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Non Blanching Rashes Module

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TopicNon Blanching Rashes
AuthorAoife Fox
Duration1.5 hours

Pre-reading for learners

Basics (10 mins)

Case 1: Meningococcal sepsis (20 min)

Case 2: Immune thrombocytopenic purpura (ITP) (15 min)

Case 3: Non-accidental injury (10 min)

Case 4: Henoch-Schonlein Purpura (20 min)

Quiz (10 mins)

5 take home learning points (5 mins)

Key learning points

  • Petechiae: are pin-point, non-blanching red lesions of the skin or conjunctiva, usually <0.5cm caused by capillaries leaking blood into the skin. Occasionally, they can be raised (palpable). They are caused by physical trauma, infectious, vascular, and haematological causes.
  • Purpura: a non-blanching area of colour change (red or purple) due to bleeding into the skin secondary to platelet disorders, vascular disorders (e.g. vasculitis), coagulation disorders (e.g. disseminated intravascular coagulation (DIC)) and infection such as meningococcaemia.
Purpura and petechiae (Image: used with gratitude from Emdocs.net)
  • Ecchymosis: a larger area of purpura usually greater than 1cm (e.g., vasculitis, disseminated intravascular coagulation).
Bilateral periorbital ecchymosis
(Image: used with gratitude from Wikipedia.org)

Diagnostic aide

DIC – Disseminated intravascular coagulopathy, TTP = thrombotic thrombocytopenic purpura

Approach to non-blanching rash

(from LITFL – LITFL – Perilous Pinhead Polka-dots)

The rash can result from the following mechanisms:

  • mechanical capillary injury
  • impaired haemostasis
  • septic emboli or invasion of the capillary walls
  • microbial toxin-induced capillary damage
  • immune complex deposition

Management

A large study called PIC (Petechiae in Children) was published in 2020. This was a prospective, multicentre cohort study looking at how good existing guidelines were at picking up children with meningococcal disease. Prior to the introduction of meningococcal B and C vaccines, the prevalence of meningococcal disease in children presenting with fever and a non-blanching rash was around 10-20%. The PIC study showed that since the introduction of the vaccines, this has fallen to around 1%. 

The PIC study looked at regional guidelines and NICE guidelines on the investigation and management of a child with a fever and a non-blanching rash in terms of their sensitivity and specificity. All the guidelines had 100% sensitivity (i.e. all children with meningococcal disease were detected by following the guidelines) but were not very specific (i.e. many children without meningococcal disease would have received treatment). The best-performing guideline in the study was the Barts Health NHS Trust guideline (below).

Barts Health NHS Trust 2019

(based on a case from EMDocs – EMDocs -The Sick Meningitis Patient – From Bad to Worse)

James, a 13-year-old boy, presents to the ED with his father. His father reports that before leaving for class the patient was complaining of slight headache and body aches. James went to school, but his teacher phoned his parents at 11 am to come and collect him as he was unwell. She said he looked sweaty, was warm to the touch, was complaining of neck pain, and was saying things that didn’t make sense. 

On examination, you notice he has extensive purpura over both thighs and abdomen. He is hypotensive with a BP of 80/40 and tachycardic with a HR of 130 bpm. 

(Image used with gratitude from Wikipedia.org)

What is the most likely diagnosis?

What is the most likely organism causing this?

What percentage of these patients present with the classic petechial/purpuric rash?

What investigations would you like to do?

What treatment would you like to commence?

What is an extensive rash an indicator of?

James develops the following rash. What is it? How does this influence his prognosis? How would you like to treat it?

(Image used with gratitude from Journal of Postgraduate Medicine – jpgmonline.com)

What other complications of bacterial meningitis might occur?

One of the nursing staff asks you to review James as his eye “looks funny”. On exam, you diagnose a unilateral 6th nerve palsy.

What has happened? Apart from the dexamethasone which you have already given, what other strategies could you employ to reduce intracranial pressure (ICP)?

In terms of the safety of yourself and your colleagues is there anything you need to consider?

James’ mum is tearful and tells you she is sure James is up to date with all his vaccinations.

What can you tell her about the meningococcal vaccine?

What is the most likely diagnosis?

What is the most likely organism causing this?

In meningococcal infection, what percentage of patients present with the classic petechial/purpuric rash?

What investigations would you like to do?

What treatment would you like to commence?

What is an extensive rash an indicator of?

