Petechiae and Hemorrhagic Rashes

Dr. Harley Eisman

Pediatric Emergency Medicine

MUHC-Montreal Children’s Hospital

Outline

Objectives Cases Definition Background Evidence Consensus Global Evaluation of Purpura Selected Disease Entities Wrap-Up

Objectives

At the end of the session the learner will:

A. Understand the important points in the clinical evaluation of the child with petechiae

B. Better use laboratory investigation in the evaluation of the child with fever and petechiae

Case 1

5 year old male referred by pediatrician fever x 48 hours petechiae on trunk for 12 hours cough,headache,abdo pain,difficulty swallowing sick contacts at school febrile,tired, non-toxic, vitals stable petechiae on face, neck,chest abdomen and 1 thigh red throat with some exudate, neck supple WBC 17.3, HGB 126, PLT 212 49%N,28%L,5%ATL

Case 2

2.5 year old male fever for 24 hours, poor feeding, less active, nausea ?

vomit parents noticed spots on face tired, febrile, vitals stable mild rhinorrhea petechiae under eyes, on face, on trunk, and on buttock WBC 9.0, HGB 137, PLT 155, N41%,S10%,L40% Coags:Normal CXR: Normal, Sinus Views Positive

Definitions

Purpura– nonblanchable purple lesion– blood extravasated outside vessel wall

a)nonpalpable - no vessel inflammation

petechiae - macules smaller than 3 mm

ecchymoses- larger than 3mm

b)palpable (macular) - vasculitis

elevated lesion

Purpura

Context

…independent of age, fever with petechiae with or without localizing signs places the patient at high risk for life threatening bacterial infections such as bacteremia, sepsis, and meningitis….

Nelson’s pg. 700

series have quoted the incidence of meningococcal disease in the setting of petechiae to be 7-11%

Local Context

Meningitis vigilance of 2001 Cowansville - Massey Vanier High

Meningococcal Disease in Quebec – Past Decade

Local Context

What do you do ?

Fever and Petechiae in ChildrenBaker et al, Pediatrics Vol.84 No.6 December 1989

190 patients prospectively enrolled 15 children( 8%) with invasive infections 39 children with nonbacteremic causes 38 children with viral causes 136 patients with clinical diagnoses

Fever and Petechiae in ChildrenBaker et al, Pediatrics Vol.84 No.6 December 1989

Invasive– Neisseria Meningitis– H.FluB– Strep Pneumo– Meningitis NYD

Non-Invasive– Strep Pyogenes(*)– RSV– Influenza– E.Coli Uti– Rotavirus– Enterovirus– Adenovirus

Additional Infectious Causes

Parvovirus B19 (Fifth Disease) Ebstein-Barr Virus

Fever and Petechiae in ChildrenBaker et al, Pediatrics Vol.84 No.6 December 1989

Location, Quantity– 40% of Invasive Disease had generalized– 11% of non-invasive had generalized– no patient with petechiae only above the

nipple line had invasive disease

Fever and Petechiae in ChildrenBaker et al, Pediatrics Vol.84 No.6 December 1989

Incidence of bacteremia in infants and children with fever and petechiaeMandl et Al, Journal of Pediatrics 131(3) Sept. 1997 398-406

Bacterial Culture Results from 411 patients with fever > 380C and petechiae

Bacterial Illness N(%)Bacteremia or clinical sepsis 8(1.9) Neisseria meningitidis 2(0.5) Clinical sepsis with negative blood culture result 3(0.7) Group A Streptococcus 1(0.2) S. Pneumoniae 2(0.5)Positive CSF culture ( n=219) 0(0.0)Throat Culture Positive for group A Strep in those > 18months (n=154)

40(26.0)

Incidence of bacteremia in infants and children with fever and petechiaeMandl et Al, Journal of Pediatrics 131(3) Sept. 1997 398-406

