Petechiae, Purpura and Vasculitis

Question 1

What are the main types of purpura?

Answer 1

1) Macular/non-palpable purpura (generally non-inflammatory)
2) palpable purpura (sign of vasculitis)

These are NON blanchable

Question 2

What kind of purpura is this?

Answer 2

Petechiae (not blanchable)- small (less than 3mm) usually found in the ‘dependent’ areas of the body (legs when standing, back/butt when lying down in a hospital bed)

generally painless

Question 3

What are the main causes of petechiae?

Answer 3

1) platelet related (low platelets or dysfunction)
2) non-platelet related (things that increase capillary fragility or allow them to leak)- sun damage can do this!!

*Petechiae are usually a sign of platelet dysfunction, and not a coagulation defect*

Question 4

What are ecchymoses?

Answer 4

large (5+mm) non-palpable purpura that may or may not be painful or tender

Question 5

While most petechiae are platelet related, ecchymoses are more likely to reflect what?

Answer 5

abnormalities in coagulation, rather than platelet defects (can result from hypercoag- OR hypocaguable states)

Question 6

What are some causes of purpura?

Answer 6

-thrombocytopenia or abnormal platelet function + infection/inflammation/trauma

poor dermal support + trauma (actinic damage, amyloid, Ehler’s Danlos, scurvy)

Anticoagulant stage + trauma (DIC, vitamin K deficiency)

Question 7

What is this?

Answer 7

Solar purpura- chronic sun damage can cause bleeding

Question 8

What is happening here?

Answer 8

thrombocytopenia + trauma (linear purpura (=vibex))

Question 9

What are the main causes of petechiae?

Answer 9

ABNORMAL PLATELET FUNCTION

• DIC and infection
• low platlets due to idiopathic, drug-induced, or autoimmune reasons
• inflammatory skin diseases

Question 10

What are the main causes of ecchymoses?

Answer 10

COAGULATION DEFECTS

• DIC and infection
• trauma
• weak skin
• Waldenstrome hypergammaglobinemia

Question 11

What is happening here?

Answer 11

Hypergammaglobulinemic Purpura of Waldenstrom

Question 12

What is this?

Answer 12

Henoch-Schonlein purpura (these are palpable- remember, unlike bland petechiae/ecchymosis, palpable purpura is assoicated with inflammation in blood vessels

due to IgA deposition in vascular walls

Question 13

Question 14

How are vasculites categorized?

Answer 14

Primarily based on the size of the blood vessel involved

Question 15

What are some diseases associated with small vessel vasculitis?

Answer 15

• Henoch Schonleion purpura (IgA vasculitis)
• Infections, drug reactions, maligancies and autoimmune disease

Question 16

What is this?

Answer 16

Small vessel vasculitis

Question 17

What is this?

Answer 17

Meningococcemia (acute)

Question 18

What is this?

Answer 18

Leukocytoclastic vasculitis

Question 19

Question 20

What are some mixed size (small and medium vessel) vasculites?

Answer 20

ANCA assoicated vasculites (Churg-Strauss, Microscopic polyangiitis, Wegener’s granulomatosis)

-Cyroglobulinemic vasculitis

Question 21

What is this?

Answer 21

Churg-Strauss vasculitis

Question 22

What is a common medium vessel vasculitis?

Answer 22

Polyarteritis nodosa

Question 23

What are some common large vessel vasculites?

Answer 23

• giant cell arteritis
• Takayasu arteritis
• Behcet’s

Question 24

Skin lesions depend on the size of the blood vessel involved. How do small vessel vasculities present?

Answer 24

These present as palpable purpura or blisters and rarely hives

Question 25

How do medium vessel vasculities present?

Answer 25

Nodules, purpura, livedo retiuclaris/racemosa or

ulcers, skin necrosis

NOTE: large vessel vasculities are less likely to affect skin

Question 26

What is this?

Answer 26

Henoch-Schonleion purpura

Question 27

What does this show?

Answer 27

IgA deposition in blood vessel wall in HSP

Question 28

What is this?

Answer 28

Polyarteritis nodosa causing deep nodules instead of palpable purpura

Question 29

What is retiform purpura?

Answer 29

A form of eccymosis with a netlike pattern resulting from vascular ischemia, usually due to an underlying thrombotic disorder

Question 30

Widespread retiform purpura is called what?

Answer 30

purpura fulminans

Question 31

Palpable purpura =

Answer 31

vasculitis

Question 32

Retiform purpura

Answer 32

Pink spots down in the dermis are clots (caused by cutting cocaine with levamisole- a medication used to treat parasitic worm infections)

Levamisole can make a subset of people extremly hypercoaguable

Question 33

What causes retiform purpura?

Answer 33

It is a pattern of purpura caused by a variety of insults that *disrupt blood flow to the skin*. Common causes:

congential coag defects, infection, cocaine cut with levamisole (if you see retiform purpura in someone that is ILL (with fever, etc.) you have to think meningococcemia)