
❑ Transitional cell cancer
❑ Glomerulonephritis
❑ Interstitial cystitis
❑ Hemorrhagic cystitis
❑ Hemoglobinuria
❑ Endocarditis
❑ Polycystic kidney disease
❑ Renal artery embolism
❑ Renal vein thrombosis
❑ Endometrial implants
❑ Wegener granulomatosis
❑ Goodpasture syndrome
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Source: Field Guide to Bedside Diagnosis, 2007
Purpura/Petechiae/Excessive Bleeding:
Differential Overview
(Field Guide to Bedside Diagnosis)
Purpura
❑Trauma
❑Senile purpura
❑Drugs
❑Vasculitis
❑Vitamin K deficiency
❑Psychogenic purpura
❑Cholesterol emboli
❑Warfarin necrosis
❑Scurvy
❑Thrombotic thrombocytopenic purpura
❑Henoch-Schonlein purpura
❑Amyloidosis
Petechiae
❑Autoimmune thrombocytopenia
❑Bacteremia
❑Hypersplenism
Excessive Bleeding
❑Over-anticoagulation
❑Thrombocytopenia
❑von Willebrand disease
❑Circulating anticoagulant
❑Disseminated intravascular coagulation
❑Hemophilia
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Source: Field Guide to Bedside Diagnosis, 2007
Allergic purpura:
Causes
(Handbook of Diseases)
The most common identifiable cause of allergic purpura is probably an autoimmune reaction directed against vascular walls, triggered by a bacterial infection (particularly streptococcal infection). Typically, an upper respiratory tract infection occurs 1 to 3 weeks before the onset of symptoms. Other possible causes include allergic reactions to some drugs and vaccines, allergic reactions to insect bites, and allergic reactions to some foods (such as wheat, eggs, milk, and chocolate).
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Source: Handbook of Diseases, 2003
Idiopathic thrombocytopenic purpura:
Causes
(Handbook of Diseases)
ITP may be an autoimmune disorder because antibodies that reduce the life span of platelets have been found in nearly all patients. The spleen probably helps to remove platelets modified by the antibody. Acute ITP usually follows a viral infection, such as rubella and chickenpox, and can follow immunization with a live virus vaccine. Chronic ITP seldom follows infection and is commonly linked to immunologic disorders, such as systemic lupus erythematosus or human immunodeficiency virus infection. It’s also linked to drug reactions.
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Source: Handbook of Diseases, 2003
Premature rupture of the membranes:
Causes
(Handbook of Diseases)
Although the cause of PROM is unknown, malpresentation and contracted pelvis commonly accompany the rupture. Predisposing factors may include:
❑ poor nutrition and hygiene and lack of proper prenatal care
❑ incompetent cervix (perhaps as a result of abortions)
❑ increased intrauterine tension due to hydramnios or multiple pregnancies
❑ defects in the amniochorial membranes’ tensile strength
❑ uterine infection.
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Source: Handbook of Diseases, 2003
Hematuria:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Appendicitis
About 15% of patients with appendicitis have either microscopic or macroscopic hematuria accompanied by bladder tenderness, dysuria, and urinary urgency. More typical findings include constant right-lower-quadrant pain (especially over McBurney’s point), nausea and vomiting, anorexia, abdominal rigidity, rebound tenderness, constipation, tachycardia, and low-grade fever.
Bladder cancer
A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma
Gross hematuria is characteristic in traumatic rupture or perforation of the bladder. Typically, the hematuria is accompanied by lower abdominal pain and, occasionally, anuria despite a strong urge to void. The patient may also develop swelling of the scrotum, buttocks, or perineum and signs of shock, such as tachycardia and hypotension.
Calculi
Bladder and renal calculi produce hematuria, which may be associated with signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Bladder calculi usually cause gross hematuria, referred pain to the lower back or penile or vulvar area and, in some patients, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, though, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders
Macroscopic hematuria is typically the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Among other features are epistaxis, purpura (petechiae and ecchymoses), and signs of GI bleeding.
Cystitis
Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes grossly bloody hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Both microscopic and macroscopic hematuria may occur with tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and fever.
