Approach to A Patient With Purpura:
Purpura is defined as purple colored spots and patches that may occur on the skin and the mucous membranes and caused by blood leaking from the small blood vessels under the skin.
When the purpura spots are less than 3 mm in diameter , they are called petechiae.
When these spots are larger than 1 cm in diameter it is called ecchymoses
Causes Of Purpura:
1. Thrombocytopenic purpura: associated with low platelet count
- Idiopathic thrombocytopenic purpura
- Marrow replacement by leukemia.
- Marrow replacement by secondary malignancy.
- Marrow aplasia.
- Drugs that can reduce the platelet count.
2. Infection:
- Meningiococcemia: in which the purpura is raised and palpable.
- Infective endocarditis. (associated with a heart murmur, splenomegaly, clubbing, Osler nodes)
- Scarlet fever
- Measles
- Rubella
- Typhoid fever
3. Vascular causes due to capillary defect:
- Senile purpura due to skin fragility and atrophy.
- Steroid induced purpura
- Henoch scholein purpura: commonly seen in children characterized by a purpuric rash over the extensor surfaces of the limbs along with arthritis, abdominal pain and acute nephritis.
4. Coagulation Deficiency:
- Hemophilia A
- Hemophilia B (Christmas disease)
- Anticoagulant therapy
5. Other Causes:
- Hypersplenism
- Amyloidosis
- Von Willibrand's disease.
- Scurvy
- Poly arteritis nodosa
- Systemic Lupus Erythematosus.
- Hemolytic uremic syndrome
- Disseminated intravenous coagulation.
- Ehler danlos syndrome
Investigation: In some patients clinical history may point towards the diagnosis for example history of steroid use or a history of certain drug intake. In cases where the underlying cause is not clear following investigations need to be done:
- A full blood count
- Complete coagulation screening
- Protein electrophoresis
- Bone marrow biopsy
- Skin biopsy for small vessel vasculitis.
Management: Treatment depends on identifying the underlying cause and managing accordingly.
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