1. Petechiae and Hemorrhagic Rashes Dr. Harley Eisman Pediatric Emergency Medicine MUHC-Montreal Children’s Hospital

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

3. 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

4. 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

5. 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

6. 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

7. Purpura

8. 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%

9. Local Context  Meningitis vigilance of 2001  Cowansville - Massey Vanier High

10. Meningococcal Disease in Quebec – Past Decade

11. Local Context

12. What do you do ?

14. Fever and Petechiae in Children Baker 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

15. Fever and Petechiae in Children Baker 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

16. Additional Infectious Causes  Parvovirus B19 (Fifth Disease)  Ebstein-Barr Virus

17. Fever and Petechiae in Children Baker 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

18. Fever and Petechiae in Children Baker et al, Pediatrics Vol.84 No.6 December 1989

19. Incidence of bacteremia in infants and children with fever and petechiae Mandl et Al, Journal of Pediatrics 131(3) Sept. 1997 398-406  Bacterial Culture Results from 411 patients with fever > 38 0 C and petechiae

20. Incidence of bacteremia in infants and children with fever and petechiae Mandl et Al, Journal of Pediatrics 131(3) Sept. 1997 398-406 Testing Performance of selected clinical and laboratory findings

21. Performance of Clinical Features Wells LC et Al, Arch Dis Child 2001;25 p220

22. Performance of Lab Test Wells LC et Al, Arch Dis Child 2001;25 p220

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

24. 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 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

25. Diagnostic assessment of haemorrhagic rash and fever Nielsen 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 38 o C  used logistic regression to determine clinical and laboratory variables predictive of meningococcal disease

26. Diagnostic assessment of haemorrhagic rash and fever Nielsen et Al, Arch Dis Child 2001;85:160-165

27. 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

28. 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

29. Algorithm – Fever and Petechiae Riordan FAI,Arch Dis Child 2001;85 172-175

30. Evaluation of Purpura

31. Purpura – Diagnostic Consideration  Platelet Disorders  Coagulation Factor Deficiency  Vascular Factors –Congenital Hereditary Telangectasia Ehrlos Danlos –Acquired Infectious HSP Mechanical Psychogenic Abuse

32. Evaluation of Purpura

38. 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

39. 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

40. Wrap -Up  Trust your clinical evaluation of the child with fever and petechiae  Laboratory test will not offer added information