Purpura - Revision history

Danbot: Strip excess bold

2026-03-22T09:34:36Z

Strip excess bold

← Older revision		Revision as of 09:34, 22 March 2026
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	*Palpable purpura are a result of either perivascular inflammation (vasculitis) or infection		*Palpable purpura are a result of either perivascular inflammation (vasculitis) or infection
	*Non-palpable petechiae usually occur in low platelet states such as [[ITP]] and [[DIC]]		*Non-palpable petechiae usually occur in low platelet states such as [[ITP]] and [[DIC]]
	*Key EM distinction: ~~'''~~palpable~~'''~~ (vasculitis/infection) vs. ~~'''~~non-palpable~~'''~~ (thrombocytopenia/coagulopathy)		*Key EM distinction: palpable (vasculitis/infection) vs. non-palpable (thrombocytopenia/coagulopathy)
	*Fever + purpura in a child is ~~'''~~[[meningococcemia]] until proven otherwise~~'''~~ — requires emergent antibiotics		*Fever + purpura in a child is [[meningococcemia]] until proven otherwise — requires emergent antibiotics
	{{Rash red flags}}		{{Rash red flags}}

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	''Both petechiae and purpura do not blanch with pressure (distinguishing feature from erythema)''		''Both petechiae and purpura do not blanch with pressure (distinguishing feature from erythema)''
	*Purpura subdivided by size:		*Purpura subdivided by size:
	**<2mm of hemorrhage: ~~'''~~petechiae~~'''~~		**<2mm of hemorrhage: petechiae
	**>2mm of hemorrhage: ~~'''~~purpura~~'''~~		**>2mm of hemorrhage: purpura
	**Large areas: ~~'''~~ecchymoses~~'''~~		**Large areas: ecchymoses
	*~~'''~~Palpable purpura~~'''~~: raised, can be felt; indicates vasculitis or septic emboli		*Palpable purpura: raised, can be felt; indicates vasculitis or septic emboli
	*~~'''~~Non-palpable (flat) purpura~~'''~~: platelet disorder, coagulopathy, or fragile vessels		*Non-palpable (flat) purpura: platelet disorder, coagulopathy, or fragile vessels

	===Key Physical Exam Features===		===Key Physical Exam Features===
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	==Evaluation==		==Evaluation==
	===All Patients===		===All Patients===
	*[[CBC]] with platelet count — ~~'''~~most critical initial test~~'''~~		*[[CBC]] with platelet count — most critical initial test
	*Peripheral blood smear (schistocytes in TTP/HUS, blasts in leukemia)		*Peripheral blood smear (schistocytes in TTP/HUS, blasts in leukemia)
	*[[PT]]/[[INR]], [[PTT]] (coagulopathy assessment)		*[[PT]]/[[INR]], [[PTT]] (coagulopathy assessment)
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	===Emergent===		===Emergent===
	*'''Meningococcemia''': immediate IV [[ceftriaxone]] (do not delay for LP); fluid resuscitation		*'''Meningococcemia''': immediate IV [[ceftriaxone]] (do not delay for LP); fluid resuscitation
	*~~'''~~DIC~~'''~~: treat underlying cause; transfuse platelets, FFP, cryoprecipitate as needed		*DIC: treat underlying cause; transfuse platelets, FFP, cryoprecipitate as needed
	*'''TTP''': emergent hematology consultation for plasma exchange; do NOT transfuse platelets (can worsen)		*'''TTP''': emergent hematology consultation for plasma exchange; do NOT transfuse platelets (can worsen)
	*~~'''~~Severe thrombocytopenia (<10,000) with active bleeding~~'''~~: platelet transfusion		*Severe thrombocytopenia (<10,000) with active bleeding: platelet transfusion

