differentiating dtpi from other causes of purpura in the

Differentiating DTPI From Other Causes of Purpura in the Sacrococcygeal Area Susan Solmos, MSN, RN, CWCN

Conflict of Interests

• None to declare

• Any images of products in clinical photos reflect the formulary in use at the time of

WOC consult and are not an endorsement of the product(s)

2

Objectives

• Compare and contrast the overlap and differentiators between purpura and DTPI

• Describe key factors to consider when determining the etiology of a sacrococcygeal lesion

• Identify three potential differential diagnoses when pressure injury is excluded

• Explain when dermatology/dermatopathology is warranted

3 Differentiating DTPI|

Acknowledgements


University of Chicago WOC Team - Maggie Mae Baenziger, BSN, RN, CWOCN - Martha Branstiter, BSN, RN, CWOCN - Kathleen Hudson, BSN, RN, CWOCN - Laura Williamson, BSN, RN, CWON - Janice Colwell, RN,MS,CWOCN,FAAN - Michele Kaplon-Jones, MSN, RN, ANP-BC, CWOCN, CFCN

- Paulina Petrishka, MSN,RN, AGPCNP-BC

- Gina Alessia, BSN, APRN-CNS, CWCN - Eric Goodman, BSN, RN, CWOCN, CFCN, CFCS

Background/Importance

• 2016: NPUAP revised Pressure Injury Staging System

– Guidance provided on differential diagnosis of

DTPI, advised against identifying vascular,

traumatic, neuropathic, or dermatologic

conditions as DTPI

• Implications of mislabeling as DTPI:

– Adversely impact benchmarks

– Financial implications

– Ineffective management of lesion/underlying

etiology

– Legal implications


Differential Diagnosis

• Consider: location, shape, characteristics and mechanism of insult

Deep Tissue Pressure Injury (DTPI)

• Exposure to intense or prolonged pressure?


Images are copyrighted and the property of their respective owners and may not be used without

permission

Differential Diagnosis: Sacrococcygeal Lesions


• If pressure injury unlikely, differentials for DTPI include:

– Bruising

– Hematoma/Morel-Lavallee lesions

– Kennedy terminal ulcer

– Dermatologic conditions

• DIC

• Vasculitis

– Necrotizing fasciitis

– Calciphylaxis

– Coumadin necrosis

• Use of assessment aids for patients with dark skin tones


Purpose

• Describe patients with atypical features where DTPI was ruled out

– Dermatology consult with dermatopathology useful

• IRB approval obtained from the University of Chicago IRB (IRB17-0457)


Setting


• 811 bed, Magnet designated urban academic medical center • Adult and pediatric level 1 trauma center

Interventions


HAPI Prevention Interventions Medical-Surgical Units Intensive Care Units

Skin assessment every shift Yes Yes

Differentiate pressure injury from other wounds

and IAD/ITD

Yes Yes

Braden Scale every shift Yes Yes

Evidence-based interventions aligned to Braden

Subscale score

Yes Yes

Active support surface If indicated Standard

Reactive support surface Standard N/A

Microshifts If indicated For hemodynamic instability

Sacral silicone dressing If indicated Standard

Heel boots If indicated Standard

Ratliff CR, Tomaselli N. WOCN Guideline for Prevention and Management of Pressure Ulcers. Vol 2. Mount Laurel, NJ: Wound Ostomy and Continence Nurses Society; 2010. Cuddigan J, National

Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel;

2009. Berlowitz D, Van Duesen Lukas C, Parker V, et al. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Agency for Healthcare Research and Quality (AHRQ), U.S.

Department of Health and Human Services; 2014. https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/index.html. Walsh NS, Blanck AW, Smith L, Cross M, Andersson L, Polito C.

Use of a Sacral Silicone Border Foam Dressing as One Component of a Pressure Ulcer Prevention Program in an Intensive Care Unit Setting: J Wound Ostomy Continence Nurs. 2012;39(2):146-149.

doi:10.1097/WON.0b013e3182435579 Braden BJ. The Braden Scale for predicting pressure sore risk: reflections after 25 years. Advances in Skin & Wound Care. 2012;25(2):61.

http://search.ebscohost.com.proxy.uchicago.edu/login.aspx?direct=true&db=rzh&AN=108155805&site=ehost-live&scope=site. Accessed October 4, 2019.

https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/index.html

Morphological Terms Used to Describe Skin Lesions


Term Description

Macule flat, non-palpable <1 cm in diameter

Papule elevated, palpable < 1 cm in diameter

Patch flat non-palpable >1 cm in diameter

Plaque raised skin lesion >1 cm in diameter

Vesicle raised, fluid-filled skin lesion <1 cm

Bulla raised, fluid-filled skin lesion >1 cm

Purpura visible hemorrhage into the skin, appears purple and is non-blanching upon

application of external pressure

Petechia <3 mm flat purpuric macules, pin-point foci of hemorrhage into the skin

Ecchymosis flat purpuric patch

Palpable purpura raised purpuric plaque (in contrast to ecchymosis or simple bruise)

Retiform purpura reticulated (net-like), branching or stellate (star-like) purpuric patch or plaque

Rapini R. Clinical and pathologic differential diagnosis. In: Bolognia JL, Jorizzo JL,Schaffer JV, eds. Dermatology. 3rd ed. Elsevier Saunders; 2012:1-22.