James develops the following rash. What is it? How does this influence his prognosis? How would you like to treat it?

What other complications of bacterial meningitis might occur?

What has happened to James? Apart from the dexamethasone which you have already given, what other strategies could you employ to reduce intracranial pressure (ICP)?

In terms of the safety of yourself and your colleagues is there anything you need to consider?

What can you tell James’ Mum about the meningococcal vaccine?

(Case from DFTB – DFTB – ITP; treatment from UpToDate – UpToDate – ITP in Children)

Maddie, a 4-year-old girl presents with bruising over her legs, trunk, and face.  Mum has noticed them appear over the last week.  She has been completely well with no other symptoms.  There is no history of trauma.  After an anxious 1 hour wait, the bloods are back-Hb 113, WCC 7.3, Plt 8 x 109/L.

What is the most likely diagnosis?

Could it be anything else?

Ok, great, we have decided it’s ITP – what is it? How did she get it?

What other symptoms and signs would you like to know about?

What is the most likely diagnosis?

Could it be anything else?

Ok, great, we have decided it’s ITP – what is it? How did she get it?

What other symptoms and signs would you like to know about?

Are there any scoring systems you could use to rate the severity?

What investigations would you like to do as part of your workup? In what situation would you like to do a bone marrow aspirate?

What treatment should we use?

When should Maddie be admitted to hospital?

Her parents are asking when the rash/bruising will resolve. What will you tell them?

What do you need to advise the parents to look out for?

When should follow up for Maddie be arranged for?

Her parents are very concerned that Maddie will develop chronic ITP and wonders if she receives treatment now can this be prevented. What will you tell them?

(Based on case from St. Emlyn’s Blog – Don’t Be Rash – Petechiae in Well Kids at St Emlyn’s)

Daisy, a 6-month-old girl, is brought by her mum to the ED with a cluster of non-blanching spots to her right lower leg noticed while bathing her. She has a mild cough and snotty nose but is otherwise well – there is no history of fever and she is feeding well without diarrhoea or vomiting and with normal urine output. There is no history of trauma, no family history of coagulopathy, and an uncomplicated birth history. She is up-to-date with his immunisations and has never needed to attend ED before.

Examining her, you find a cluster of non-blanching spots, around five discrete lesions, approximately 2mm in diameter which do not disappear under pressure to the capillary bed. The rest of the examination is normal, apart from a runny nose. No other petechiae could be identified on top-to-toe examination. Her obs are normal.

Do you want to do blood tests on Daisy?

What are the causes of petechiae in children?

What factors in the history and presentation might make you suspicious of NAI?

It is always important to consider the child’s age and their developmental milestones. In Daisy’s case, what are they?

What is a normal pattern of bruising in children?

 A word of warning…

Do you want to do blood tests on Daisy?

What are the causes of petechiae in children?

What factors in the history and presentation might make you suspicious of NAI?

It is always important to consider the child’s age and their developmental milestones. In Daisy’s case what are they?

What is a normal pattern of bruising in children?

(based on a case from LITFL – LIFTL – Horrible Spots and Pain)

A 4-year-old boy is brought to the emergency department by his parents with a history of increasing numbers of red spots on his legs over the past 6 days. They took him to two different family doctors and have tried various creams. The spots have spread to his buttocks and his arms, and now his legs are sore and look swollen. He has also had abdominal pains.

On examination he looks well with age-appropriate vital signs, but he is reluctant to move his lower limbs.

A urine dipstick shows 2+ RBCs.

His rash looks like this:

What is the diagnosis?

What other symptoms not already mentioned would you look for?

What are the differentials?

What investigations would you like to do?

In what circumstances would you like to admit Jack to hospital?

When would you speak to a nephrologist?

What complications can occur?

Jack’s mum is wondering what the usual time course of the illness is. Can you counsel her on what to expect?

What is your management?

What is the role of steroids?

What is the diagnosis?

What other signs and symptoms not already mentioned would you look for?

What are the differentials?

What investigations would you like to do?

In what circumstances would you like to admit Jack to hospital?

When should you speak to a nephrologist?

What complications can occur?

Jack’s mum is wondering what the usual time course of the illness is.
Can you counsel her on what to expect?

What is your management?

What is the role of steroids?

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Question 4

Answer 4

Question 5

Answer 5


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Author

  • Aoife Fox is an emergency medicine trainee with an interest in medical informatics. She spends her time nurturing her sourdough starter and talking about her sourdough starter.

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