Purpura

Purpura: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Purpura is the extravasation of red blood cells from the blood vessels into the skin, subcutaneous tissue, or mucous membranes. It’s characterized by discoloration that’s easily visible through the epidermis, usually purplish or brownish red. Purpuric lesions include petechiae, ecchymoses, and hematomas. (See Identifying purpuric lesions.) Purpura differs from erythema in that it doesn’t blanch with pressure because it involves blood in the tissues, not just dilated vessels.

Purpura results from damage to the endothelium of small blood vessels, a coagulation defect, ineffective perivascular support, capillary fragility and permeability, or a combination of these factors. These faulty hemostatic factors, in turn, can result from thrombocytopenia or another hematologic disorder, an invasive procedure or, of course, the use of an anticoagulant.

Additional causes are nonpathologic. Purpura can be a consequence of aging, when loss of collagen decreases connective tissue support of upper skin blood vessels. In an elderly or cachectic person, skin atrophy and inelasticity and loss of subcutaneous fat increase susceptibility to minor trauma, causing purpura to appear along the veins of the forearms, hands, legs, and feet. Prolonged coughing or vomiting can produce crops of petechiae in loose face and neck tissue. Violent muscle contraction, as occurs in seizures or weight lifting, sometimes results in localized ecchymoses from increased intraluminal pressure and rupture. A high fever, which increases capillary fragility, can also produce purpura.

History and physical examination

Ask the patient when he first noticed the lesion and whether he has noticed other lesions on his body. Does he or his family have a history of bleeding disorders or easy bruising? Find out what medications he’s taking, if any, and ask him to describe his diet. Ask about recent trauma or transfusions and the development of associated signs, such as epistaxis, bleeding gums, hematuria, and hematochezia. Also ask about systemic complaints that may suggest infection, such as a fever. If the patient is female, ask about heavy menstrual flow.

Gender Cue: Purpura is more common in women and particularly in individuals with large areas of subcutaneous fat, such as the breasts, abdomen, buttocks, thighs, and calves.

Inspect the patient’s entire skin surface to determine the type, size, location, distribution, and severity of purpuric lesions. Also inspect the mucous membranes. Remember that the same mechanisms that cause purpura can also cause internal hemorrhage, although purpura isn’t a cardinal indicator of this condition.

Medical causes

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.

Special considerations

Reassure the patient that purpuric lesions aren’t permanent and will fade if the underlying cause can be successfully treated. Warn him not to use cosmetic fade creams or other products in an attempt to reduce pigmentation. If he has a hematoma, apply pressure and cold compresses initially to help reduce bleeding and swelling. After the first 24 hours, apply hot compresses to help speed blood absorption.

Prepare the patient for diagnostic tests. These may include a peripheral blood smear, bone marrow examination, and blood tests to determine platelet count, bleeding and coagulation times, capillary fragility, clot retraction, one-stage prothrombin time, partial thromboplastin time, and fibrinogen levels.

Pediatric pointers

Neonates commonly exhibit petechiae, particularly on the head, neck, and shoulders, after vertex deliveries. Thought to result from the trauma of birth, these petechiae disappear within a few days. Other causes in infants include thrombocytopenia, vitamin K deficiency, and infantile scurvy.

The most common type of purpura in children is allergic purpura. Other causes in children include trauma, hemophilia, autoimmune hemolytic anemia, Gaucher’s disease, thrombasthenia, congenital factor deficiencies, Wiskott-Aldrich syndrome, acute ITP, von Willebrand’s disease, and the rare but life-threatening purpura fulminans, which usually follows bacterial or viral infection.

As a child grows and tests his motor skills, the risk of accidents multiplies, and ecchymoses and hematomas commonly occur. However, when you assess a child with purpura, be alert for signs of possible child abuse: bruises in different stages of resolution, from repeated beatings; bruise patterns resembling a familiar object, such as a belt, hand, or thumb and finger; and bruises on the face, buttocks, or genitalia, areas unlikely to be injured accidentally.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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