Diverticulitis
When diverticulitis involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left-lower-quadrant pain, abdominal tenderness, constipation or diarrhea and, at times, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Endocarditis (subacute infective)
Occasionally, subacute infective endocarditis produces embolization, resulting in renal infarction and microscopic or gross hematuria. Among common related findings are constant fever, chills, night sweats, fatigue, pallor, anorexia, weight loss, polyarthralgia, petechiae, flank pain, severe back pain, stiff neck, cardiac murmurs, tachycardia, and splenomegaly.
Glomerulonephritis
Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and red cell casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial)
Typically, this infection causes microscopic hematuria. However, some patients with acute interstitial nephritis may develop gross hematuria. Other findings are fever, maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute — almost colorless — urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive)
Obstructive nephropathy may cause microscopic or macroscopic hematuria, but rarely is urine grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease
Polycystic kidney disease, a hereditary disorder, may cause recurrent microscopic or gross hematuria. Although usually asymptomatic before age 40, it may cause increased blood pressure, polyuria, dull flank pain, and signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that’s aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or stones.
Prostatic hyperplasia (benign)
About 20% of patients with enlarged prostates have macroscopic hematuria, usually when a significant obstruction is present. The hematuria is usually preceded by diminished urinary stream, tenesmus, and a feeling of incomplete voiding. It may be accompanied by urinary hesitancy, frequency, and incontinence; nocturia; perineal pain; and constipation. Inspection reveals a midline mass representing the distended bladder; rectal palpation reveals an enlarged prostate.
Prostatitis
Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, fever with chills, nausea, vomiting, perineal and low back pain, and decreased libido. Rectal palpation reveals a tender, swollen, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and decreased libido.
Pyelonephritis (acute)
Acute pyelonephritis typically produces microscopic or macroscopic hematuria that progresses to grossly bloody hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, anorexia, vomiting, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer
The classic triad of signs and symptoms of renal cancer includes grossly bloody hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction
Typically, this disorder produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after infarction, fever and increased blood pressure.
Renal papillary necrosis (acute)
Acute renal papillary necrosis usually produces grossly bloody hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma
About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymoses over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis
Gross hematuria is often the first sign of renal tuberculosis. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis
Grossly bloody hematuria usually occurs in renal vein thrombosis. In abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Sickle cell anemia
In this hereditary disorder, gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms of sickle cell anemia may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus
Gross hematuria and proteinuria may occur when systemic lupus erythematosus (SLE) involves the kidneys. Cardinal associated features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma
With urethral trauma, initial hematuria may occur, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymoses.
Vaginitis
When vaginitis spreads to the urinary tract, it may produce macroscopic hematuria. Related signs and symptoms may include urinary frequency and urgency, dysuria, nocturia, perineal pain, pruritus, and a malodorous vaginal discharge.
Vasculitis
Hematuria is usually microscopic in vasculitis. Associated signs and symptoms include malaise, myalgia, polyarthralgia, fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests
Renal biopsy is the diagnostic test most often associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract, as in cystoscopy.
Drugs
Drugs that commonly cause hematuria are anticoagulants, aspirin toxicity, analgesics, cyclophosphamide, metyrosine, phenylbutazone, penicillin, rifampin, and thiabendazole.
Treatments
Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. Following a kidney transplant a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Purpura:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Cholesterol emboli
Purpura caused by cholesterol emboli are most commonly found in the lower extremities of patients with atherosclerotic vascular disease and usually occur after anticoagulation therapy or an invasive arterial procedure, such as angiogram or cardiac catheterization; however, they may occur spontaneously. Associated findings include livedo reticularis, cyanosis, gangrene, nodules, and ulceration of the skin.
Disseminated intravascular coagulation
Disseminated intravascular coagulation (DIC) can cause varying degrees of purpura, depending on its severity and underlying cause. The patient may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis, such as oliguria.
Dysproteinemias
With multiple myeloma, petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemia typically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and low-grade fever may precede or accompany the purpura, which gradually fades over 1 to 2 weeks. Persistent pigmentation develops after repeated outbreaks.
