Presentation on theme: "Approach to child with purpura"— Presentation transcript:
1 Approach to child with purpura Ahmed S.BarefahKAAU,MBBS
2 Questions What is the definition of purpuric rash? What are the causes of purpura?How to approach such a case?
3 Definitionred, nonblanching maculopapular lesions caused by intradermal capillary bleeding.classified aspetechiae (pinpoint hemorrhages less than 2 mm in greatest diameter),purpura (2 mm to 1 cm) orecchymoses (more than 1 cm).results from the extravasation of blood from the vasculature into the skin or mucous membranes.
6 Thrombocytopenia may be caused by increased platelet destruction Immunenonimmunedecreased platelet productionCongenitalAcquiredsequestration of platelets.
7 Immune Thrombocytopenia Idiopathic (immune) thrombocytopenic purpuraby far the most common etiology of thrombocytopenia in childhood.caused by the development of IgG autoantibodies to platelet membrane antigens as a result of an unbalanced response to an infectious agent or autoimmunitysudden onset of bruises, purpura, mucosal hemorrhage and petechiae in a child who is otherwise in excellent health.
8 ITP antecedent viral infection is common. The peak incidence is between two and four years of age.80 to 90 percent of children recovering within six to 12 months.Chronic idiopathic thrombocytopenic purpura is more likely to present in teenage girls and children with underlying immune disorders. It has a more insidious onset
9 Immune Thrombocytopenia Drugspenicillin, valproic acid (Depakene), quinidine, sulfonamides, cimetidine (Tagamet) and heparin.Post-transfusion purpuraacute onset of thrombocytopenia approximately five to 14 days after a transfusion.RarelyHIV, CMV, HSV10% of SLE cases
11 Non-Immune Thrombocytopenia hemolytic-uremic syndrometriad of microangiopathic hemolytic anemia, thrombocytopenia and acute renal injury.infection by verocytotoxin-producing Escherichia colithrombotic thrombocytopenic purpuraoccurs more often in adults, and neurologic (rather than renal) symptoms are more prominent
12 Non-Immune Thrombocytopenia disseminated intravascular coagulopathyoverwhelming sepsis, incompatible blood transfusion, snake bite, giant hemangioma and malignancy.Purpura fulminansacute, often lethal syndrome of DIC.may develop because of a severe bacterial infection, notably meningococcal disease, or because of protein C or S deficiency
13 Decreased Platelet Production CongenitalThrombocytopeniaabsent radii (TAR) syndromeinherited as an autosomal recessive traitFanconi anemiapancytopenia, hyperpigmentation and café au lait spots, short stature, skeletal abnormalitiesWiskott-Aldrich syndrome
14 Decreased Platelet Production AcquiredBone marrow suppressionDrugs such as alkylating agents, antimetabolites, anticonvulsants, chlorothiazide diuretics and estrogensInfection as viral and bacterial infections, especially septicemia and Intrauterine infection with TORCH organismsBone marrow infiltrationpatients with leukemia, histiocytosis, storage diseases, neuroblastoma, myelofibrosis and osteopetrosis
15 Sequestration of Platelets Splenomegaly or giant hemangioma can result in thrombocytopenia because of platelet sequestration.The association of thrombocytopenia and giant hemangioma is referred to as Kasabach-Merritt syndrome.
16 Platelet Dysfunction Glanzmann's thrombasthenia autosomal recessive disorder caused by congenital deficiency in the platelet membrane glycoproteins IIb and IIIa.Bernard-Soulier diseaseautosomal recessive disorder caused by a congenital deficiency in platelet membrane glycoprotein Ib
17 Vascular Factors Congenital Causes Hereditary hemorrhagic telangiectasiaautosomal dominant disorderdevelopment of fragile telangiectasia of the skin and mucous membranesEhlers-Danlos syndromecharacterized by skin hyperelasticity, joint hypermobility and fragility of the skin and blood vessels
18 Vascular Factors Acquired Causes Henoch-Schönlein purpuraIgA-mediated systemic vasculitis of small blood vesselsnonthrombocytopenic purpura, abdominal pain, arthritis and nephritisthe most common form of vasculitis in childrenhistory of a preceding URTICharacteristically palpable, gravity dependant purpura
19 Vascular Factors Acquired Causes Meningococcemia and rickettsial diseases may cause direct damage to blood vessels, with resultant purpura.Child abuse
20 HistoryAge of Onset Birth Intrauterine infection, maternal idiopathic thrombocytopenic purpura, maternal systemic lupus erythematosus, maternal medication, TAR syndrome, congenital amegakaryocytic thrombocytopenia2 to 4 years Idiopathic thrombocytopenic purpura4 to 7 years Henoch-Schönlein purpura
21 History Onset/chronicity Acute onset ITP, HSP, medication, mechanical causeLong duration Abnormality of platelets, coagulopathy
22 History Pattern of bleeding Mucosal bleeding Thrombocytopenia, von Willebrand's diseaseIntramuscular and intra-articular bleeding Hemophilia
23 History Associated symptoms Abdominal pain, blood in stools, joint pain HSPLethargy, fever, bone pain LeukemiaIntermittent fever, muscoskeletal symptoms SLELethargy, polyuria, polydipsia, failure to thrive UremiaPurpura, but otherwise healthy ITP
24 HistoryPast health Antecedent viral infection, especially an upper respiratory tract infection ITP, HSPDrug useFamily historyMaternal historySocial history
29 RED FLAGS Fever, lethargy, weight loss, bone pain, joint pain, pallor, Lymphadenopathyhepatosplenomegaly
30 SummaryPetechiae and purpura result from a wide variety of underlying disorders and may occur at any agered, nonblanching maculopapular lesions caused by intradermal capillary bleedingClassified into platelet or vascular causesIdiopathic thrombocytopenic purpura is the most common cause of thrombocytopenia in children.Henoch-Schönlein purpura is the most common form of vasculitis in children, and the purpuric rash is almost always palpable.