Download - Purpura
APPROACH TO PURPURA
By Dr.Kamran M Saeed
PGR Medicine DHQ Rwp
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Terms• Petechiae
– Pinpoin-sized (<3mm) macule of blood in the skin
• Purpura– Larger macule/papule (>3mm) of blood in
the skin• Echymosis
– Large confluent area of Purpua
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CAUSES• Primary cutaneous pathology• Systemic disease
• Palpable• Non-palpable
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Primary cutaneous disorders
• Trauma• Solar purpura• Steroid purpura• Capillaritis• Livedoid vasculopathy
NON PALPABLE
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Systemic diseases
• Clotting disturbances – Thrombocytopenia (including ITP)– Abnormal platelet function– Clotting factor defects
• Vascular fragility– Amyloidosis– Ehlers-Danlos syndrome– Scurvy
NON PALPABLE
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Systemic diseases• Thrombi
– DIC– Monoclonal cryoglobulinemia– HIT & thrombosis – TTP & HUS– Warfarin reaction
• Emboli– Cholesterol– Fat
• Possible immune complex– Gardner-Diamond syndrome (autoerythrocyte sensitivity)– Waldenström's hypergammaglobulinemic purpura
NON PALPABLE
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Systemic diseases• Vasculitis
– Cutaneous small-vessel vasculitis – Polyarteritis nodosa
• Emboli – Acute meningococcemia – Disseminated gonococcal infection – Rocky Mountain spotted fever – Ecthyma gangrenosum
P
A
L
P
A
B
L
E
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PRIMARY CUTANEOUS DISORDERS
(non-palpable)
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Solar Purpura
• Caused by chronic sun exposure• Usually on forearms, extensor surface
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Steroid purpura
• 2ndry to:– potent topical glucocorticoids – Endogenous/exogenous Cushing's syn.
• On any location
Steroid & Solar purpura, both are caused by alteration of the supporting connective tissue that surrounds the dermal blood vessels
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Capillaritis
• Pigmented purpuric dermatosis• Perivascular lymphocytic inflammation• Bright red petechiae, 1–2 mm size,
scattered w/in annular or coin-shaped yellow-brown macules
• Mainly in lower part of legs
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SYSTEMIC DISEASES(non-palpable purpura)
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Clotting disturbances
• Thrombocyotopenia & abnormal plt function, clotting factor defects:
– Usually starts in lower extremities, may later involve whole body
– Also includes purpura 2ndry to VHF
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Vascular fragility
• Congenital, acquired & herititary– Ehlers-danlos syn– Scurvy– Systemic amyloidosis
• Fragile blood vessels especially capillaries d/t poor/lax supporting tissue
•prominent in the lower extremities•perifollicular in distribution, with flattened corkscrew hairs
• Generalized.• Associated features,
like joint hypermobility, lax skin, hernias, MVP, AA
•can occur at any site•Periorbital hemorrhage
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Thrombi
• DIC:– Triggered by
1. Infection
2. Injury
3. Neoplasms
– Generalized– Purpura fulminans
•A form of DIC associated w/ fever & hypotension•Occurs more in children•Following an infection such as varicella, scarlet fever, or URTI
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Thrombi
• Monoclonal cryoglobulinemia:– Associated with:
1. MM
2. Waldenström's macroglobulinemia
3. Lymphocytic leukemia
4. Lymphoma
– Primarily lower extremities– hemorrhagic infarcts (fingers & toes)– Exacerbation following cold exposure
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Thrombi
• TTP & HUS– Hemorrhagic infarcts– Generalized thrombocytopenic purpura– Fever– Microangiopathic hemolytic anemia– Renal failure
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Thrombi
• Warfarin:– warfarin-induced necrosis– develops between 3rd & 10th Day of
treatment• Heparin:
– HIT
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Emboli
• Cholesterol emboli:– Usually in lower extremities– Atherosclerosis– Anticoagulation– Vascular procedures– Livedo reticularis
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Emboli
• Fat embolism:– Post trauma– Upper body distribution
• Other emboli:– Atrial myxomas– Infective endocarditis
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Possible immune complex
• Gardner-Diamond syndrome:– Females– Ecchymoses w/in areas of painful, warm
erythema– ?Psychogenic purpura?
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Possible immune complex
• Waldenström's hypergammaglobulinemia– Chronic disorder – Petechiae on lower extremities– IgG–anti-IgG molecules– Ppt by prolonged standing or walking
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SYSTEMIC DISEASES(palpable purpura)
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Vasculitic
• Cutaneous small-vessel vasculitis:– Leukocyotoclastic vasculitis (LCV)– Inflammatory damage to cutaneous
vessels– Causes:
1. Drugs
2. Infections
3. CTD/autoimmune (HSP)
• PAN:
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Emboli
• G –ve cocci (meningococcus, gonococcus)
• G –ve (Enterobacteriaceae)• G +ve cocci (Staphylococcus)• Rickettsia• Candida & opportunistic fungi
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Emboli
• Acute meningococcemia:– primarily on trunk, lower extremities,
pressure sites– 1mm to several cm– gunmetal-gray color w/in the lesions– Associated findings
• Preceding URTI• Fever• Meningitis• DIC
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Emboli
• Disseminated gonococcal infection:– Papules & vesicopustules w/ central
purpura or hemorrhagic necrosis– Distal extremities– Associated features
1. Arthralgias
2. Tenosynovitis
3. Fever
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Emboli
• Rocky Mountain spotted fever:– fever, chills, severe headache, and
photophobia precede onset of cutaneous eruption
– erythematous macules & papules on wrists, ankles, palms, & soles
– Spread centripetally
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Emboli
• Ecthyma gangrenosum:– edematous, erythematous papules or
plaques and then develop central purpura and necrosis
– Associated w/ G –ve infections
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PURPURA
Non-palpable
Primary Skin pathologies
SystemicClotting problems
Vessel fragilityThrombiEmboliimmune
Palpable
VasculitisEmboli
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THE END
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