You are the GP in a small rural town. Sienna McKenzie, is 3 years old, her mother rang you in a panic this morning because Sienna has developed a rash "which looks like bruises" over her legs, she has been a little unwell the last 2 days with a mild fever and coryzal symptoms.
You advised to take her straight to the ED and you would meet her there.
Purpuric rashes can be associated with life-threatening diseases. An unwell, febrile child with purpura should be treated for meningococcal septicaemia without waiting for the results of investigations. Septicaemia from other organisms such as haemophilus influenza, streptococci, staphylococci and some gram-negative organism can cause purpura.
Purpuric and petechial (pinpoint purpura) are non-blanching (test with a glass) red/purple spots. Can be caused by infection (eg severe life threatening such as meningococcal or enteroviral), Henoch-Schonlein purpura and thrombocytopenia.
| History | Examination |
|---|---|
|
Fever Poor feeding Miserable Lethargy History of focal infection eg Meningitis, osteomyelitis Gastroenteritis, cellulitis Predisposing conditions eg. sickle cell disease, Immunodeficiency |
Fever Purpuric rash (meningococcal septicaemia) Irritability Shock Multi-organ failure |
Intravenous antibiotics /ideally after taking blood cultures/penicillin G 60mg/kg i.v fourth hourly. The clinical course of meningococcal septicaemia can be rapidly progressive with time of onset from fever until death as short as12 hours. Overall mortality for meningococcal disease is 10%.
If Sienna was unwell, as in the above question, would do blood cultures but only if they did not delay treatment with antibiotics. If not unwell Platelet count and coagulation studies to differentiate HSP from other causes of purpura such as DIC, acute leukaemia and aplastic anaemia.
Vasculitic illness predominantly involving small vessels in the skin, large joints and gastrointestinal tract, children present with petechial or purpuric rash, abdominal pain and arthritis. Children with this condition should be monitored for several months because 50-70% of cases develop nephritis (usually with microscopic haematuria and proteinuria) – good prognosis with fewer than 5% developing chronic renal failure.
Children with thromobocytopenia can develop petechiae and purpura and superficial bleeding – it can cause epistaxis and other mucosal bleeding (profuse bleeding uncommon, intracranial bleeding serious but rare complication), clinical examination for hepatosplenomegaly/lymphadenopathy then bone marrow to exclude acute leukaemia or aplastic anaemia. Critically ill/severe sepsis or shock or extensive tissue damage – disseminated intravascular coagulation (DIC).