	===Condition-Specific===		===Condition-Specific===
	*~~'''~~[[ITP]]~~'''~~: if bleeding or platelets <30,000: IV [[dexamethasone]], consider IVIG; hematology consultation		*[[ITP]]: if bleeding or platelets <30,000: IV [[dexamethasone]], consider IVIG; hematology consultation
	*~~'''~~[[Henoch-Schönlein purpura]] / IgA vasculitis~~'''~~: supportive care, NSAIDs for joint pain; monitor renal function		*[[Henoch-Schönlein purpura]] / IgA vasculitis: supportive care, NSAIDs for joint pain; monitor renal function
	*~~'''~~Drug-induced thrombocytopenia~~'''~~: discontinue offending agent, supportive care		*Drug-induced thrombocytopenia: discontinue offending agent, supportive care
	*~~'''~~[[HUS]]~~'''~~: supportive care, dialysis if needed; avoid antibiotics in typical (STEC) HUS		*[[HUS]]: supportive care, dialysis if needed; avoid antibiotics in typical (STEC) HUS
	*~~'''~~Vasculitis~~'''~~: rheumatology consultation, may require immunosuppression		*Vasculitis: rheumatology consultation, may require immunosuppression

	==Disposition==		==Disposition==

Danbot: Expanded with EM-focused content: palpable vs non-palpable distinction, red flags, TTP/DIC/meningococcemia management, evaluation strategy, disposition

2026-03-20T23:30:26Z

Expanded with EM-focused content: palpable vs non-palpable distinction, red flags, TTP/DIC/meningococcemia management, evaluation strategy, disposition

← Older revision		Revision as of 23:30, 20 March 2026
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	==Background==		==Background==
	{{Skin anatomy background images}}		{{Skin anatomy background images}}
	*Palpable ~~[[petechiae]] and~~ purpura are a result of either perivascular inflammation (vasculitis) or infection.		*Purpura results from extravasation of blood into the skin or mucous membranes
			*Palpable purpura are a result of either perivascular inflammation (vasculitis) or infection
	*Non-palpable petechiae usually occur in low platelet states such as [[ITP]] and [[DIC]]		*Non-palpable petechiae usually occur in low platelet states such as [[ITP]] and [[DIC]]
			*Key EM distinction: '''palpable''' (vasculitis/infection) vs. '''non-palpable''' (thrombocytopenia/coagulopathy)
			*Fever + purpura in a child is '''[[meningococcemia]] until proven otherwise''' — requires emergent antibiotics
	{{Rash red flags}}		{{Rash red flags}}

	==Clinical Features==		==Clinical Features==
	''Both ~~petechia~~ and purpura do not blanch''		''Both petechiae and purpura do not blanch with pressure (distinguishing feature from erythema)''
	*Purpura subdivided ~~into~~:		*Purpura subdivided by size:
	**<2mm of hemorrhage: petechiae		**<2mm of hemorrhage: '''petechiae'''
	**>2mm of hemorrhage: ecchymoses		**>2mm of hemorrhage: '''purpura'''
			**Large areas: '''ecchymoses'''
			*'''Palpable purpura''': raised, can be felt; indicates vasculitis or septic emboli
			*'''Non-palpable (flat) purpura''': platelet disorder, coagulopathy, or fragile vessels

			===Key Physical Exam Features===
			*Distribution: dependent areas (gravitational), generalized, or localized
			*Palpability: palpable vs. non-palpable
			*Associated findings: fever, arthralgia, abdominal pain, renal involvement (Henoch-Schönlein purpura / IgA vasculitis)
			*Mucosal involvement: oral petechiae, gingival bleeding (suggests severe thrombocytopenia)
			*Signs of systemic illness: hemodynamic instability, altered mental status
	{{Purpura rash images}}		{{Purpura rash images}}

			===Red Flags===
			*Fever + petechiae/purpura (meningococcemia, endocarditis, Rocky Mountain spotted fever)
			*Rapidly spreading purpura (DIC, purpura fulminans)
			*Platelets <10,000 (high risk of spontaneous bleeding)
			*Active hemorrhage from mucosal sites
			*Altered mental status with purpura (TTP — emergent plasma exchange)

	==Differential Diagnosis==		==Differential Diagnosis==
	{{Purpura DDX}}		{{Purpura DDX}}

