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4-month-old with new onset petechiae on bilateral lower extremities
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A 4-month-old male presents to pediatric dermatology clinic for evaluation of new-onset red spots on his bilateral lower extremities. The lesions have been present for 1 day and were noticed only after the patient’s mother undressed the child after they returned from their daily local hike together. The lesions do not appear to be increasing in size or number.
On physical exam, multiple, scattered 1-mm to 3-mm pinkish-red, round macules are noted on the patient’s bilateral legs; a sharp symmetric “cutoff” of the lesions is noted at the proximal bilateral thighs. Diascopy with a glass slide reveals that the lesions truly do not blanch, confirming the suspicion of petechiae. The child appears well nourished and is otherwise completely asymptomatic.
Shehla Admani
Andrew C. Krakowski
Review of systems is negative for recent fevers, conjunctivitis, rash, or upper respiratory infection symptoms. Interestingly, the mother notes that she normally does the hike with the patient lying in a trailer-rated stroller. This most recent hike, however, she tried carrying him in his new baby sling.
What should be the next step in this patient’s care?
A. The lesions are suspicious for abuse.
B. Admit the patient for IV doxycycline.
C. Check a urinalysis because this condition frequently has renal involvement.
D. Ask the mother to demonstrate exactly how she carried her child on the hike.
E. Obtain a more detailed history of the child’s diet.
Diagnosis: Petechiae secondary to tourniquet phenomenon
New-onset petechiae or purpura in an infant can be very concerning and can frequently lead to an extensive workup. It is not always possible to find a definitive cause for these lesions. In fact, in one study looking at otherwise healthy infants presenting to the ED with petechiae or purpura, an exact cause was not found in almost 25% of the cases, and for most patients the diagnoses were only speculative. Consequently, the differential diagnosis for petechiae and purpura should be broad, including infections (eg, Rocky Mountain spotted fever, parvovirus, etc), vasculitis, dietary deficiency and both accidental and non-accidental trauma.
An important entity to keep in mind when examining a child with a petechial rash is Rocky Mountain spotted fever (RMSF). RMSF is at tick-borne illness caused by Rickettsia rickettsii and has a classic triad of fever, rash and headache. The rash typically begins on the ankles, wrists or forearms and spreads centripetally to involve the proximal extremities and trunk. Blanching pink macules can be seen, as well as papules and petechiae. Early diagnosis and treatment are key because delay in treatment is associated with a higher mortality. The antimicrobial agent of choice is doxycycline.
It is important to note that several viral infections also have been associated with petechial rash, including human respiratory syncytial virus, Epstein-Barr virus, cytomegalovirus, adenovirus, enterovirus and parvovirus B19.
Henoch-Schönlein purpura (HSP) is a leukocytoclastic vasculitis that predominately affects the small blood vessels. The classic presentation includes lower-extremity palpable purpura, arthritis, abdominal pain and renal disease. The purpuric rash is usually in dependent areas, but can be seen on the arms, face and ears as well. In some cases, a maculopapular or urticarial rash can precede the purpura and usually disappears within 24 hours. Mild cases of HSP can be treated with supportive care, including the use of analgesics and nonsteroidal anti-inflammatory medications. More severe cases can require corticosteroid treatment. Symptoms typically last 3 to 4 weeks and up to one-third of patients will have at least one episode of recurrence.
Purpura or petechiae combined with “corkscrew” hairs and gingival hemorrhage raise the suspicion for scurvy or ascorbic acid (vitamin C) deficiency. In the past, scurvy was seen in sea voyagers and the poor who went for extensive periods of time without eating fruit, as well as in the rich who boiled their milk intending to destroy bacteria but at the same time ridding the milk of its ascorbic acid content.
Modern day cases of scurvy are rare and can be seen in the context of neurodevelopmental disabilities, psychiatric illness, severe food allergies, malabsorptive disorders, abuse/neglect, and also in patients with severely restricted diets secondary to religious purposes. In addition, infantile scurvy can be seen in patients whose lactating mothers are extremely deficient in ascorbic acid.
It is important to note that infants may not have the classic presentation of scurvy and early signs can be nonspecific, including fever, irritability, tachypnea, digestive disturbances and loss of appetite.
Petechiae in children also can be caused by external sources. Although bruising can be a sign of a healthy, active child, it also can be a result of abuse and should not be taken lightly. In up to 44% of fatal and near-fatal physical abuse cases, bruising was missed as an initial warning sign. The diagnosis of child abuse can be challenging because suspected child abuse investigations can have serious psychosocial implications for both patients and families; it is very important to take into consideration the location of the bruising.
On physical exam, multiple, scattered 1-mm to 3-mm pinkish-red, round macules are noted on the patient’s bilateral legs.
Source: Krakowski AC
Bruises on the extremities and forehead can result from normal play and activity; however, bruises on the genital area or behind the ears should immediately raise a red flag. In addition, bruises located on protected body surfaces with more underlying fatty tissue such as buttocks, abdomen, chest and cheeks warrant more concern.
In this case, the simplest answer turned out to be the correct one. A quick history and confirmatory physical exam revealed that the petechial rash was secondary to a tourniquet effect from the baby sling he was carried in during the hike. This is analogous to a tourniquet effect previously reported in the literature thought to be secondary to tightly applied disposable diapers. Similarly, the Rumpel-Leede phenomenon is well documented to occur in a health care setting; in this scenario, petechiae may develop in local areas after application of pressure to friable vessels; most frequently, this may be noticed after the use of a blood pressure cuff.
Fortunately, our patient’s lesions resolved spontaneously during the next several days, and he continues to thrive. With a simple adjustment to the baby sling carrier, the infant is now able to enjoy hikes with his mother and remains petechiae free.
References:
Bingham AC. J Pediatr. 2003;142:560-563.
For more information:
Shehla Admani, MD, is a clinical research fellow in pediatric dermatology at Rady Children’s Hospital, San Diego. She can be reached at 8010 Frost St., Suite 602, San Diego, CA 92123; email: sadmani@rchsd.org.
Andrew C. Krakowski, MD, is an attending physician at Rady Children’s Hospital, San Diego.
Disclosure: Admani and Krakowski report no relevant financial disclosures.