Case 1: Vascular Disorder as Differential for DTPI

• 40-year-old female

• Admit to medical surgical unit

– Ischemic changes of lower extremity

– Connective tissue disorder

– Diabetes

– Advanced stage chronic kidney disease

• Clinical course complicated by gangrene of toe, leading to sepsis and amputation

• WOC consult received for multiple “quarter-sized deep purple lesions on sacrococcygeal area”


Case 1: Initial Consult

• CWCN observes multiple, large, dark purple plaques with jagged and stellate borders involving sacrococcygeal area, buttocks, lower back, and posterior thighs (not photographed)

• CWCN observed patient on deflated active support surface during transport mattress 4 days prior

– Episode of intense pressure identified in patient with known comorbidities, presumed to be DTPI with irregular distribution pattern


Case 1: Follow Up Consult Day 12

• Plaques progressed to hard leathery eschar

• Presumed to be evolving DTPI

• Treated conservatively due to extent of lesions and guarded clinical prognosis



permission

plaques progressed to eschar purpura with jagged, stellate borders

Case 1: Follow Up Consult Day 14

• Transferred to ICU due to deteriorating condition

• New retiform purpura noted, no episodes of intense pressure

• Due to similar appearance, all lesions now considered not to be DTPI

• Intensely painful

• Dermatology consult for presumed calciphylaxis


Images are copyrighted and the property of their respective owners and may not be used without permission

retiform purpura intensely painful with palpation

retiform purpura over sites not exposed to pressure

Case 1: Dermatology Impressions

• Dermatology differentials included:

– Calciphylaxis

– Vasculitis

– Deep fungal infection

– Purpura fulminans

• Biopsy obtained for dermatopathology with bacterial and fungal cultures

• Results: thrombo-occlusive vasculopathy (microvascular occlusion by thrombi)

– No microorganisms

– Further coagulation evaluation identifies antiphospholipid syndrome

– Treated conservatively due to underlying conditions, poor prognosis and uncertainty of outcome

– Expired during hospitalization



eschar with irregular edges, new areas of retiform purpura, intensely painful with palpation

Thrombo-occlusive Vasculopathy

• Thought to be caused by microvascular occlusion

– due to platelet or cellular plugs (erythrocytes, leukocytes or cancer cells), cold-related gelling, vessel-invasive organisms, coagulation abnormalities (due to sepsis, congenital or acquired protein C or S deficiency, warfarin-induced skin necrosis, anti-phospholipid syndrome)

• Morphology

– non-inflammatory purpura

• Leads to intravascular coagulation, embolization or crystal deposition and calciphylaxis



Case 2: Systemic Infectious Process as Differential to DTPI

• 60-year-old female admitted to ICU

– Abdominal pain and weakness concerning for diverticulosis

– Comorbid conditions included immunosupression, chronic kidney disease, poor nutritional status and diabetes mellitus

– Skin intact on admission

– Clinical course complicated by multiple thrombi requiring heparin therapy; however, heparin induced thrombocytopenia and neutropenia occurred, agatroban initiated


Case 2: Initial Consult (Day 1)

• Sitting in bed, oxygen via nasal cannula, independent in repositioning

• LOS ~35 days

• Unable to identify pressure as precipitating event

• CWCN determined DTPI unlikely, differentials included heparin necrosis

• Dermatology consult requested



single large dark purple hemorrhaghic bulla, purpuric lesions less evident and noted to buttocks, intergluteal cleft

Case 2: Dermatology Impressions (Day 5)

• Dermatology obtained biopsy, differentials included:

– bullous fixed drug eruption

– bullous hemorrhagic dermatosis

– heparin necrosis

– herpes simplex virus

• Results: leukocytoclastic vasculitis with numerous gram-negative and gram-positive bacteria, blood culture positive for P aeruginosa

• Diagnosis of septic vasculitis



new large dark purple hemorrhagic bullae, new areas of necrosis

initial bullae necrosed,

suture evident

Case 2 (Day 10)

• Patient’s condition continued to deteriorate, ventilator and vasopressors required

