Petechial Rash (Case 55)

Chapter 98 Petechial Rash (Case 55)



Sabina B. Singh, MD




Case


A 4-year-old child presents with fever and a red rash that began today (petechial).




Differential Diagnosis













Meningococcemia Trauma Enteroviral infection
Rocky Mountain spotted fever (RMSF) Henoch-Schönlein purpura (HSP) Thrombocytopenia


Speaking Intelligently


Petechial and purpuric rashes are amongst the most feared rashes in medicine. Petechiae are pinpoint (<3 mm) flat round lesions under the skin caused by intradermal hemorrhage. They are nonblanching. Purpura are larger in size and form when the petechiae coalesce.


Patients who are ill appearing and have abnormal vital signs need emergent medical care.


Infection with Neisseria meningitidis or Rickettsia is the primary concern in these patients, because these infections can be rapidly fatal. Early recognition of these disease processes is paramount, and early treatment will improve outcomes. In addition to examining the skin rash, all other systems should be examined. Ill-appearing patients need aggressive treatment with initial emphasis on the airway, breathing, and circulation (ABCs). First the airway should be assessed for patency, the breathing assisted (oxygen supplementation to intubation), followed by IV access. While inserting the IV, blood should be drawn for a complete blood count (CBC), blood culture, chemistry, prothrombin time (PT), and partial thromboplastin time (PTT), and an initial fluid bolus of normal saline, 20 mL/kg, should be given. Broad-spectrum antibiotics should be given early and not withheld for the lumbar puncture. Patients refractory to fluid resuscitation may require vasopressor support. Parents should be kept informed.


Patients with suspected meningococcemia should be placed on respiratory isolation.



Patient Care



Clinical Thinking



• Assess for airway, breathing, and circulation. Address deficiencies before progressing in the evaluation.

• Laboratory studies should be rapidly evaluated and interpreted.

• Aggressive fluid resuscitation with crystalloid fluids (20 mL/kg).

• Use of vasopressors in fluid refractory shock.

• Early broad-spectrum antibiotic administration.

• Respiratory isolation and personal protective equipment.


History



• History of onset, progression, site, and severity of the rash itself.

• Fever suggests a potential infectious cause of the petechial rash.

• History of bleeding diathesis in family or patient, such as easy bruising, gingival bleeding, heavy menstrual cycles, or history of blood transfusion.

• History of prior injuries, scars, or bruising.

• History of recent trauma and illness.

• Recent medication use, which may precipitate platelet dysfunction.


Physical Examination



• Vital signs: Changes associated with sepsis are hyperpyrexia, hypopyrexia, tachypnea, tachycardia, and hypotension.

• Airway, breathing, and circulation are the primary concern in ill patients.

• Head: Evidence of trauma.

• Head, ears, eyes, nose, and throat (HEENT): Oral petechiae, rhinorrhea.

• Skin: Petechial/purpuric rash, including location, size, characteristics, and progression (Figure 98-1).

• Neurologic: Evaluate mental status, signs of meningeal irritation (Kernig sign and Brudzinski sign), and focal neurologic deficits.

• Examination should be directed toward assessment of all organ systems and adequate end-organ perfusion, including mental status, neurologic deficits, and urine output.

image

Figure 98-1 Petechial rash.



Tests for Consideration



• CBC $53

• Blood culture $100

• Chemistry panel $29

• Inflammatory markers (erythrocyte sedimentation rate[ESR], C-reactive protein [CRP] $25 each

• PT/PTT, bleeding time $75

• Fibrinogen $55

• Cerebrospinal fluid (CSF): Cell counts, chemistries, and culture $175


Imaging Considerations


→ Head CT: If evidence of focal neurologic deficit $750




Clinical Entities: Medical Knowledge



















Meningococcemia
Pϕ N. meningitidis is the causative agent of meningococcemia. It is a rapidly progressing disease transmitted through respiratory secretions. Humans are the only known host. N. meningitidis invades endothelial cells of small blood vessels and causes damage by liberating endotoxin. Consequently, endothelial permeability increases, resulting in shock and multiorgan failure and disseminated intravascular coagulation (DIC).
TP Meningococcal disease is a continuum. Patients may present following a viral prodrome with fever, headache, myalgias, and arthralgias, or they may present in shock. Clinical deterioration may be precipitous. Classic skin findings are a petechial/purpuric rash. Extracutaneous manifestations include changes in mental status, neck stiffness, irritability, seizure, and unstable vital signs.
Dx History and physical examination often alert the physician to the diagnosis. A high white blood cell count and pleocytosis on the CSF are supporting evidence. Confirmation is provided when the blood or CSF culture is positive for Neisseria. Skin scrapings and punch biopsies can also identify infection with N. meningitidis.
Tx Treatment is aggressive resuscitation and early initiation of broad-spectrum parenteral antibiotics (penicillin or cephalosporins). In penicillin-allergic patients chloramphenicol is the drug of choice. Droplet isolation must be instituted in cases of presumed infection. Furthermore, intimate patient contacts and health-care workers who may have been in contact with the patient must receive prophylaxis with antibiotics. See Nelson Essentials 100.

















