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7-month-old female with petechiae, purpura on the legs
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Laura F. Sandoval
Andrew C. Krakowski
An otherwise healthy, 7-month-old girl presented to the pediatric ED with new-onset lower extremity petechiae and purpura. Her parents reported no recent illness, fever or changes in activity or appetite. The child is up to date on her immunizations, and her parents have denied any history of trauma or restrictive diets. There was no family history of bleeding disorders or connective tissue disorders. The child’s mother does report a recent history of postpartum depression.
Physical exam revealed multiple scattered, ill-defined, nonblanchable, violaceous macules and patches localizing only to the bilateral, symmetric lower legs. The lesions favored the anterior and medial aspects, and a sharp “cut-off” was noted superiorly. The child’s palms and soles were clear, with no edema, vesicles or bullae observed. Her pulse was normal in both lower extremities.
Figure 1. Patient displays multiple scattered, ill-defi ned, nonblanchable, violaceous macules and
patches localized to the bilateral, symmetric lower legs.
Source: Krakowski AC
Labs were significant for mild transaminitis with elevated aspartate transaminase at 76 U/L and alanine transaminase at 67 U/L, elevated platelets of 556 TH/µ, and elevated creatine kinase of 182 U/L. Fibrinogen, aPTT, PT, and INR were within normal limits. The skeletal survey was normal. MRI and MRA of the lower extremities also were normal.
Case Discussion
A rare event that can result in significant delays in medical treatment, the Rumpel-Leede phenomenon (C) was first reported in 1909 by Theodor Rumpel, and again in 1911 by Carl Stockbridge Leede, while treating patients with scarlet fever who developed petechiae on their arms where tourniquets had been applied. The Rumpel-Leede sign has since been reported in association with leukemia, liver disease and infantile scurvy. Classically, the sign has been reported in certain adult patient populations after application of an ambulatory blood pressure cuff.
The differential diagnosis for petechiae or purpura in an otherwise healthy-appearing infant is broad and includes infection, vasculitides, congenital or acquired bleeding disorders, and accidental and nonaccidental trauma.
Despite being afebrile and appearing otherwise healthy, the child was admitted for direct observation. No new petechiae were noted over the next 24 hours, her labs normalized, and the child remained in excellent health. When further questioned about events preceding the rash, the patient’s mother recalled transporting the infant during an extended jog in a forward-facing baby carrier 1 day prior to the appearance of the patient’s rash.
The remainder of the patient’s inpatient course was unremarkable, and she was discharged. Two days later, at follow-up with the pediatric dermatology department, all of the patient’s lesions had faded, and no new lesions were identified. The family deferred further evaluation at that time.
This infant’s findings are consistent with a presentation of so-called “baby carrier purpura.” This benign, self-limited condition appears to be a Rumpel-Leede–like phenomenon characterized by acute dermal capillary rupture caused by tourniquetlike forces leading to distal petechiae or purpura in specific association with baby carriers.
The tourniquetlike forces exerted by excessively tight baby carriers may be sufficient to induce a Rumpel-Leede–like phenomenon in an infant population where capillary fragility may be more likely due to young age. Similar findings might be expected with tight-fitting clothing or diapers. It is unclear if this child’s initial labs were indicative of mild muscle damage from the tourniquetlike effect or simply reflective of an underlying viral etiology that may have lowered the threshold for a Rumpel-Leede–like phenomenon to occur.
Recognition of the specific clinical presentation of “baby carrier purpura” — when the appropriate history and physical exam findings are identified — may help to reassure families and providers alike and may help spare infants from unnecessary, costly and invasive evaluations and treatments.
- For more information:
- Laura F. Sandoval, DO, is a second-year dermatology resident at Sampson Regional Medical Center, in Clinton, N.C. She can be reached at lsandovaldo10@gmail.com.
- Andrew C. Krakowski, MD, is chief medical officer of DermOne in West Conshohocken, Pa.
Disclosures: Sandoval and Krakowski report no relevant financial disclosures.