approach to child with purpura
DESCRIPTION
Approach to child with purpura. Ahmed S.Barefah KAAU,MBBS. Questions . What is the definition of purpuric rash? What are the causes of purpura ? How to approach such a case?. Definition . red, nonblanching maculopapular lesions caused by intradermal capillary bleeding. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/1.jpg)
Approach to child with purpura
Ahmed S.BarefahKAAU,MBBS
![Page 2: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/2.jpg)
Questions
• What is the definition of purpuric rash?
• What are the causes of purpura?
• How to approach such a case?
![Page 3: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/3.jpg)
Definition
• red, nonblanching maculopapular lesions caused by intradermal capillary bleeding.
• classified as o petechiae (pinpoint hemorrhages less than 2 mm in
greatest diameter),o purpura (2 mm to 1 cm) or o ecchymoses (more than 1 cm).
• results from the extravasation of blood from the vasculature into the skin or mucous membranes.
![Page 4: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/4.jpg)
![Page 5: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/5.jpg)
Causes
Pupura
Platelet Vascular
Function Count Congenital Acquired
![Page 6: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/6.jpg)
Thrombocytopenia
• may be caused by– increased platelet destruction• Immune• nonimmune
– decreased platelet production• Congenital• Acquired
– sequestration of platelets.
![Page 7: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/7.jpg)
Immune Thrombocytopenia
• Idiopathic (immune) thrombocytopenic purpura– by far the most common etiology of
thrombocytopenia in childhood.– caused by the development of IgG autoantibodies to
platelet membrane antigens as a result of an unbalanced response to an infectious agent or autoimmunity
– sudden onset of bruises, purpura, mucosal hemorrhage and petechiae in a child who is otherwise in excellent health.
![Page 8: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/8.jpg)
ITP
– antecedent viral infection is common. – The peak incidence is between two and four years
of age.– 80 to 90 percent of children recovering within six
to 12 months.– Chronic idiopathic thrombocytopenic purpura is
more likely to present in teenage girls and children with underlying immune disorders. It has a more insidious onset
![Page 9: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/9.jpg)
Immune Thrombocytopenia
• Drugs– penicillin, valproic acid (Depakene), quinidine,
sulfonamides, cimetidine (Tagamet) and heparin. • Post-transfusion purpura – acute onset of thrombocytopenia approximately
five to 14 days after a transfusion.• Rarely – HIV, CMV, HSV– 10% of SLE cases
![Page 10: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/10.jpg)
Immune Thrombocytopenia
• Neonatal isoimmune (alloimmune) thrombocytopenia
• Neonatal autoimmune thrombocytopenia
![Page 11: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/11.jpg)
Non-Immune Thrombocytopenia
• hemolytic-uremic syndrome– triad of microangiopathic hemolytic anemia,
thrombocytopenia and acute renal injury. – infection by verocytotoxin-producing Escherichia
coli• thrombotic thrombocytopenic purpura – occurs more often in adults, and neurologic
(rather than renal) symptoms are more prominent
![Page 12: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/12.jpg)
Non-Immune Thrombocytopenia
• disseminated intravascular coagulopathy– overwhelming sepsis, incompatible blood
transfusion, snake bite, giant hemangioma and malignancy.
• Purpura fulminans – acute, often lethal syndrome of DIC.– may develop because of a severe bacterial
infection, notably meningococcal disease, or because of protein C or S deficiency
![Page 13: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/13.jpg)
Decreased Platelet Production
• Congenital – Thrombocytopenia absent radii (TAR) syndrome • inherited as an autosomal recessive trait
– Fanconi anemia• pancytopenia, hyperpigmentation and café au lait
spots, short stature, skeletal abnormalities– Wiskott-Aldrich syndrome
![Page 14: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/14.jpg)
Decreased Platelet Production
• Acquired– Bone marrow suppression • Drugs such as alkylating agents, antimetabolites,
anticonvulsants, chlorothiazide diuretics and estrogens • Infection as viral and bacterial infections, especially
septicemia and Intrauterine infection with TORCH organisms
– Bone marrow infiltration• patients with leukemia, histiocytosis, storage diseases,
neuroblastoma, myelofibrosis and osteopetrosis
![Page 15: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/15.jpg)
Sequestration of Platelets
• Splenomegaly or giant hemangioma can result in thrombocytopenia because of platelet sequestration.