Rocky Mountain Spotted Fever
Pϕ Rocky Mountain spotted fever is a tickborne disease due to Rickettsia rickettsii infection. Bacteria are introduced into the bloodstream by infected ticks after a blood meal of greater than 6 hours. Rickettsia enter the bloodstream and target vascular endothelial cells, leading to increased vascular permeability, leading to multisystem organ dysfunction. Infection is characterized by fever, myalgias, headache, and petechial rash. It is the most common fatal tickborne disease, and therefore it is imperative to maintain a high index of suspicion for RMSF. In the United States, RMSF is more common in the Southeast states.
TP Typically patients will have a history of tick attachment. Fever is nearly ubiquitous. A rash is present in 85% to 90% of patients. It typically begins as blanching maculopapular lesions, which can progress to petechial or purpuric. Lesions start around the wrists and ankles with involvement of the palms and sole; the rash then spreads in a centripetal manner to the rest of the body. Central nervous system changes include confusion and lethargy. Pulmonary involvement may lead to acute respiratory distress syndrome. Gastrointestinal (GI) manifestations may include GI bleeding and focal hepatocellular necrosis. Renal failure may also occur.
Dx Diagnosis can be suggested by history and physical examination. Results of laboratory studies should be evaluated. Nonspecific signs of RMSF include hyponatremia, anemia, thrombocytopenia, and elevated liver function test results. Cerebrospinal fluid evaluation should be completed to rule out other infectious causes. Serologic assays to detect IgG levels are done for definitive diagnosis.
Tx Treatment consists of early recognition of the disease. If the tick is still present, it should be removed. Provide aggressive fluid resuscitation as needed. Tetracycline or chloramphenicol is the antibiotic of choice, even in children under 9 years of age. Antibiotic prophylaxis is not indicated. See Nelson Essentials 122.

















Enteroviral Infection
Pϕ Enteroviruses are a group of single-stranded RNA virus belonging to the Picornaviridae family. The enteroviral group consists of coxsackievirus, echovirus, and poliovirus. Transmission occurs via the fecal-oral route. These viruses enter the human host through the gastrointestinal or respiratory tract. Replication causes minor viremia on the third day of infection, followed by a second major viremic episode on days 3 to 7.
TP Enteroviral infection can cause a constellation of symptoms, but most cases include fever, viral prodrome, and gastrointestinal symptoms. Exanthematous rashes may occur as maculopapular, blanching rash mimicking rubella and usually have a benign 3- to 5-day course. It may occur following cessation of fever. Cardiac involvement, central nervous system involvement, oral lesions, and musculoskeletal pain may also be presenting signs.
Dx Diagnosis is based on clinical judgment in conjunction with seasonal outbreak patterns and other historical features. Definitive diagnosis made by recovering the organism from throat, blood, urine, and stool cultures. Physicians should use ancillary studies to eliminate bacterial causes of illness.
Blood: CBC, chemistries, inflammatory markers.
Cerebrospinal fluid: Cell count, chemistries, culture, and enteroviral polymerase chain reaction (PCR) testing.
Tx Treatment is supportive. Antibiotics can be given prophylactically to those patients with severe illness while awaiting culture and PCR results. See Nelson Essentials 122.

















Trauma
Pϕ Traumatic petechiae are commonly associated with increased intrathoracic pressure. Common causes are prolonged vomiting, whooping cough, strangulation, and crush injury to the chest and abdomen. Petechiae are usually located above the nipple lines secondary to reflux of blood through the valveless veins of the head and neck.
TP Patients are well appearing, with petechiae limited to the face, neck, and upper trunk (usually above the nipple line).
Dx Diagnosis may be based on a well-appearing patient with adequate history of vomiting or coughing before development of lesions . More ominous causes of petechiae must be ruled out.
Tx Treatment is supportive care. See Nelson Essentials 42.

















Henoch-Schönlein Purpura
Pϕ Henoch-Schönlein purpura is an inflammatory disorder characterized by generalized small vessel vasculitis. It has a multifactorial etiology. All organ systems may be affected. HSP is characterized by petechial/purpuric rash, migratory polyarthritis, renal involvement, and gastrointestinal involvement.
TP Patients are commonly well appearing and afebrile. There is usually a history of prodromal illness, followed by rash, abdominal pain, edema, vomiting, and arthritis. A petechial rash that can progress to purpura is commonly seen localized to lower extremities.
Dx Evaluation should include a CBC, ESR, urinalysis, and a chemistry panel. Additional serologic studies may be added in cases of unknown etiology.
Tx Treatment is supportive care. Minor complaints may be treated symptomatically. Corticosteroid therapy should be initiated for intestinal complications. See Nelson Essentials 87.








Thrombocytopenia
Pϕ Thrombocytopenia is defined as a decreased platelet count. Etiologies can be divided into increased destruction, decreased production, or sequestration. Multiple etiologies exist; a partial list includes:

image Decreased production
image Malignancies
< div class='tao-gold-member'>

Related posts:

  1. Diarrhea (Case 6)
  2. Physical Abuse (Case 53)
  3. Intraventricular Hemorrhage (Case 37)
  4. The Chronic Child (Case 46)

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Petechial Rash (Case 55)

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access