Easy bruising syndrome
Easy bruising syndrome is characterized by recurrent bruising on the legs, arms, and trunk, either spontaneously or following minor trauma. Bruising may be preceded by pain and is more common in women than in men, especially during menses.
Fat emboli
Petechiae that occur on the upper body a few days after a major injury are caused by fat emboli. The patient may experience fever, tachycardia, tachypnea, blood-tinged sputum, cyanosis, anxiety, restlessness, altered level of consciousness, seizures, coma, or rash.
Idiopathic thrombocytopenic purpura
Chronic idiopathic thrombocytopenic purpura (ITP) typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.
Leukemia
Leukemia produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.
Acute leukemias also produce severe prostration and high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemias begin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, low-grade fever, anorexia, and weight loss.
Liver disease
Hepatic disease may cause purpura, particularly ecchymoses, and other bleeding tendencies. Associated findings include hepatomegaly, ascites, right-upper-quadrant pain, jaundice, nausea, vomiting, and anorexia.
Meningococcemia
With meningococcemia, cutaneous and oropharyngeal petechia and purpura are initially discrete but become confluent, developing into hemorrhagic bullae and ulcerations. Fulminant infection results in extensive purpura and ecchymosis with irregular borders (purpura fulminans), most notably on the extremities. These lesions may develop necrotic centers. Associated symptoms include spiking fevers, chills, myalgia and arthralgia, and recent upper respiratory tract infection. Rapid progression of symptoms leads to headache, neck stiffness, and nuchal rigidity. Septic shock ensues within hours of onset of symptoms, accompanied by altered mental status and hypotension.
Myeloproliferative disorders
Myeloproliferative disorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.
Nutritional deficiencies
With vitamin C deficiency (scurvy), the characteristic pattern of purpura is perifollicular petechiae, which coalesce to form ecchymoses, in the “saddle area” of the thighs and buttocks. Additional hemorrhaging occurs in arm and leg muscles (with phlebothrombosis), viscera, joints (with limb and joint pain), and nail beds. Related findings include scaly dermatitis; pallor; tender, swollen, bleeding gums and loosened teeth; dry mouth; and poor wound healing. Nonspecific symptoms include weakness, lethargy, and anorexia. Irritability, depression, insomnia, and hysteria may also develop.
Vitamin K deficiency produces abnormal bleeding tendencies, such as ecchymosis, gum bleeding, epistaxis, hematuria, and GI and intracranial bleeding.
Vitamin B12 deficiency can cause varying degrees of purpura. GI findings include anorexia, nausea, vomiting, weight loss, abdominal discomfort, and jaundice. Dyspnea, peripheral neuropathies, ataxia, glossitis and, occasionally, depression also occur.
Folic acid deficiency also can cause varying degrees of purpura. The patient may be irritable and forgetful and may complain of fatigue, weakness, dyspnea, palpitations, nausea, anorexia, headaches, and fainting spells. Additional findings include pallor, slight jaundice, and glossitis.
Rocky Mountain spotted fever
The initial skin lesions of Rocky Mountain spotted fever are small pink macules that evolve into blatant petechia and palpable purpura. Hemorrhagic macules may develop. The palms and soles are particularly affected. Extensive cutaneous necrosis occurs in a small percentage of patients experiencing gangrene of the extremities, necessitating amputation. Associated signs and symptoms include fever, severe headache, generalized myalgia, photophobia, nausea, and vomiting. Late in the course of the illness, shock and death may occur.
Septicemia
Thrombocytopenia or the effects of toxins in acute infection can lead to purpura, especially in the form of petechiae. Associated findings include fever, chills, headache, tachycardia, lethargy, diaphoresis, and anorexia. Signs and symptoms specific to the area of infection — for example, cough, wound drainage, and urinary burning — also occur.
Systemic lupus erythematosus
Systemic lupus erythematosus (SLE) is a chronic inflammatory disorder that may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic “butterfly rash” appears in the disorder’s acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud’s phenomenon, seizures, psychotic behavior, photosensitivity, fever, anorexia, weight loss, and lymphadenopathy.