	{{Purpura DDX by findings}}		{{Purpura DDX by findings}}

	==Evaluation==		==Evaluation==
	*For children with fever and petechiae/purpura consider using the Barts Health NHS Trust guideline for workup~~. This guideline~~ performed well ~~head to head vs other guidelines~~ in Petechiae in Children (PiC) study. <ref>Thomas et, al. Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet Infectious Diseases, 2020, https://doi.org/10.1016/S1473-3099(20)30474-6</ref> <ref>Tessa Davis. Petechiae in Children – the PiC Study, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.30782</ref>		===All Patients===
	[[File:Management of children with fever and non-blanching rash.png\|thumb\|Fever and non-blanching rash in children algorithm from Barts Health NHS Trust guideline. ~~Original image from https://dontforgetthebubbles.com/petechiae-in-children-study/~~]]		*[[CBC]] with platelet count — '''most critical initial test'''
			*Peripheral blood smear (schistocytes in TTP/HUS, blasts in leukemia)
			*[[PT]]/[[INR]], [[PTT]] (coagulopathy assessment)
			*[[BMP]] (renal function — assess for HUS, TTP)

			===If Thrombocytopenic===
			*Consider [[DIC]] panel: fibrinogen, D-dimer, fibrin degradation products
			*[[LDH]], haptoglobin, reticulocyte count if concern for TTP/HUS
			*Type and screen
			*Consider blood cultures, [[lactate]] if febrile

			===If Platelets Normal===
			*Evaluate for coagulopathy (PT/INR, PTT)
			*If palpable purpura: ESR, CRP, UA (renal involvement), complement levels (C3, C4)
			*Consider skin biopsy referral (vasculitis workup)
			*[[Blood cultures]], [[lactate]] if concern for septic emboli or endocarditis

			===Pediatric===
			*For children with fever and petechiae/purpura consider using the Barts Health NHS Trust guideline for workup, which performed well in the Petechiae in Children (PiC) study<ref>Thomas et al. Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet Infectious Diseases, 2020, https://doi.org/10.1016/S1473-3099(20)30474-6</ref><ref>Tessa Davis. Petechiae in Children – the PiC Study, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.30782</ref>
			[[File:Management of children with fever and non-blanching rash.png\|thumb\|Fever and non-blanching rash in children algorithm from Barts Health NHS Trust guideline.]]

	==Management==		==Management==
	*~~Management directed by~~ underlying ~~condition~~		===Emergent===
			*'''Meningococcemia''': immediate IV [[ceftriaxone]] (do not delay for LP); fluid resuscitation
			*'''DIC''': treat underlying cause; transfuse platelets, FFP, cryoprecipitate as needed
			*'''TTP''': emergent hematology consultation for plasma exchange; do NOT transfuse platelets (can worsen)
			*'''Severe thrombocytopenia (<10,000) with active bleeding''': platelet transfusion

			===Condition-Specific===
			*'''[[ITP]]''': if bleeding or platelets <30,000: IV [[dexamethasone]], consider IVIG; hematology consultation
			*'''[[Henoch-Schönlein purpura]] / IgA vasculitis''': supportive care, NSAIDs for joint pain; monitor renal function
			*'''Drug-induced thrombocytopenia''': discontinue offending agent, supportive care
			*'''[[HUS]]''': supportive care, dialysis if needed; avoid antibiotics in typical (STEC) HUS
			*'''Vasculitis''': rheumatology consultation, may require immunosuppression

	==Disposition==		==Disposition==
	*~~Depends on underlying etiology~~		===Admit===
			*Fever with petechiae/purpura and ill appearance
			*Suspected meningococcemia, TTP, HUS, DIC
			*Severe thrombocytopenia (<20,000) or active bleeding
			*New diagnosis requiring urgent workup (possible leukemia, aplastic anemia)
			*Hemodynamic instability

