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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.

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petechiae and hemorrhagic rashes

Petechiae and Hemorrhagic Rashes

Dr. Harley Eisman

Pediatric Emergency Medicine

MUHC-Montreal Children’s Hospital

outline
Outline
  • Objectives
  • Cases
  • Definition
  • Background
  • Evidence
  • Consensus
  • Global Evaluation of Purpura
  • Selected Disease Entities
  • Wrap-Up
objectives
Objectives
  • At the end of the session the learner will:
  • Understand the important points in the clinical evaluation of the child with petechiae
  • Better use laboratory investigation in the evaluation of the child with fever and petechiae
case 1
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
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
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

context
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
Local Context
  • Meningitis vigilance of 2001
  • Cowansville - Massey Vanier High
fever and petechiae in children baker et al pediatrics vol 84 no 6 december 1989
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 children baker et al pediatrics vol 84 no 6 december 198915
Non-Invasive

Strep Pyogenes(*)

RSV

Influenza

E.Coli Uti

Rotavirus

Enterovirus

Adenovirus

Fever and Petechiae in ChildrenBaker et al, Pediatrics Vol.84 No.6 December 1989
  • Invasive
    • Neisseria Meningitis
    • H.FluB
    • Strep Pneumo
    • Meningitis NYD
additional infectious causes
Additional Infectious Causes
  • Parvovirus B19 (Fifth Disease)
  • Ebstein-Barr Virus
fever and petechiae in children baker et al pediatrics vol 84 no 6 december 198917
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
slide19
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
slide20
Incidence of bacteremia in infants and children with fever and petechiaeMandl et Al, Journal of Pediatrics 131(3) Sept. 1997 398-406

Testing Performance of selected clinical and laboratory findings

performance of clinical features
Performance of Clinical Features

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

performance of lab test
Performance of Lab Test

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

coagulation profiles
Coagulation Profiles

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

slide24
The Management of fever and petechiae:making sense of rash decisionsBrogan 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 fever nielsen et al arch dis child 2001 85 160 165
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
evaluation of children with petechial rashes consensus
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
meningococcemia
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
purpura diagnostic consideration
Purpura – Diagnostic Consideration
  • Platelet Disorders
  • Coagulation Factor Deficiency
  • Vascular Factors
    • Congenital
      • Hereditary Telangectasia
      • Ehrlos Danlos
    • Acquired
      • Infectious
      • HSP
      • Mechanical
      • Psychogenic
      • Abuse
henoch schonlein 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
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
Wrap -Up
  • Trust your clinical evaluation of the child with fever and petechiae
  • Laboratory test will not offer added information