Trauma
Traumatic injury can cause local or widespread purpura. Specific signs and symptoms depend on the type and location of the trauma.
Other causes
Diagnostic tests
Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas caused by extravasated blood.
Drugs
The anticoagulants heparin and warfarin can produce purpura. Administration of warfarin can result in painful areas of erythema that become purpuric then necrotic with an adherent black eschar. The lesions develop between the 3rd and 10th day of drug administration.
Surgery and other procedures
Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. Such procedures include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and use of plasma expanders such as dextran.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hematuria:
Principal Causes of Hematuria
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Hematuriawithout proteinuria
- Glomerular disorders
- Acute postinfectious glomerulonephritis
- Immunoglobulin A nephropathy
- Henoch-Schönlein nephritis
- Alport syndrome
- Membranoproliferative glomerulonephritis
- Systemic lupus erythematosus
- Familial benign hematuria (thin basementmembrane nephropathy)
- Nonfamilial benign hematuria
- Nonglomerular disorders
- Urinarytract infection
- Trauma
- Exercise
- Hydronephrosis
- Renal vein thrombosis
- Hemoglobinopathies
- Idiopathic hypercalciuria
- Urolithiasis
- Polycystic kidney disease
- Renal tuberculosis
- Vascular malformations
- Foreign body in the urethra or bladder
- Neoplasm
- Bleeding disorders
- Drugs
- Hematuria with proteinuria
- Glomerulardisorders
- Acutepostinfectious glomerulonephritis
- Immunoglobulin A nephropathy
- Henoch-Schönlein nephritis
- Alport syndrome
- Membranoproliferative glomerulonephritis
- Systemic lupus erythematosus
- Membranous nephropathy
- Glomerulonephritis of chronic infection
- Idiopathic rapidly progressive glomerulonephritis
- Hemolytic-uremic syndrome
- Polyarteritis nodosa
- Antiglomerular basement membrane disease(Goodpasture disease)
- Focal segmental glomerulosclerosis
- Wegener granulomatosis
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Purpura and Bleeding:
Principal Causes of Purpura and Bleeding
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Lossof vascular integrity
- Trauma
- Infection
- Henoch-Schönlein purpura
- Drugs
- Langerhans histiocytosis
- Ehlers-Danlos syndrome
- Vitamin C deficiency
- Hereditary hemorrhagic telangiectasia(Osler-Rendu-Weber disease)
- Thrombocytopenia
- Increasedplatelet destruction
- Immune-mediated
- Neonatal alloimmune thrombocytopenia
- Maternal autoimmune thrombocytopenia
- Idiopathic thrombocytopenic purpura
- Collagen vascular disease
- Drug-induced thrombocytopenia
- Infection
- Hemolytic-uremic syndrome
- Thrombotic thrombocytopenic purpura
- Wiskott-Aldrich syndrome
- Decreased platelet production
- Infection
- Specific platelet disorders
- Congenitalamegakaryocytic thrombocytopenia
- Thrombocytopenia–absent radiisyndrome
- Bone marrow suppression (generalized)
- Bone marrow replacement
- Megaloblastic anemia
- Platelet sequestration
- Hypersplenism
- Large hemangiomas
- Abnormal platelet function
- Thrombasthenia(Glanzmann disease)
- Giant platelet syndrome (Bernard-Souliersyndrome)
- Storage pool deficiency
- Drugs
- Uremia
- Coagulation disorders
- Factordeficiencies
- VonWillebrand disease
- Factor VIII deficiency (hemophiliaA)
- Factor IX deficiency (hemophilia B,Christmas disease)
- Deficiencies of Factors I, II, V, VII,X, XI, and XIII
- Vitamin K deficiency
- Disseminated intravascular coagulation
- Liver disease
- Circulating anticoagulants
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Hematuria:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Bladder cancer.A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma.Gross hematuria is characteristic in traumatic rupture or perforation of the bladder. Typically, hematuria is accompanied by lower abdominal pain and, occasionally, anuria despite a strong urge to void. The patient may also develop swelling of the scrotum, buttocks, or perineum and signs of shock, such as tachycardia and hypotension.
