II. Definitions

  1. General: Non-blanching cutaneous Hemorrhages
  2. Petechiae: Pinpoint Hemorrhages <2 mm in diameter
  3. Purpura: 2 to 10 mm in diameter
  4. Ecchymosis: >10 mm in diameter

III. Signs: Purpura

  1. Visible non-blanching Hemorrhages
    1. Compare with Contusions which are Traumatic non-blanching Hemorrhages
    2. Contrast with Vascular Skin Reaction which does blanch
  2. Occurs in the skin or mucus membranes
  3. Size: 2-10 mm in diameter (see definitions above)
  4. Characteristics
    1. Palpable Purpura suggests Vasculitis
  5. Distribution
    1. Petechiae on the head or neck
      1. Violent coughing (e.g. Pertussis), Vomiting or strangulation
    2. Purpura on Lower extremities (gravity dependent)
      1. Henoch-Schonlein Purpura
    3. Purpura on palms and soles
      1. Rickettsial infection

IV. Signs: Associated Conditions

  1. See Purpura Causes
  2. See Thrombocytopenia
  3. Fever and ill appearing or signs of toxicity
    1. Meningococcemia or Meningitis
    2. Pneumococcal Pneumonia
    3. Sepsis with Disseminated Intravascular Coagulation (DIC)
    4. Rocky Mountain Spotted Fever
  4. Fever without signs of toxicity
    1. Mononucleosis (EBV)
    2. Adenovirus
    3. Pertussis
    4. Streptococcal Pharyngitis
      1. Also most common cause of Henoch-Schonlein Purpura
  5. Preceding viral illness
    1. Idiopathic Thrombocytopenic Purpura
  6. Hepatosplenomegaly and Lymphadenopathy
    1. Malignancy (e.g. Leukemia)
    2. Mononucleosis (EBV)
  7. Hypertension
    1. Chronic Renal Failure
    2. Renal Vasculitis
    3. Hemolytic Uremic Syndrome
  8. Hemarthrosis
    1. Hemophilia
    2. Von Willebrand Disease
  9. Arthralgias
    1. Henoch-Schonlein Purpura
    2. Rheumatologic causes (esp with eye symptoms)
  10. Skeletal abnormalities
    1. Thrombocytopenia-absent radii (TAR syndrome)
    2. Fanconi's Anemia (Short Stature)
  11. Skin hyperelasticity and joint hypermobility
    1. Ehlers-Danlos Syndrome
  12. Telangiectases
    1. Hereditary Hemorrhagic Telangiectasia
    2. Liver disease

V. Labs: General

  1. Initial Tests
    1. Complete Blood Count with Platelet Count
    2. Peripheral Smear
    3. Coagulation tests (INR, PTT)
    4. Urinalysis with microscopic exam
  2. Tests to consider
    1. Comprehensive Metabolic Panel
    2. Blood Cultures (fever, ill appearance and Petechiae/Purpura)
    3. Streptococcal Test
    4. Monospot (EBV titer in age <5 years old, Monospot inaccurate in that group)

VII. Labs: Platelet Count and Indices

VIII. Labs: Urinalysis with Hematuria or Proteinuria

IX. Causes

X. Approach: Children (older protocol)

  1. Step 1 (non-bleeding cause)
    1. If unable to identify cause, go to step 2 below
    2. Identify potential cause based on history and exam
      1. See Purpura Causes
      2. See Signs above
  2. Step 2 (bleeding cause)
    1. Obtain Bleeding Disorder lab-work
      1. Complete Blood Count (CBC) with Platelet Count
      2. Peripheral Blood Smear
      3. ProTime
      4. Activated Partial Thromboplastin Time (aPTT)
    2. Evaluate Platelet Count
      1. Platelet Count low: Go to Step 3a below
      2. Platelet Count normal: Go to Step 3b below
  3. Step 3a (Low Platelet Count)
    1. See Thrombocytopenia
    2. Prothrombin Time and aPTT prolonged
      1. Sepsis
      2. Disseminated Intravascular Coagulopathy
    3. Prothrombin Time and aPTT not prolonged
      1. Idiopathic Thrombocytopenic Purpura
      2. Hemolytic-Uremic Syndrome
      3. Thrombotic Thrombocytopenic Purpura
      4. Systemic Lupus Erythematosus
      5. Bone Marrow aplasia
      6. Platelet Sequestration
  4. Step 3b (Normal Platelet Count)
    1. Prothrombin Time and aPTT prolonged
      1. Coagulation Factor deficiency
      2. Von Willebrand's Disease
      3. Circulating Anticoagulant
      4. Liver disease
    2. Prothrombin Time and aPTT not prolonged
      1. Go to Step 4 below
  5. Step 4 (Bleeding Time)
    1. Obtain Bleeding Time
    2. Bleeding Time prolonged
      1. See Platelet Dysfunction
      2. Von Willebrand's Disease
    3. Bleeding Time normal
      1. Child Abuse (Nonaccidental Trauma)
      2. Von Willebrand's Disease
      3. Vascular Purpura