• The association of thrombocytopenia and giant hemangioma is referred to as Kasabach-Merritt syndrome.
![Page 16: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/16.jpg)
Platelet Dysfunction
• Glanzmann's thrombasthenia – autosomal recessive disorder caused by congenital
deficiency in the platelet membrane glycoproteins IIb and IIIa.
• Bernard-Soulier disease – autosomal recessive disorder caused by a
congenital deficiency in platelet membrane glycoprotein Ib
![Page 17: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/17.jpg)
Vascular Factors
• Congenital Causes – Hereditary hemorrhagic telangiectasia• autosomal dominant disorder• development of fragile telangiectasia of the skin and
mucous membranes– Ehlers-Danlos syndrome• characterized by skin hyperelasticity, joint
hypermobility and fragility of the skin and blood vessels
![Page 18: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/18.jpg)
Vascular Factors Acquired Causes
• Henoch-Schönlein purpura – IgA-mediated systemic vasculitis of small blood
vessels– nonthrombocytopenic purpura, abdominal pain,
arthritis and nephritis– the most common form of vasculitis in children– history of a preceding URTI – Characteristically palpable, gravity dependant
purpura
![Page 19: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/19.jpg)
Vascular Factors Acquired Causes
• Meningococcemia and rickettsial diseases may cause direct damage to blood vessels, with resultant purpura.
• Child abuse
![Page 20: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/20.jpg)
History
• Age of Onset • Birth Intrauterine infection, maternal idiopathic
thrombocytopenic purpura, maternal systemic lupus erythematosus, maternal medication, TAR syndrome, congenital amegakaryocytic thrombocytopenia
• 2 to 4 years Idiopathic thrombocytopenic purpura
• 4 to 7 years Henoch-Schönlein purpura
![Page 21: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/21.jpg)
History
• Onset/chronicity • Acute onset ITP, HSP, medication, mechanical
cause • Long duration Abnormality of platelets,
coagulopathy
![Page 22: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/22.jpg)
History
• Pattern of bleeding • Mucosal bleeding Thrombocytopenia, von
Willebrand's disease • Intramuscular and intra-articular bleeding
Hemophilia
![Page 23: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/23.jpg)
History
• Associated symptoms • Abdominal pain, blood in stools, joint pain HSP• Lethargy, fever, bone pain Leukemia • Intermittent fever, muscoskeletal symptoms SLE• Lethargy, polyuria, polydipsia, failure to thrive
Uremia • Purpura, but otherwise healthy ITP
![Page 24: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/24.jpg)
History
• Past health • Antecedent viral infection, especially an upper
respiratory tract infection ITP, HSP• Drug use• Family history• Maternal history• Social history
![Page 25: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/25.jpg)
Examination
• General findings • Poor growth Chronic disorder Fever
Hypertension Infection Chronic renal failure,renal vasculitis
![Page 26: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/26.jpg)
Examination
• Characteristics of purpura • Location on lower extremeties Henoch-
Schönlein purpura • Location on palms and soles Rickettsial
infection • Palpable purpura Vasculitis
![Page 27: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/27.jpg)
Laboratory Evaluation
• A thorough history and a careful physical examination are critical first steps in the evaluation of children with purpura.
![Page 28: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/28.jpg)
![Page 29: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/29.jpg)
RED FLAGS
Fever, lethargy, weight loss, bone pain,joint pain,pallor, Lymphadenopathy hepatosplenomegaly
![Page 30: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/30.jpg)
Summary
• Petechiae and purpura result from a wide variety of underlying disorders and may occur at any age
• red, nonblanching maculopapular lesions caused by intradermal capillary bleeding
• Classified into platelet or vascular causes• Idiopathic thrombocytopenic purpura is the most
common cause of thrombocytopenia in children.• Henoch-Schönlein purpura is the most common form of
vasculitis in children, and the purpuric rash is almost always palpable.
![Page 31: Approach to child with purpura](https://reader036.vdocuments.net/reader036/viewer/2022062315/5681649d550346895dd682b8/html5/thumbnails/31.jpg)
Thank you any question ;)