II. Definitions
- General: Non-blanching cutaneous Hemorrhages
- Petechiae: Pinpoint Hemorrhages <2 mm in diameter
- Purpura: 2 to 10 mm in diameter
- Ecchymosis: >10 mm in diameter
III. Signs: Purpura
- Visible non-blanching Hemorrhages
- Compare with Contusions which are Traumatic non-blanching Hemorrhages
- Contrast with Vascular Skin Reaction which does blanch
- Occurs in the skin or mucus membranes
- Size: 2-10 mm in diameter (see definitions above)
- Characteristics
- Palpable Purpura suggests Vasculitis
- Distribution
- Petechiae on the head or neck
- Violent coughing (e.g. Pertussis), Vomiting or Strangulation
- Purpura on Lower extremities (gravity dependent)
- Purpura on palms and soles
- Rickettsial infection
- Petechiae on the head or neck
IV. Signs: Associated Conditions
- See Purpura Causes
- See Thrombocytopenia
- Fever and ill appearing or signs of toxicity
-
Fever without signs of toxicity
- Mononucleosis (EBV)
- Adenovirus
- Pertussis
- Streptococcal Pharyngitis
- Also most common cause of Henoch-Schonlein Purpura
- Preceding viral illness
-
Hepatosplenomegaly and Lymphadenopathy
- Malignancy (e.g. Leukemia)
- Mononucleosis (EBV)
- Hypertension
- Hemarthrosis
-
Arthralgias
- Henoch-Schonlein Purpura
- Rheumatologic causes (esp with eye symptoms)
- Skeletal abnormalities
- Thrombocytopenia-absent radii (TAR syndrome)
- Fanconi's Anemia (Short Stature)
- Skin hyperelasticity and joint Hypermobility
- Telangiectases
V. Labs: General
- Initial Tests
- Complete Blood Count with Platelet Count
- Peripheral Smear
- Coagulation tests (INR, PTT)
- Urinalysis with microscopic exam
- Tests to consider
- Comprehensive Metabolic Panel
- Blood Cultures (fever, ill appearance and Petechiae/Purpura)
- Streptococcal Test
- Monospot (EBV titer in age <5 years old, Monospot inaccurate in that group)
VI. Labs: Complete Blood Count and Peripheral Smear
- Schistocytes
- Atypical Lymphocytosis
- Infectious Mononucleosis
- Cytomegalovirus
- Leukemia blast cells with similar appearance
- Reticulocyte Count increased
VII. Labs: Platelet Count and Indices
- Anemia and Thrombocytopenia
- Thrombocytopenia with otherwise normal CBC
- Altered Platelet size
- See Mean Platelet Volume (MPV)
VIII. Labs: Urinalysis with Hematuria or Proteinuria
IX. Causes
- See Purpura Causes
X. Approach: Children (older protocol)
- Step 1 (non-bleeding cause)
- If unable to identify cause, go to step 2 below
- Identify potential cause based on history and exam
- See Purpura Causes
- See Signs above
- Step 2 (bleeding cause)
- Obtain Bleeding Disorder lab-work
- Complete Blood Count (CBC) with Platelet Count
- Peripheral Blood Smear
- ProTime
- Activated Partial Thromboplastin Time (aPTT)
- Evaluate Platelet Count
- Platelet Count low: Go to Step 3a below
- Platelet Count normal: Go to Step 3b below
- Obtain Bleeding Disorder lab-work
- Step 3a (Low Platelet Count)
- See Thrombocytopenia
- Prothrombin Time and aPTT prolonged
- Prothrombin Time and aPTT not prolonged
- Step 3b (Normal Platelet Count)
- Prothrombin Time and aPTT prolonged
- Coagulation Factor deficiency
- Von Willebrand's Disease
- Circulating Anticoagulant
- Liver disease
- Prothrombin Time and aPTT not prolonged
- Go to Step 4 below
- Prothrombin Time and aPTT prolonged
- Step 4 (Bleeding Time)
- Obtain Bleeding Time
- Bleeding Time prolonged
- Bleeding Time normal
- Child Abuse (Nonaccidental Trauma)
- Von Willebrand's Disease
- Vascular Purpura
XI. Disposition
- See Thrombocytopenia for hospitalization indications related to Low Platelets
- Admit or observe febrile or ill appearing patients with Petechiae or Purpura if no clear cause
- Well-appearing, afebrile infants with isolated, localized Petechiae and normal history exam are unlikely to have serious illness
XII. Precautions: Patients with bleeding tendency
- See Thrombocytopenia for activity and procedure limitations based on Platelet Count
- Caution with fever or ill appearing patients
- Consider Meningococcus, Pneumococcus, DIC, Rocky Mountain Spotted Fever
- Consider HSP, TTP, HUS
- Caution with strenuous activity or Contact Sport
- Caution with Intramuscular Injections
- Avoid Aspirin and NSAIDs
XIII. References
- Behar, Spangler, Swadron in Herbert (2016) EM:Rap 16(3): 14-6
- Baselga (1997) J Am Acad Dermatol 37:673-705 [PubMed]
- Leung (2001) Am Fam Physician 64(3): 419-28 [PubMed]
- Stevens (1995) Am Fam Physician 52(5):1355-62 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| 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, ﾊﾝｼﾞｮｳｼｭｯｹﾂ, ﾊﾝｼﾞｮｳｼｭｯｹﾂ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, ﾃﾝｼﾞｮｳｼｭｯｹﾂｾｲﾋｼﾝ, ﾃﾝｼﾞｮｳｼｭｯｹﾂ |
| 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, ｼﾊﾝﾋﾞｮｳ, 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 |