Calculi.Bladder and renal calculi produce hematuria, which may be associated with signs of a urinary tract infection (UTI), such as dysuria and urinary frequency and urgency. Bladder calculi usually cause gross hematuria, referred pain to the lower back or penile or vulvar area and, in some patients, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, however, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, a fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders.Macroscopic hematuria is usually the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Other features include epistaxis, purpura (petechiae and ecchymoses), and signs of GI bleeding.
Cortical necrosis (acute).Accompanying gross hematuria in acute cortical necrosis are intense flank pain, anuria, leukocytosis, and a fever.
Cystitis.Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes grossly bloody hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Microscopic and macroscopic hematuria may occur with tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and a fever.
Diverticulitis.When diverticulitis involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left lower quadrant pain, abdominal tenderness, constipation or diarrhea and, at times, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Glomerulonephritis.Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and red cell casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, a mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial).Typically, nephritis causes microscopic hematuria. However, the patient with acute interstitial nephritis may develop gross hematuria. Other findings are a fever, a maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute—almost colorless—urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive).Obstructive nephropathy may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease.Polycystic kidney disease is a hereditary disorder that may cause recurrent microscopic or gross hematuria. Although it commonly produces no symptoms before age 40, it may cause increased blood pressure, polyuria, dull flank pain, and signs of a UTI, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that's aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or calculi.
Prostatitis.Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, a fever with chills, nausea, vomiting, perineal and low back pain, and a decreased libido. Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and a decreased libido.
Pyelonephritis (acute).Acute pyelonephritis typically produces microscopic or macroscopic hematuria that progresses to grossly bloody hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include a persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, anorexia, vomiting, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer.The classic triad of signs and symptoms of renal cancer includes grossly bloody hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include a fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction.Typically, renal infarction produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after infarction, a fever and increased blood pressure.
Renal papillary necrosis (acute).Acute renal papillary necrosis usually produces grossly bloody hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma.About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymoses over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis.Gross hematuria is commonly the first sign of renal tuberculosis. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis.Grossly bloody hematuria usually occurs in renal vein thrombosis. In abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include a fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Schistosomiasis.Schistosomiasis usually causes intermittent hematuria at the end of urination. It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower abdominal masses.
Sickle cell anemia.Sickle cell anemia is a hereditary disorder in which gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus (SLE).Gross hematuria and proteinuria may occur when SLE involves the kidneys. Cardinal associated features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud's phenomenon, seizures or psychoses, a recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma.Initial hematuria may occur, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymoses.
Vasculitis.Hematuria is usually microscopic in vasculitis. Associated signs and symptoms include malaise, myalgia, polyarthralgia, a fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests.Renal biopsy is the diagnostic test most commonly associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract such as in cystoscopy.
Drugs.Drugs that commonly cause hematuria are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, phenylbutazone, oxyphenbutazone, penicillin, rifampin, and thiabendazole.
Treatments.Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. Following a kidney transplant, a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Purpura:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Autoerythrocyte sensitivity.With autoerythrocyte sensitivity, painful ecchymoses appear either singly or in groups, usually preceded by local itching, burning, or pain. Common associated findings include epistaxis, hematuria, hematemesis, and menometrorrhagia. Abdominal pain, diarrhea, nausea, vomiting, syncope, headache, and chest pain are also common.
Disseminated intravascular coagulation (DIC).DIC can cause varying degrees of purpura, depending on its severity and underlying cause. Rarely, the patient develops life-threatening purpura fulminans, with symmetrical cutaneous and subcutaneous lesions on the arms and legs. Or, he may have cutaneous oozing, hematemesis, or bleeding from incision or needle insertion sites. Other findings include acrocyanosis; nausea; dyspnea; seizures; severe muscle, back, and abdominal pain; and signs of acute tubular necrosis such as oliguria.