			===Discharge===
			*Well-appearing child with petechiae above the nipple line (mechanical cause — coughing, vomiting), normal CBC, and no fever
			*Known stable ITP with platelet count at baseline and no bleeding
			*Chronic/known vasculitis with mild flare — arrange outpatient follow-up
			*Return precautions: fever, spreading rash, bleeding, altered mental status, worsening symptoms

	==See Also==		==See Also==
	*[[General approach to rashes]]		*[[General approach to rashes]]
			*[[ITP]]
			*[[DIC]]
			*[[TTP]]
			*[[Henoch-Schönlein purpura]]
			*[[Meningococcemia]]

	==References==		==References==
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	[[Category:Dermatology]]		[[Category:Dermatology]]
	[[Category:Symptoms]]		[[Category:Symptoms]]
			[[Category:Hematology]]

Rossdonaldson1: /* Background */

2024-12-11T18:11:37Z

Background

← Older revision		Revision as of 18:11, 11 December 2024
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	==Background==		==Background==
			{{Skin anatomy background images}}
	*Palpable [[petechiae]] and purpura are a result of either perivascular inflammation (vasculitis) or infection.		*Palpable [[petechiae]] and purpura are a result of either perivascular inflammation (vasculitis) or infection.
	*Non-palpable petechiae usually occur in low platelet states such as [[ITP]] and [[DIC]]		*Non-palpable petechiae usually occur in low platelet states such as [[ITP]] and [[DIC]]

Rossdonaldson1: /* See Also */

2022-08-17T22:20:13Z

Rossdonaldson1 at 21:21, 26 November 2020

2020-11-26T21:21:59Z

← Older revision		Revision as of 21:21, 26 November 2020
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	**<2mm of hemorrhage: petechiae		**<2mm of hemorrhage: petechiae
	**>2mm of hemorrhage: ecchymoses		**>2mm of hemorrhage: ecchymoses

			{{Purpura rash images}}

	==Differential Diagnosis==		==Differential Diagnosis==
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	*For children with fever and petechiae/purpura consider using the Barts Health NHS Trust guideline for workup. This guideline performed well head to head vs other guidelines in Petechiae in Children (PiC) study. <ref>Thomas et, al. Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet Infectious Diseases, 2020, https://doi.org/10.1016/S1473-3099(20)30474-6</ref> <ref>Tessa Davis. Petechiae in Children – the PiC Study, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.30782</ref>		*For children with fever and petechiae/purpura consider using the Barts Health NHS Trust guideline for workup. This guideline performed well head to head vs other guidelines in Petechiae in Children (PiC) study. <ref>Thomas et, al. Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet Infectious Diseases, 2020, https://doi.org/10.1016/S1473-3099(20)30474-6</ref> <ref>Tessa Davis. Petechiae in Children – the PiC Study, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.30782</ref>
	[[File:Management of children with fever and non-blanching rash.png\|thumb\|Fever and non-blanching rash in children algorithm from Barts Health NHS Trust guideline. Original image from https://dontforgetthebubbles.com/petechiae-in-children-study/]]		[[File:Management of children with fever and non-blanching rash.png\|thumb\|Fever and non-blanching rash in children algorithm from Barts Health NHS Trust guideline. Original image from https://dontforgetthebubbles.com/petechiae-in-children-study/]]
	~~{{Purpura rash images}}~~

	==Management==		==Management==

Hoxbox: /* Evaluation */

2020-11-14T12:19:22Z

Evaluation

← Older revision		Revision as of 12:19, 14 November 2020
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	==Evaluation==		==Evaluation==
			*For children with fever and petechiae/purpura consider using the Barts Health NHS Trust guideline for workup. This guideline performed well head to head vs other guidelines in Petechiae in Children (PiC) study. <ref>Thomas et, al. Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet Infectious Diseases, 2020, https://doi.org/10.1016/S1473-3099(20)30474-6</ref> <ref>Tessa Davis. Petechiae in Children – the PiC Study, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.30782</ref>
			[[File:Management of children with fever and non-blanching rash.png\|thumb\|Fever and non-blanching rash in children algorithm from Barts Health NHS Trust guideline. Original image from https://dontforgetthebubbles.com/petechiae-in-children-study/]]
	{{Purpura rash images}}		{{Purpura rash images}}

