Bruising

Julie W. Stern, MD

Bruising - BASICS

Bruising - description

Bruises are the result of extravasation of blood into the skin. Conventional usage often groups petechiae and bruises (or ecchymoses) together as purpura and defines them as follows:

• Petechiae: Flat, red, or reddish purple, 1–3 mm, nonblanching
• Ecchymoses: Larger than petechiae, local extravasation, nonpulsatile, sometimes palpable, color depends on age of lesion

Bruising - etiology

Table 1 Most Common Causes of Bruising

Bruising - DIAGNOSIS

Bruising - signs & symptoms

General goal is to determine if the cause of the bruising is thrombocytopenia, a coagulation disorder, or an extrinsic factor (such as trauma, infection):

• Phase 1: Determine if the history of bruising and/or petechiae is acute or chronic in onset and if there is known trauma versus spontaneous lesions (see tables “Most Common Causes of Bruising” and “How to Estimate the Age of Bruises”):
  • Acute onset of diffuse subcutaneous bleeding with bruises of different ages may indicate severe thrombocytopenia.
  • Generally, children will not bruise or develop petechiae spontaneously until the platelet count is <20,000/mm².
  • Idiopathic thrombocytopenic purpura, leukemia, aplastic anemia, and so forth, can cause this bleeding.
  • A hematologist should be consulted because of the risk of potentially life-threatening bleeding.
  • Chronic history of recurrent bleeding may indicate an inherited coagulation defect such as von Willebrand disease or hemophilia. Familial history may be positive, although von Willebrand disease often goes undiagnosed into adulthood if there has been no challenge such as surgery.
• Phase 2: Perform screening tests for bleeding disorders to categorize the abnormality:
  • Platelet count to assess level of thrombocytopenia
  • PT/PTT: Prolongation of either 1 or both of these may aid in diagnosis of von Willebrand disease, coagulation factor deficiencies, liver disease, vitamin K deficiency.
  • Bleeding time: Prolongation may indicate a platelet aggregation disorder or von Willebrand disease. Use as a screening test is controversial.

Table 2 How to Estimate the Age of Bruises

Bruising - history

• Significant bruising in the neonatal period may indicate neonatal thrombocytopenia, congenital infections, and sepsis with disseminated intravascular coagulation.
• Hemophilia more typically presents with bleeding in the neonatal period.
• Other inherited disorders of coagulation may not be diagnosed until a child is older; tend to be mild, may be uncovered with preoperative testing or postoperative bleeding complications.
• Idiopathic thrombocytopenic purpura may occur at any age.
• Pattern of bruising, especially in a younger child, may indicate normal toddler activity, child abuse, or religious practices such as coining (common among southeast Asians).
• Use of aspirin, ibuprofen, cough syrups with guaifenesin, and some antihistamines cause platelet dysfunction; use of these drugs may also unmask an otherwise mild inherited bleeding disorder.
• Infections such as meningococcemia or viruses and collagen vascular diseases may present with ecchymosis or petechiae.
• Positive familial history of inherited disorders of coagulation factors or platelet aggregation may aid in directing the workup.
• Negative familial history does not rule out any of these disorders.

Bruising - physical exam

• Those with idiopathic thrombocytopenic purpura often appear well, though often with a history of an antecedent viral illness.
• Ill appearance should raise concerns about malignancy, infection (especially meningococcemia), or other acquired coagulation factor deficiencies such as those seen with liver failure.
• Bruising in unusual locations (back, genitalia, thorax) should raise suspicions of child abuse, especially if lesions are in different stages of healing (see table “How to Estimate the Age of Bruises”) or suggest the pattern of a hand or belt.
• Purpura confined mostly to the legs is typical of Henoch-Schönlein purpura.
• Most toddlers will have multiple ecchymoses in the pretibial regions that occur with normal activity.
• Petechiae entirely above the nipple line are consistent with Valsalva maneuver, severe cough, and viral infections.
• Hemophilia generally causes deeper bleeding in muscles and joints, although bruising is common in the infant and younger child.
• Severe thrombocytopenia, streptococcal pharyngitis, varicella, measles, and other viral infections can cause bleeding in mucous membranes; Von Willebrand disease can also present with gingival and/or mucous membrane bleeding.
• Involvement of the reticuloendothelial system can be found with malignancies such as leukemia or with viral or bacterial infections, indicated by hepatosplenomegaly or lymphadenopathy.
• Syndromes such as Fanconi anemia and thrombocytopenia absent radii may present with upper extremity limb malformations and bruising.

Clinical pearls:

• The amount of bruising may not correlate with the amount of internal bleeding that has occurred. Hemophiliacs can significantly drop their hemoglobin during a thigh or psoas bleed without having much in the way of ecchymosis.
• A child presenting with idiopathic thrombocytopenic purpura may have bruises and petechiae from head to toe without changing the hemoglobin much at all.

Factors that make this an emergency include:

• Severe thrombocytopenia below 10,000–20,000/mm³ carries a higher risk of spontaneous internal bleeding including intracranial bleeding.
• Bleeding or bruising accompanied by evidence of leukemia or other malignancy
• Evidence of sepsis (disseminated intravascular coagulation) or meningococcemia

Bruising - tests

Bruising - lab

• CBC: Platelet count is the most important; abnormalities of WBC or Hgb may aid in diagnosis of bone marrow infiltration or failure.
• PT: Elevation may indicate warfarin ingestion or factor VII deficiency or vitamin K deficiency.
• aPTT: Prolongation is seen with hemophilia and may be seen in von Willebrand disease.
• Both PT and PTT: Both are prolonged in disseminated intravascular coagulation, liver failure, and severe vitamin K deficiency.
• Bleeding time: Lengthened in platelet aggregation disorders and with drug effects
• Fibrinogen: Decreased in liver failure, disseminated intravascular coagulation
• Urinalysis: Hematuria and/or proteinuria may indicate Henoch-Schönlein purpura, nephrotic syndrome, or other vasculitis.