XI. Disposition

  1. See Thrombocytopenia for hospitalization indications related to Low Platelets
  2. Admit or observe febrile or ill appearing patients with Petechiae or Purpura if no clear cause
  3. Well-appearing, afebrile infants with isolated, localized Petechiae and normal history exam are unlikely to have serious illness
    1. Lee (2012) Pediatric Emerg Care 28(6): 503-5 +PMID: 22653463 [PubMed]

XII. Precautions: Patients with bleeding tendency

  1. See Thrombocytopenia for activity and procedure limitations based on Platelet Count
  2. Caution with fever or ill appearing patients
    1. Consider Meningococcus, Pneumococcus, DIC, Rocky Mountain Spotted Fever
    2. Consider HSP, TTP, HUS
  3. Caution with strenuous activity or Contact Sport
  4. Caution with Intramuscular Injections
  5. Avoid Aspirin and NSAIDs

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Ontology: Ecchymosis (C0013491)

Definition (NCI_NCI-GLOSS) A small bruise caused by blood leaking from broken blood vessels into the tissues of the skin or mucous membranes.
Definition (MSH) Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia.
Concepts Pathologic Function (T046)
MSH D004438
SnomedCT 77643000, 302227002
LNC LA7430-7
Spanish EQUIMOSIS, Equimosis NEOM, equimosis (anomalía morfológica), equimosis (hallazgo), equimosis, Equimosis
Dutch ecchymosen, ecchymose NAO, ecchymose, Ecchymose
French Ecchymoses, Ecchymose SAI, MEURTRISSURES ECCHYMOTIQUES, Ecchymose, Bleu
German Ekchymose NNB, Ekchymosen, EKCHYMOSIS, Ekchymose
Italian Ecchimosi NAS, Macchie emorragiche, Ecchimosi
Portuguese Equimose NE, Equimoses, EQUIMOSES, Equimose
Japanese 斑状出血NOS, 斑状出血, ハンジョウシュッケツ, ハンジョウシュッケツNOS
Swedish Blodutgjutning
Czech ekchymóza, Ekchymóza, Ekchymózy, Ekchymóza NOS
Finnish Mustelma
Russian EKKHIMOZ, ЭКХИМОЗ
English ecchymosis, ecchymosis (physical finding), Ecchymosis NOS, Ecchymosis [Disease/Finding], ecchymoses, ECCHYMOSIS, Ecchymoses, Ecchymosis (finding), Ecchymosis (morphologic abnormality), Ecchymosis
Polish Siniaki, Wybroczyny krwawe
Hungarian Ecchymosis k.m.n., Ecchymosis, Ecchymosisok
Norwegian Blodansamling, Ekkymose

Ontology: Petechiae (C0031256)

Definition (MSH) Pinhead size (3 mm) skin discolorization due to hemorrhage.
Definition (CHV) Pinpoint, flat, round red spots under the skin caused by bleeding
Definition (CHV) Pinpoint, flat, round red spots under the skin caused by bleeding
Definition (CHV) Pinpoint, flat, round red spots under the skin caused by bleeding
Definition (CHV) Pinpoint, flat, round red spots under the skin caused by bleeding
Definition (SNOMEDCT_US) A group of small reddish or purplish spots in skin or mucous membrane as a result of localized hemorrhage.
Definition (SCTSPA) Grupo de pequeños puntos rojizos o morados en la piel o las membranas mucosas como resultado de una hemorragia localizada.
Definition (NCI_NCI-GLOSS) Pinpoint, unraised, round red spots under the skin caused by bleeding.
Definition (NCI) Purple or red hemorrhagic pinpoint spots in the skin or mucous membranes.
Concepts Disease or Syndrome (T047)
MSH D011693
ICD10 R23.3
SnomedCT 206906004, 271813007, 141618008, 164431004, 158259006, 50091001
English PETECHIAE, RASH PETECHIAL, [D]Petechiae, [D]Petechiae (context-dependent category), Petechiae (finding), Petechiae (disorder), petechial hemorrhages, petechial hemorrhages (___cm), petechial hemorrhages (physical finding), petechiae (diagnosis), petechiae, Rash petechial, petechial rash, petechial hemorrhage, [D]Petechiae (situation), Petechia, Petechial hemorrhage, Petechial haemorrhage, Petechial eruption, Petechial rash, Petechia (morphologic abnormality), petechia, Petechiae, hemorrhage; petechial, petechial; hemorrhage
Dutch petechiën rash, petechie, rash met petechiën, petechiae, bloeding; petechiaal, petechiaal; bloeding, Petechiae
French Rash pétéchial, Pétéchies, ERUPTION PETECHIQUE, PETECHIES, Pétéchie
German Petechie, Ausschlag petechienartig, petechienartiger Ausschlag, Petechien, AUSSCHLAG PETECHIAL, PETECHIEN
Italian Petecchia, Esantema petecchiale, Eruzione petecchiale, Petecchie
Portuguese Petéquia, Exantema petequial, Erupção petequial, Petequia, ERUPCAO DE PETEQUIAS, PETEQUIAS, Petéquias
Spanish Erupción petequial, [D]petequias (categoría dependiente del contexto), petequias (trastorno), petequias (hallazgo), Petequia, ERUPCION PETEQUIAL, PETEQUIAS, [D]petequias (situación), [D]petequias, erupción petequial, hemorragia petequial, petequia (anomalía morfológica), petequias, petequia, Petequias
Japanese 点状出血, 点状出血性皮疹, テンジョウシュッケツセイヒシン, テンジョウシュッケツ
Czech Petechie, Vyrážka charakteru petechií, petechie
Hungarian Petechiák, Petechia, Petechiás kiütés, petechiás exanthema
Norwegian Petekkier