• Purpura and bullae continue to develop and necrose

• Condition continued to decline despite aggressive measures, transitioned to palliative care within ICU and expired

21 Presentation Title Here |


Septic Vasculitis

• Caused by occlusion of blood vessels by growing organisms

• Morphology

– Usually manifests as retiform purpura or non-inflammatory tissue necrosis

– Lesions can be initially erythematous, but typically progress to purpura or eschars, which may be bullous or pustular

• Frequently occurs in patients who are immunosuppressed, may also occur with chronic disease or malnutrition

• Can be caused by Gram-negative bacteria (such as Pseudomonas aeruginosa) or Gram-positive bacteria (such as Staphylococcus aureus), as well as angioinvasive fungi

– Immediate antibiotic therapy is crucial, although prognosis is usually poor



Case 3: Systemic Infectious Process as Differential to DTPI

• 50+-year-old male admitted to ICU

– in septic shock from gram-negative bacteremia

– Sedated and intubated/ mechanically ventilated for respiratory failure and required maximum vasopressor support

– past medical history of chronic kidney disease, hypertension and diabetes


Case 3: Initial CWCN Consult

• Anasarca, grossly edematous scrotum with weeping erosions

• Penis edematous with dusky, tense, fluid-filled bullae

• Ischemic changes to distal extremities

– Presumed vasopressor induced ischemic injuries

• Skin otherwise intact, full prevention interventions in place consistent with ICU level of care



Case 3: (Day 6) • Clinical condition: now with multi-organ failure and DIC

• Gray bullae with purpura evident beneath over sacrum

• Retiform purpura over knees, lips, scalp and forehead

• CWCN determined lesions inconsistent with pressure injury in appearance or location

• Dermatology consult, biopsy deferred (DIC)

– presumptive diagnosis of purpura fulminans in setting of septic shock, DIC and vasopressor use

–



Gray-roofed bullae, purpura beneath retiform purpura retiform purpura retiform purpura to eschar

Purpura Fulminans

• Term reserved for extensive and severe purpuric lesions

• Usually secondary to warfarin skin necrosis, sepsis-induced DIC, post-infectious purpura

and homozygous defects in anti-coagulant protein C and S

• Morphology

– Initial appearance: well-demarcated erythematous macules that progress rapidly to develop irregular central areas of blue–black hemorrhagic necrosis

– Hemorrhage into the necrotic dermis causes lesions to become painful, dark and raised, sometimes with vesicle or bulla formation

– Often progress within 24–48 hours to full-thickness skin necrosis or more extensive soft-tissue necrosis

• This patient was in septic shock, requiring multiple vasopressors in the setting of bacteremia, contributing to the multifocal appearance of purpuric lesions



Differential Diagnosis: Sacrococcygeal Lesions


• If pressure injury unlikely, differentials for DTPI include:

– Bruising

– Hematoma/Morel-Lavallee lesions

– Kennedy terminal ulcer

– Dermatologic conditions

• DIC

• Vasculitis

– Necrotizing fasciitis

– Calciphylaxis

– Coumadin necrosis


Additional Cases

28

Case 4: Hematoma as Differential for DTPI

• 50+-year-old female

29 Differentiating DTPI |

Case 4: Hematoma as Differential for DTPI

• WOC consult received 5 days after admit for presumed DTPI

• Had been in multiple procedures and multiple surgeries, DTPI in differentials

• Care withdrawn during hospitalization



Hematoma as Differential for DTPI

• 55+-year-old motorcycle versus car



Hematoma as Differential for DTPI



Day 4

Day 8

Day 22

Hematoma/Morel-Lavallee Lesions

• Secondary to trauma

• Deep bruises or injury lead to deep or superficial hematoma

– Internal pressure causes ischemia

• May be palpable

• May be evident on CT scan


Black JM, Brindle CT, Honaker JS. Differential diagnosis of suspected deep tissue injury: Differential diagnosis of suspected deep tissue injury. Int Wound J. 2016;13(4):531-539. doi:10.1111/iwj.12471

Case 6: Necrotizing Fasciitis/Fournier’s Gangrene as Differential for DTPI

• 55+-year-old male

• 1 week ago, felt weak all over, got into bed, and hasn't gotten out of bed since

• Bed soiled with urine/feces

• Family called EMS

• Admit with positive sepsis screen, positive UA, blood and urine cultures pending

• Seen on consult in ICU for pressure injury

– WBC 26.5*, RBC 4.73, Hemoglobin 13.4*, Hematocrit 39.2*

– Total CK 714*, C-Reactive protein 140*



Necrotizing Fasciitis/Fournier’s Gangrene as Differential for DTPI

• Sedated, intubated

• Responds to palpation with

withdrawal (to pain)