Dysproteinemias.With multiple myeloma,petechiae and ecchymoses accompany other bleeding tendencies: hematemesis, epistaxis, gum bleeding, and excessive bleeding after surgery. Similar findings occur with cryoglobulinemia, which may also produce malignant maculopapular purpura. Hyperglobulinemiatypically begins insidiously with occasional outbreaks of purpura over the lower legs and feet. These outbreaks eventually become more frequent and extensive, involving the entire lower leg and possibly the trunk. The purpura usually occurs after prolonged standing or exercise and may be heralded by skin burning or stinging. Leg edema, knee or ankle pain, and a low-grade fever may precede or accompany the purpura, which gradually fades over 1 or 2 weeks. Persistent pigmentation develops after repeated outbreaks.
Ehlers-Danlos syndrome (EDS).Besides petechiae, EDS is marked by easy bruising, epistaxis, gum bleeding, hematuria, melena, menorrhagia, and excessive bleeding after surgery. EDS characteristically produces soft, velvety, hyperelastic skin; hyperextensible joints; increased skin and blood vessel fragility; and repeated dislocations of the temporomandibular joint.
Idiopathic thrombocytopenic purpura (ITP).Chronic ITP typically begins insidiously, with scattered petechiae that are usually found on the distal arms and legs. Deep-lying ecchymoses may also occur. Other findings include epistaxis, easy bruising, hematuria, hematemesis, and menorrhagia.
Leukemia.Leukemia produces widespread petechiae on the skin, mucous membranes, retina, and serosal surfaces that persist throughout the course of the disease. Confluent ecchymoses are uncommon. The patient may also exhibit swollen and bleeding gums, epistaxis, and other bleeding tendencies. Lymphadenopathy and splenomegaly are common.
Acute leukemias also produce severe prostration and a high fever and may cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Confusion, headache, seizures, vomiting, papilledema, and nuchal rigidity may occur late in the disease. Chronic leukemiasbegin insidiously with minor bleeding tendencies, malaise, fatigue, pallor, a low-grade fever, anorexia, and weight loss.
Myeloproliferative disorders.Myeloproliferativedisorders, which include polycythemia vera, paradoxically can cause hemorrhage accompanied by ecchymoses and ruddy cyanosis. The oral mucosa takes on a deep purplish red hue, and slight trauma causes swollen gums to bleed. Other findings include pruritus, urticaria, and such nonspecific signs and symptoms as lethargy, weakness, fatigue, and weight loss. The patient typically complains of a headache, a sensation of fullness in the head, and rushing in the ears; dizziness and vertigo; dyspnea; paresthesia of the fingers; double or blurred vision and scotoma; and epigastric distress. He may also experience intermittent claudication, hypertension, hepatosplenomegaly, and impaired mentation.
Systemic lupus erythematosus (SLE).SLE may produce purpura accompanied by other cutaneous findings, such as scaly patches on the scalp, face, neck, and arms; diffuse alopecia; telangiectasia; urticaria; and ulceration. The characteristic butterfly rash appears in the disorder's acute phase. Common associated signs and symptoms include nondeforming joint pain and stiffness, Raynaud's phenomenon, seizures, psychotic behavior, photosensitivity, fever, anorexia, weight loss, and lymphadenopathy.
Thrombotic thrombocytopenic purpura.Generalized purpura, hematuria, vaginal bleeding, jaundice, and pallor are among the usual presenting signs and symptoms in thrombotic thrombocytopenic purpura. Most patients have fever, and some also experience fatigue, weakness, headache, nausea, abdominal pain, arthralgia, and hepatosplenomegaly. Possible neurologic effects include seizures, paresthesia, cranial nerve palsies, vertigo, and an altered level of consciousness. Renal failure may also occur.
Trauma.Traumatic injury can cause local or widespread purpura.
Other causes
Diagnostic tests.Invasive procedures, such as venipuncture and arterial catheterization, may produce local ecchymoses and hematomas due to extravasated blood.
Drugs.The anticoagulants heparin and warfarin can produce purpura.
Surgery and other procedures.Any procedure that disrupts circulation, coagulation, or platelet activity or production can cause purpura. These include pulmonary and cardiac surgery, radiation therapy, chemotherapy, hemodialysis, multiple blood transfusions with platelet-poor blood, and the use of plasma expanders such as dextran.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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