Purpura

Because the differential diagnosis of purpura is very large, begin by determining whether the purpura is palpable or nonpalpable. Subsequent workup is dictated by the history, physical, and review of systems to determine appropriate diagnostic tests. If, after careful evaluation, the cause of purpura cannot be determined, the patient should be referred to an appropriate consultant, usually a hematologist, unless a collagen vascular disorder is likely, in which case a rheumatologist is an appropriate choice.

Differential Diagnosis

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)

Workup and Diagnosis

• History and physical examination
  –History of present illness, past medical history, illness exposure, medication history, and a complete review of systems including systemic symptoms (e.g., arthralgias, myalgias, fever), characteristic spread patterns (e.g., RMSF usually starts peripherally and spreads centrifugally onto the trunk), and CNS symptoms (may suggest SLE or meningococcemia)
  –Focused physical examination with complete skin exam and notation of palpable versus nonpalpable rash

• Initial laboratory evaluation includes CBC with differential and PT/PTT/INR (to rule out coagulopathy), urinalysis (evaluate for hematuria in HSP), LFTs (to evaluate for hepatitis), BUN/creatinine (evaluate renal insufficiency (which may occur in PAN, HSP, SLE, and many other palpable purpura-inducing diseases), ESR and/or C-reactive protein (to evaluate for collagen vascular disease)
• Blood cultures and consider skin cultures by a punch biopsy if the patient is febrile
• ANA and rheumatoid factor titers and a viral hepatitis screen may be indicated
• Age-appropriate malignancy screening
• Punch biopsy is diagnostic for leukocytoclastic vasculitis

Treatment

• Discontinue causative medications
• Correct coagulopathies as necessary
• Treat malignancy as necessary
• Sun protection and avoidance of trauma will prevent actinic and age-related purpura
• Treat stasis-associated lower extremity purpura with compression stockings, elevation, and diuretics if edema is present
• Infections: Prompt antimicrobial treatment (e.g., doxycycline for RMSF, ceftriaxone for meningococcemia) is imperative to prevent mortality
• Autoimmune diseases: High-dose corticosteroids followed by steroid-sparing medications (e.g., methotrexate, cyclosporine, azathioprine, mycophenolate mofetil) for long-term treatment
• Idiopathic pigmented purpuras are most common on the lower legs of men, and may resolve spontaneously or persist indefinitely; high potency topical steroids and oral vitamin C sometimes hasten their resolution

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Clotting symptoms: Introduction (review 257 causes)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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