Rossdonaldson1 at 22:54, 9 September 2020

2020-09-09T22:54:36Z

← Older revision		Revision as of 22:54, 9 September 2020
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	==Disposition==		==Disposition==
			*Depends on underlying etiology

	==See Also==		==See Also==

Rossdonaldson1 at 22:53, 9 September 2020

2020-09-09T22:53:41Z

@@ Line 10: / Line 10: @@
 **<2mm of hemorrhage: petechiae
 **>2mm of hemorrhage: ecchymoses
 ==Differential Diagnosis==

Rossdonaldson1: /* Purpural Rash */

2020-09-09T22:52:59Z

Purpural Rash

← Older revision		Revision as of 22:52, 9 September 2020
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	===[[Purpura]]l Rash===		===[[Purpura]]l Rash===
	<gallery mode="packed">		<gallery mode="packed">
	~~File:HSPVasc01.jpg\|Palpable purpura~~
	File:PetechiaeSkin.png\|Petechiae		File:PetechiaeSkin.png\|Petechiae
	File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]		File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]
	File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]		File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]
	File:HSPVasc01.jpg\|[[Henoch-schonlein purpura]]		File:HSPVasc01.jpg\|[[Henoch-schonlein purpura]] (Palpable purpura)
	File:Baby_purpura.png\|Neonatal [[purpura fulminans]]		File:Baby_purpura.png\|Neonatal [[purpura fulminans]]
	File:PurpuraFulminans.png\|[[Purpura fulminans]]		File:PurpuraFulminans.png\|[[Purpura fulminans]]

Rossdonaldson1: /* Purpural Rash */

2020-09-09T22:48:00Z

Purpural Rash

← Older revision		Revision as of 22:48, 9 September 2020
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	File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]		File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]
	File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]		File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]
			File:HSPVasc01.jpg\|[[Henoch-schonlein purpura]]
	File:Baby_purpura.png\|Neonatal [[purpura fulminans]]		File:Baby_purpura.png\|Neonatal [[purpura fulminans]]
	File:PurpuraFulminans.png\|[[Purpura fulminans]]		File:PurpuraFulminans.png\|[[Purpura fulminans]]

← Older revision		Revision as of 22:52, 9 September 2020
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	===[[Purpura]]l Rash===		===[[Purpura]]l Rash===
	<gallery mode="packed">		<gallery mode="packed">
	~~File:HSPVasc01.jpg\|Palpable purpura~~
	File:PetechiaeSkin.png\|Petechiae		File:PetechiaeSkin.png\|Petechiae
	File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]		File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]
	File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]		File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]
	File:HSPVasc01.jpg\|[[Henoch-schonlein purpura]]		File:HSPVasc01.jpg\|[[Henoch-schonlein purpura]] (Palpable purpura)
	File:Baby_purpura.png\|Neonatal [[purpura fulminans]]		File:Baby_purpura.png\|Neonatal [[purpura fulminans]]
	File:PurpuraFulminans.png\|[[Purpura fulminans]]		File:PurpuraFulminans.png\|[[Purpura fulminans]]

← Older revision		Revision as of 22:48, 9 September 2020
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	File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]		File:Rocky Mountain Spotted Fever Rash.jpg\|[[Rocky mountain spotted fever]]
	File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]		File:Henoch-schonlein-purpura.jpg\|[[Henoch-Schonlein purpura]]
			File:HSPVasc01.jpg\|[[Henoch-schonlein purpura]]
	File:Baby_purpura.png\|Neonatal [[purpura fulminans]]		File:Baby_purpura.png\|Neonatal [[purpura fulminans]]
	File:PurpuraFulminans.png\|[[Purpura fulminans]]		File:PurpuraFulminans.png\|[[Purpura fulminans]]

← Older revision		Revision as of 22:20, 17 August 2022
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	==See Also==		==See Also==
	*[[~~Rashes~~]]		*[[General approach to rashes]]

	==References==		==References==