• Foul odor


deep purple with necrosis, without flash, edema evident

induration and crepitus, foul, brown and watery exudate


violet hue evident with flash perinuem boggy

vesicles lateral thigh

Necrotizing Fasciitis/Fournier’s Gangrene as Differential for DTPI

• Emergently to OR with general surgery and urology

• Tissue culture (Positive)

– >1,000,000 CFU/gram of tissue Candida albicans

– 70,000 CFU/gram of tissue Enterococcus faecium

• Resistant to vancomycin and ampicillin

• No anaerobic bacterial growth

• Treated for sepsis, multiple serial debridements, ultimately discharged to LTAC with plans for subsequent plastic surgery


saturating gauze before first post-op removal


Necrotizing Fasciitis

• Rapidly progressive infection of the fascia

• Diabetes a common comorbidity

• Severe pain, often septic

• Morphology

– Skin may appear pale, quickly becomes red or bronze

– May be warm or swollen

– Next, skin appears violet may have blisters

– Induration, fluctuance and crepitus common

– Necrosis/gangrene present

• Fournier’s gangrene is a necrotizing infection of the fascia


Black JM, Brindle CT, Honaker JS. Differential diagnosis of suspected deep tissue injury: Differential diagnosis of suspected deep tissue injury. Int Wound J. 2016;13(4):531-539. doi:10.1111/iwj.12471 Wong C, Chang H, Pasupathy S, Khin L, Tan J, Low C et al. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. The Journal of Bone and Joint Surgery. 2004; 86(4): 869-870.

Case 7: Calciphylaxis as Differential for DTPI

• Admitted from nursing home after a fall

• History of CVA (L sided weakness), ESRD, CHF,

cachexia

• Exam limited by severe pain

• Calcium, phosphate WNL

• PTH grossly elevated >600 (ref 15-75 pg/mL)

• Buttocks, thighs with reticulated purpura, extreme

pain with palpation



permission

stellate purpura and necrosis

without flash

Case 7: Calciphylaxis as Differential for DTPI (Day 7 & 13)



purpura progressed to eschar (day 7) view 2 (day 7), new areas of purpura

continues to develop stellate purpura (day 13)

Calciphylaxis

• Progressive calcification of cutaneous blood vessels

– Chronic renal failure most frequently implicated

– Diabetes, obesity implicated as well

– Elevated calcium, phosphate and PTH common

• Morphology

– Areas of leather-like induration with superimposed erythrematous nodules, plaques

or livedo reticularis (net-like erythema or reticulated purpura)

– Pruritus and intense pain present

– Progress to necrosis

– Common in areas of fat deposition

NOTE: in patients with dark skin tones livedo reticularis may appear as dark brown or

violaceous patches


Black JM, Brindle CT, Honaker JS. Differential diagnosis of suspected deep tissue injury: Differential diagnosis of suspected deep tissue injury. Int Wound J. 2016;13(4):531-539. doi:10.1111/iwj.12471 Craft N and Fox, LP (eds). VisualDx: Essential Adult DEematolgy

Case 8: Herpetic Lesions as Differential for DTPI

• Cluster of painful lesions on erythematous base, scalloped edges

• Presumed disseminated HSV in setting of immune compromise, swab obtained

– HSV2



painful erosions on erythematous base, scalloped edges

Herpes Simplex Virus- HSV 2

• 21% of patients with primary genital herpes develop non-genital involvement

• Morphology

– Vesicles (may be hemorrhagic), pustules or erosions on an erythematous base

– Scalloped edges common (group of vesicles erode)

– sites most often affected are the lumbosacral area and legs

– pudendal nerve (which innervates the external genitalia) originates from the sacral nerve ganglia of S2-4


Vassantachart JM, Menter A. Recurrent lumbosacral herpes simplex virus infection. Baylor University Medical Center Proceedings. 2016;29(1):48-49. doi:10.1080/08998280.2016.11929356

Documentation Tips

• Describe lesion(s)

• Identify if episode of intense/prolonged pressure present (or absent!)

• Identify differentials

• Referrals/recommendations (depending on care setting and goals of care)

• “Lesion inconsistent with pressure injury in appearance or location, no episode of intense or prolonged pressure identified.”


Summary

1) DTPI and purpura in the setting of vascular disorders and systemic infectious processes can have morphological overlap that confounds diagnosis

2) Suspected DTPI with an uncharacteristic shape and/or the presence of additional lesions distributed outside of typical pressure areas should prompt further evaluation

3) An interdisciplinary approach may be useful in determining the cause of purpura when DTPI is ruled out by the CWCN

– Also review labs, imaging etc


Questions?


differentiating dtpi from other causes of purpura in the

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