Ontology: Purpura (C0034150)

Definition (MSH) Purplish or brownish red discoloration, easily visible through the epidermis, caused by hemorrhage into the tissues. When the size of the discolorization is >2-3 cm it is generally called Ecchymoses (ECCHYMOSIS).
Definition (NCI) A small blood vessel hemorrhage into the skin and/or mucous membranes. Newer lesions appear reddish in color. Older lesions are usually a darker purple color and eventually become a brownish-yellow color.
Definition (NCI_CTCAE) A disorder characterized by hemorrhagic areas of the skin and mucous membrane. Newer lesions appear reddish in color. Older lesions are usually a darker purple color and eventually become a brownish-yellow color.
Definition (CSP) small hemorrhage in the skin, mucous membrane or serosal surface, or a group of hemorrhagic diseases characterized by purpuric lesions.
Concepts Disease or Syndrome (T047)
MSH D011693
ICD10 D69.2
SnomedCT 423902002, 118653003, 267564008, 246989006, 154822006, 191313005, 12393003, 387778001
English Purpuras, PURPURA, Purpura (finding), purpura, purpura (physical finding), purpura was seen, purpura (diagnosis), Purpura NOS, Purpura [Disease/Finding], purpuras, skin purpura, purpura skin, Purpura (disorder), Purpura of skin, Peliosis, Disorder characterised by purpura, Disorder characterized by purpura, Purpura (morphologic abnormality), Purpuric disorder (disorder), Purpuric disorder, peliosis, Peliosis, NOS, Purpura, NOS, Purpura
French PURPURA, Purpura SAI, Péliose, Purpura
Portuguese PURPURA, Peliose, Púrpura NE, Púrpura
Spanish PURPURA, Peliosis, Púrpura NEOM, púrpura (hallazgo), trastorno purpúrico, trastorno caracterizado por púrpura, enfermedad purpúrica (trastorno), enfermedad purpúrica, peliosis, púrpura (anomalía morfológica), púrpura, Purpura, Púrpura
German PURPURA, Peliosis, Purpura NNB, Purpura
Dutch purpura NAO, peliose, purpura, Purpura
Italian Peliosi, Porpora NAS, Porpora
Japanese 紫斑病, 紫斑NOS, 紫斑, シハンNOS, シハンビョウ, シハン
Swedish Hudblödning
Czech purpura, Purpura, Purpura NOS, Pelióza
Finnish Purppura
Russian PURPURA, PETEKHII, ПЕТЕХИИ, ПУРПУРА
Croatian Not Translated[Purpura]
Polish Plamica
Hungarian Purpura, Purpura k.m.n., Peliosis
Norwegian Punktblødninger i huden, Purpura

Ontology: Purpuric rash (C0151882)

Concepts Disease or Syndrome (T047)
SnomedCT 284078000
English RASH PURPURIC, Purpuric rashes, Rash purpitic, Rash purpuric, purpuric rash, Purpuric rash (disorder), Purpuric rash
Dutch purpura
French Rash purpurique, Rash purpitique, ERUPTION PURPURIQUE
German Purpuraauschlag, Purpuraausschlag, AUSSCHLAG HAEMORRHAGISCH
Italian Esantema purpureo
Portuguese Exantema purpúrico, Erupção purpúrica, ERUPCAO PURPURICA
Spanish Erupción purpúrica, ERUPCION PURPURICA, erupción purpúrica (trastorno), erupción purpúrica
Japanese 紫斑性皮疹, シハンセイヒシン
Czech Purpura
Hungarian exanthema purpurás, Kiütés purpurás, Purpurás kiütés