Bruising - differencial diagnosis

• Congenital/Anatomic:
  • Coagulation factor abnormality: hemophilia, von Willebrand disease
  • Platelet defect: Bernard-Soulier syndrome, Glanzmann thrombasthenia, and storage pool defects
  • Congenital alloimmune or isoimmune thrombocytopenia
  • Neonatal extramedullary hematopoiesis
  • Hereditary hemorrhagic telangiectasia
• Infectious:
  • Meningococcemia
  • Viral infections (coxsackieviruses, echoviruses)
  • Rocky Mountain spotted fever
  • Syphilis
  • Pertussis—secondary to severe cough
  • Septic or fat emboli
  • Disseminated intravascular coagulation—acquired factor deficiency
• Toxic, environmental, drugs:
  • Warfarin—acquired factor deficiency
  • Corticosteroids—striae caused by increased capillary fragility
  • Aspirin and ibuprofen—cause a qualitative platelet abnormality
  • Sulfonamides
  • Bismuth
  • Chloramphenicol
• Trauma:
  • Normal activity
  • Child abuse
  • Valsalva, crying, forceful coughing
  • Cupping or coin rubbing
  • Tight garments
• Tumor (quantitative platelet abnormality): Bone marrow replacement—leukemia, myelofibrosis, or (rarely) metastatic solid tumors
• Genetic/Metabolic:
  • Uremia
  • Vitamin C deficiency
  • Vitamin K deficiency—owing to antibiotics, biliary atresia, malabsorption (acquired factor deficiency)
• Allergic/Inflammatory/Vasculitic:
  • Henoch-Schönlein purpura
  • Bone marrow failure—aplastic anemia (including Fanconi, paroxysmal nocturnal hemoglobinuria)
  • Increased destruction—idiopathic thrombocytopenic purpura, Evan syndrome, lupus
  • Nephrotic syndrome
  • Collagen vascular disease
  • Ehlers-Danlos syndrome
  • Snake bite (copperhead)
• Miscellaneous (disorders that simulate bruises):
  • Ataxia telangiectasia
  • Cherry angiomata
  • Kaposi sarcoma

Bruising - TREATMENT

Thrombocytopenia precautions for platelets <20–50K, toddlers may need a helmet until platelet count recovers, patients with hemophilia may need restricted activity, generally not needed for patients with von Willebrand disease. Depends on underlying cause:

• Factor replacement for hemophilia
• Platelet transfusion for thrombocytopenia due to decreased production
• IVIG/steroids/winRho for ITP

Bruising - FOLLOW UP

Bruising - disposition

Bruising - admission criteria

Severe thrombocytopenia, suspected child abuse, significant bleeding, significant head trauma

Bruising - discharge criteria

Improved platelet count for patients with ITP, resolution of acute bleeding episode

Bruising - issues for referral

Outpatient evaluation for bruising without significant thrombocytopenia, family history of bleeding disorder

Bruising - complications

Significant bleeding with a bleeding disorder, thrombocytopenia

Bruising - patient monitoring

Recurrent and chronic ITP possible

Bruising - bibliography

1. Berntorp E. Progress in haemophilic care: Ethical issues. Haemophilia. 2002;8:435–438.
2. Buchanan GR. Bleeding signs in children with idiopathic thrombocytopenic purpura. J Pediatr Hematol Oncol. 2003;25(suppl 1):S42–S46.
3. Horton TM, Stone JD, Yee D, et al. Case series of thrombotic thrombocytopenic purpura in children and adolescents. J Pediatr Hematol Oncol. 2003;25:336–339.
4. Khair K, Liesner R. Bruising and bleeding in infants and children–a practical approach. Br J Haematol. 2006;133(3):221–231.
5. Kos L, Shwayder T. Related Articles, Cutaneous manifestations of child abuse. Pediatr Dermatol. 2006;23(4):311–320.
6. Manno CS. Difficult pediatric diagnoses: Bleeding and bruising. Pediatr Clin North Am. 1991;38:637–655.
7. Wight J, Paisley S. The epidemiology of inhibitors in haemophilia A: A systematic review. Haemophilia. 2003;9:418–435.

Bruising - CODES

Bruising - icd9

• 287.0 Allergic purpura
• 287.0 Henoch (-Schönlein) purpura
• 287.4 Secondary thrombocytopenia
• 772.6 Cutaneous hemorrhage
• 782.7 Spontaneous ecchymoses

Bruising - FAQ

• Q: Is hemophilia always diagnosed in the newborn period?
• A: No. A familial history may provide clues, but a significant number of patients represent a spontaneous mutation. Additionally, not all boys with hemophilia will bleed with circumcision, and the diagnosis may not be made until the infants become more active.
• Q: What is a common cause of bruising among girls?
• A: Girls may 1st come to attention at menarche and be diagnosed at that time with von Willebrand disease. Rarely, girls whose fathers have hemophilia may be unfavorably lyonized and, therefore, have decreased factor levels consistent with mild hemophilia.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Bruising

Read excerpts from these other book chapters related to Bruising:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Bruising

• Back to symptom: Bruising: Introduction (review 329 causes)
• Next Book Extract About Bruising: Medications causing Bruising
• All Book Extracts: All Online Book Extracts for Bruising

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Medications causing Bruising

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Medications causing Bruising
• Videos relating to Bruising
• Drug interactions causing Bruising
• Diagnosis Checklist for Bruising
• Types of Bruising

Tools & Services:

• Bookmark this page
• Take a survey relating to Bruising
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City