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Unexplained, painful bruising in a teenage female
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A 13-year-old previously healthy female is seen by her primary for evaluation of some unexplained painful bruising of her upper extremities that began about 2 weeks earlier. She denied any injury or recent illness, and she was taking no medications. The problem began as erythematous bumps that were somewhat painful and appeared to be progressive with more areas of spontaneous, firm swelling over the first week, followed by bruising.
The bruises seem to be appearing almost exclusively on the extensor surfaces of her arms, but she also complains of some pain on her lateral, lower left leg, but no skin changes were noticed, and she has had no fever recently or any other systemic symptoms.
On examination, her vital signs are normal, and her skin exam reveals the apparent bruising described above (Figures 1-4), with some underlying swelling. The patient also has an impetiginous lesion near her chin (Figure 5), which further history revealed that she has had a sore in that location before, but cannot remember when. Otherwise, her skin is clear, with no petechiae, other areas of bruising or other lesions seen, and the rest of her exam is normal.
Figure 1. Left forearm
Figure 2. Left upper arm
Figure 3. Right upper arm
Figure 4. Right forearm
Images: Brien JH
Figure 5. Recurrent chin sore
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Case Discussion
The lesion on her chin turned out to be cutaneous herpes simplex infection, an uncommon trigger for erythema nodosum (B), which is thought to be a delayed hypersensitivity reaction resulting in a panniculitis with a surrounding inflammatory reaction. It usually occurs on the anterior aspects of the lower legs (shins), but can occur anywhere. It is most commonly associated with group A streptococcal infections, but can be triggered by a wide variety of infectious and noninfectious causes.
It is a clinical diagnosis with a good history and physical exam, which often reveals the history of painful bumps with varying degrees of erythema that usually goes through some color changes, similar to a bruise within a couple of weeks.
A biopsy revealing inflammation about the subcutaneous fat without vasculitis would help confirm the diagnosis, but is usually not necessary if the clinical course is typical and no menacing underlying disease is suspected. Some triggering infections, such as tuberculosis and HIV, as well as noninfectious causes such as lupus, cancer, and other severe inflammatory diseases should be considered, but most of the time, the problem resolves spontaneously without knowing the specific cause.
Figure 6. Gianotti-Crosti syndrome
One would expect a coagulopathy to result in more generalized, ongoing bruising and possibly petechiae. Coagulopathies are usually quickly ruled out with supporting lab results. However, unreported abuse should also be considered. Trauma or abuse should be carefully ruled out with a good history and an exam showing a suspicious pattern of injury. This was not the case with the child presented.
Gianotti-Crosti syndrome is another immune-mediated condition that results in small reddish-purple lesions on the extremities that may include some vesicular component. This also is known as papular acrodermatitis of childhood (Figure 6). The reaction is usually triggered by Epstein-Barr virus in this country. Ferdinando Gianotti, MD, and Agostino Crosti, MD, Italian dermatologists, first described these lesions in 1955 in patients with hepatitis B virus, which may lead the list of triggers in countries with a high rate of hepatitis B infections.
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- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.