Sensitivity Specificity PPV NPVIll Appearance 1.00 0.88 0.11 1.00Purpura 0.83 0.97 0.31 0.99WBC >15000or <5000

1.00 0.64 0.05 1.00

PT > 13.5 sec 0.67 0.98 0.40 0.99PTT > 30 sec 0.50 0.50 0.05 0.99

Testing Performance of selected clinical and laboratory findings

Performance of Clinical Features

Wells LC et Al, Arch Dis Child 2001;25 p220

Performance of Lab Test

Wells LC et Al, Arch Dis Child 2001;25 p220

Coagulation Profiles

Willword, Pediatric Emergency Care, 2003 Vol 19(4) p. 244

The Management of fever and petechiae:making sense of rash decisions

Brogan PA,Raffles A. Arch Dis Child 2000;83:506-7

Guideline to detect SBS in children with fever and petechiae derived from cohort of 55 patients Risk Factors

– cap refill > 2 seconds

– irritability

– lethargy

– wbc < 5000 or > 15 000

– elevation of CRP > 5 mg/dl sensitivity 100%, specificity 60%, PPV 20%, NPV 100%, NNT 5 no risk - observe 4 hours abnormal CRP or WBC but well, IV Antbx x 48 hours Ill - ICU

Diagnostic assessment of haemorrhagic rash and feverNielsen et Al, Arch Dis Child 2001;85:160-165

Prospective non-interventional study enrolled 264 patients

– presence of hemorrhage in the skin– rectal temperature greater than 38oC

used logistic regression to determine clinical and laboratory variables predictive of meningococcal disease

Diagnostic assessment of haemorrhagic rash and feverNielsen et Al, Arch Dis Child 2001;85:160-165

Expanatory Variable P Value Adjustedoddsratio

95%CI

Skin Hemorrhages,type C,D,or E 0.002 11.2 2.5to50.7

Universal distribution 0.036 5.1 11.1to23.7

Maximum diameter of skin hemorrhages > 2mm 0.012 7.0 1.5to32.0

General condition, score <7 0.001 14.0 3.1to62.6

Nuchal Rigidity 0.040 6.9 1.1to44.0

Neutrophil band forms >0.5 X 109/L 0.002 38.3 3.8to385.1

CRP >500nmol/l 0.0001 12.4 4.7 to 32.7

Evaluation of Children with Petechial Rashes - Consensus

Nelson et al, PIDJ 1998;17:1135-40– surveyed 833 Pediatricians– non toxic febrile children 1,2,5,and 7 years

0102030405060708090

100

% C

hoosing

BloodCulture

LP Admission Observation Strep Test

1 yo

2 yo

5 yo

7 yo

Meningococcemia

Mimic a viral like illness first sign may be change in behavior 75% fever 75% petechiae and or purpura - 50%

both 50% positive blood cultures 50% meninigitis

Algorithm – Fever and PetechiaeRiordan FAI,Arch Dis Child 2001;85 172-175

Evaluation of Purpura

Purpura – Diagnostic Consideration

Platelet Disorders Coagulation Factor Deficiency Vascular Factors

– Congenital• Hereditary Telangectasia• Ehrlos Danlos

– Acquired• Infectious• HSP• Mechanical • Psychogenic• Abuse

Evaluation of Purpura

Evaluation of Purpura

Henoch Schonlein Purpura

Clinical constellation and rash are diagnostics Males 2:1 over age 2 May have low grade fever Supportive therapy Prednisone 2mg/kg/day

– GI, CNS, Testicular Symptoms Albustix at home for 3 months to look for

renal involvement Follow Up with PCP

Idiopathic Thrombocytopenic Puprpura

1-4 weeks after a viral illness Bruising and purpura Mucous membrane (nose) bleeds CNS hemorahges < 1% No evidence of hematologic malignancy Treatment

– Expectant– Steroid– IVIG

Wrap -Up

Trust your clinical evaluation of the child with fever and petechiae

Laboratory test will not offer added information