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Petechiae and Hemorrhagic Rashes

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At the end of the session the learner will: Understand the important points in the clinical evaluation of ... Brogan PA,Raffles A. Arch Dis Child 2000;83:506-7 ... – PowerPoint PPT presentation

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Title: Petechiae and Hemorrhagic Rashes


1
Petechiae and Hemorrhagic Rashes
  • Dr. Harley Eisman
  • Pediatric Emergency Medicine
  • MUHC-Montreal Childrens Hospital

2
Outline
  • Objectives
  • Cases
  • Definition
  • Background
  • Evidence
  • Consensus
  • Global Evaluation of Purpura
  • Selected Disease Entities
  • Wrap-Up

3
Objectives
  • At the end of the session the learner will
  • Understand the important points in the clinical
    evaluation of the child with petechiae
  • Better use laboratory investigation in the
    evaluation of the child with fever and petechiae

4
Case 1
  • 5 year old male referred by pediatrician
  • fever x 48 hours
  • petechiae on trunk for 12 hours
  • cough,headache,abdo pain,difficulty swallowing
  • sick contacts at school
  • febrile,tired, non-toxic, vitals stable
  • petechiae on face, neck,chest abdomen and 1 thigh
  • red throat with some exudate, neck supple
  • WBC 17.3, HGB 126, PLT 212 49N,28L,5ATL

5
Case 2
  • 2.5 year old male
  • fever for 24 hours, poor feeding, less active,
    nausea ?vomit
  • parents noticed spots on face
  • tired, febrile, vitals stable
  • mild rhinorrhea
  • petechiae under eyes, on face, on trunk, and on
    buttock
  • WBC 9.0, HGB 137, PLT 155, N41,S10,L40
  • CoagsNormal
  • CXR Normal, Sinus Views Positive

6
Definitions
  • Purpura
  • nonblanchable purple lesion
  • blood extravasated outside vessel wall
  • a)nonpalpable - no vessel inflammation
  • petechiae - macules smaller than 3 mm
  • ecchymoses- larger than 3mm
  • b)palpable (macular) - vasculitis
  • elevated lesion

7
Purpura
8
Context
  • independent of age, fever with petechiae with or
    without localizing signs places the patient at
    high risk for life threatening bacterial
    infections such as bacteremia, sepsis, and
    meningitis.
  • Nelsons pg. 700
  • series have quoted the incidence of meningococcal
    disease in the setting of petechiae to be 7-11

9
Local Context
  • Meningitis vigilance of 2001
  • Cowansville - Massey Vanier High

10
Meningococcal Disease in Quebec Past Decade
11
Local Context
12
What do you do ?
13
Look at the Evidence
14
Fever and Petechiae in Children Baker et al,
Pediatrics Vol.84 No.6 December 1989
  • 190 patients prospectively enrolled
  • 15 children( 8) with invasive infections
  • 39 children with nonbacteremic causes
  • 38 children with viral causes
  • 136 patients with clinical diagnoses

15
Fever and Petechiae in Children Baker et al,
Pediatrics Vol.84 No.6 December 1989
  • Invasive
  • Neisseria Meningitis
  • H.FluB
  • Strep Pneumo
  • Meningitis NYD
  • Non-Invasive
  • Strep Pyogenes()
  • RSV
  • Influenza
  • E.Coli Uti
  • Rotavirus
  • Enterovirus
  • Adenovirus

16
Additional Infectious Causes
  • Parvovirus B19 (Fifth Disease)
  • Ebstein-Barr Virus

17
Fever and Petechiae in Children Baker et al,
Pediatrics Vol.84 No.6 December 1989
  • Location, Quantity
  • 40 of Invasive Disease had generalized
  • 11 of non-invasive had generalized
  • no patient with petechiae only above the nipple
    line had invasive disease

18
Fever and Petechiae in Children Baker et al,
Pediatrics Vol.84 No.6 December 1989
19
Incidence of bacteremia in infants and children
with fever and petechiae Mandl et Al, Journal of
Pediatrics 131(3) Sept. 1997 398-406
  • Bacterial Culture Results from 411 patients with
    fever gt 380C and petechiae

20
Incidence of bacteremia in infants and children
with fever and petechiae Mandl et Al, Journal of
Pediatrics 131(3) Sept. 1997 398-406
Testing Performance of selected clinical and
laboratory findings
21
Performance of Clinical Features
Wells LC et Al, Arch Dis Child 200125 p220
22
Performance of Lab Test
Wells LC et Al, Arch Dis Child 200125 p220
23
Coagulation Profiles
Willword, Pediatric Emergency Care, 2003 Vol
19(4) p. 244
24
The Management of fever and petechiaemaking
sense of rash decisions Brogan PA,Raffles A. Arch
Dis Child 200083506-7
  • Guideline to detect SBS in children with fever
    and petechiae
  • derived from cohort of 55 patients
  • Risk Factors
  • cap refill gt 2 seconds
  • irritability
  • lethargy
  • wbc lt 5000 or gt 15 000
  • elevation of CRP gt 5 mg/dl
  • sensitivity 100, specificity 60, PPV 20, NPV
    100, NNT 5
  • no risk - observe 4 hours
  • abnormal CRP or WBC but well, IV Antbx x 48 hours
  • Ill - ICU

25
Diagnostic assessment of haemorrhagic rash and
fever Nielsen et Al, Arch Dis Child
200185160-165
  • Prospective non-interventional study
  • enrolled 264 patients
  • presence of hemorrhage in the skin
  • rectal temperature greater than 38oC
  • used logistic regression to determine clinical
    and laboratory variables predictive of
    meningococcal disease

26
Diagnostic assessment of haemorrhagic rash and
fever Nielsen et Al, Arch Dis Child
200185160-165
27
Evaluation of Children with Petechial Rashes -
Consensus
  • Nelson et al, PIDJ 1998171135-40
  • surveyed 833 Pediatricians
  • non toxic febrile children 1,2,5,and 7 years

28
Meningococcemia
  • Mimic a viral like illness
  • first sign may be change in behavior
  • 75 fever
  • 75 petechiae and or purpura - 50 both
  • 50 positive blood cultures
  • 50 meninigitis

29
Algorithm Fever and Petechiae Riordan FAI,Arch
Dis Child 200185 172-175
30
Evaluation of Purpura
31
Purpura Diagnostic Consideration
  • Platelet Disorders
  • Coagulation Factor Deficiency
  • Vascular Factors
  • Congenital
  • Hereditary Telangectasia
  • Ehrlos Danlos
  • Acquired
  • Infectious
  • HSP
  • Mechanical
  • Psychogenic
  • Abuse

32
Evaluation of Purpura
33
Evaluation of Purpura
34
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35
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38
Henoch Schonlein Purpura
  • Clinical constellation and rash are diagnostics
  • Males 21 over age 2
  • May have low grade fever
  • Supportive therapy
  • Prednisone 2mg/kg/day
  • GI, CNS, Testicular Symptoms
  • Albustix at home for 3 months to look for renal
    involvement
  • Follow Up with PCP

39
Idiopathic Thrombocytopenic Puprpura
  • 1-4 weeks after a viral illness
  • Bruising and purpura
  • Mucous membrane (nose) bleeds
  • CNS hemorahges lt 1
  • No evidence of hematologic malignancy
  • Treatment
  • Expectant
  • Steroid
  • IVIG

40
Wrap -Up
  • Trust your clinical evaluation of the child with
    fever and petechiae
  • Laboratory test will not offer added information

41
Thank You for Your Attention
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