Peds Case 21- 6Y/o W Bruising

Front 1

Petechiae and Purpura

Back 1

Trauma
Platelet deficiency or dysfunction (e.g. immune-mediated thrombocytopenia, bone marrow infiltration or suppression, malignancy)
Coagulation abnormalities (e.g. hereditary or acquired clotting-factor deficiencies)
Vascular fragility (e.g., immune-mediated vasculitis)

Combinations of the above (e.g., infection causing coagulation abnormalities, vascular fragility, platelet consumption)

Front 2

bacterial endocarditis

Back 2

usual presenting complaints are fever, fatigue, and weight loss

petechial rash is commonly seen in patients with bacterial endocarditis, but larger lesions that could be mistaken for bruising are not characteristic, making this an unlikely diagnosis for Alex.

A fever is usually present, but may be low-grade.

Front 3

meningococcal septiciemia

Back 3

may present with petechiae and purpura, which can be confused with bruising. While the early stages of meningococcemia may only have mild symptoms, by the time the hemorrhagic rash appears, patients are usually very ill appearing

Front 4

Rocky Mt Spotted Fever

Back 4

hallmark is fever

rash of RMSF is often petechial, and starts on the extremities before moving centrally.

Front 5

Systemic lupus erythematosus often presents with

Back 5

constitutional symptoms such as fever and malaise.

rash can be variable

more common in older children and in girls

Front 6

Henoch-Schonlein purpura (HSP)
anaphylactoid purpura

Back 6

otherwise well appearing child with bruising, leg pain (due to arthritis)
rash primarily in lower extremities

50% of cases follows an URI

periarticular vasculitis= arthritis and arthralgia

self-limited, IgA-mediated, small vessel vasculitis
involves skin, GI tract, joints and kidneys (1/3 kids)
most common form of vasculitis (about 50%) in children. hallmark: non-thrombocytopenic purpura.
One-third have renal involvement, most common manifestation is hematuria. Renal involvement less common under 2y/o (25%)
5% progress to chronic renal failure, and fewer than 1% will have end stage renal disease.
Arthritis, mainly of the knees and ankles, 75%
colicky abdominal pain in 65%
Two-thirds recent upper respiratory tract infection

usually lasts a month or so and goes away without any treatment. At this point, all we need to do is repeat a urine test in a few days and follow his blood pressure.

half of kids with HSP may develop some intestinal bleeding b/c vasc inflamm
pain can be tx w short course of oral steroids but controversial (reducing gastrointestinal manifestations but not kidney involv)

Front 7

Leukemia

Back 7

presents with constitutional sx:s fever, malaise and weight loss

bone pain is a presentation of leukemia due to an infiltration of the bone marrow by malignant cells

petechiae can be caused by thrombocytopenia due to bone marrow replacement by malignant cells

adenopathy and splenomegaly
arthralgia b/c bone and joint pain

Front 8

Idiopathic thrombocytopenic purpura

Back 8

often presents with asymptomatic petechiae

nonspecific URI precedes cases 50% of the time.

caused by the binding of an antiplatelet antibody to the platelet surface, leading to removal and destruction of platelets in the spleen and liver.
common cause of isolated thrombocytopenia in otherwise healthy children.
smear: thrombocytopenia with a giant (immature) platelet.

Front 9

Coagulation disorder

Back 9

petechiae or superficial bruising, but more often present with easy bruising in deep tissues or hemarthrosis

hemophilia more likely bleed into joints and soft tissues than superficially
vWBD= mucosal bleeding and superficial brusing in response to trauma

no splenomegaly

Front 10

viral infections

Back 10

some present with rashes that can be petechial, such as enteroviruses.
less common assc w bruising and rash not restricted to lower extremities.
low grade fever and while constitutional complaints are frequently seen, they may be absent.
Prominent coughing and/or vomiting can also cause petechiae, generally above the nipple line

can cause splenomegaly

Front 11

hepatomegaly

Back 11

downward displacement of the liver with air-trapping in pulmonary disease

Hepatomegaly may occur as a result of inflammation (e.g., viral hepatitis), infiltration (e.g., leukemia/lymphoma), accumulation of storage products (e.g., glycogen-storage disease), congestion (e.g., congestive heart failure) or obstruction (e.g., biliary atresia).

liver edge may be palpable up to 3.5 cm below the costal margin in newborns, and up to 2 cm below the costal margin in older children (though more typically not more than 1 cm)

Front 12

Causes of arthritis to consider in a school-age child

Back 12

- Trauma
- Septic arthritis
- Transient synovitis
- Reactive arthritis (e.g., post-streptococcal arthritis)
- Lyme disease
- Rheumatic fever
- Juvenile Idiopathic Arthritis
- Systemic Lupus Erythematosus
- Henoch-Schönlein Purpura

Arthralgia refers to pain in or around the joint -- without signs of synovitis

"arthritis" is used in the presence of true synovitis, defined as either joint swelling or joint pain with limitation of motion on exam.

Front 13

splenomegaly

Back 13

spleen tip is palpable in up to one-third of neonates, approximately 10% of normal children, and 2% of healthy adolescents. A spleen edge felt more than 2 cm below the left costal margin is considered abnormal.


Splenomegaly in children is most often caused by infection (e.g., EBV, CMV, bacterial sepsis, endocarditis),
hemolysis (e.g., sickle cell disease),
malignancy (e.g., leukemia, lymphoma),
storage diseases (e.g., Gaucher disease),
systemic inflammatory diseases (e.g., SLE or juvenile idiopathic arthritis - JIA)
congestion (e.g., related to portal hypertension).

Front 14

labs for ITP vs. leukemia vs. HSP

Back 14

platelet count is essential to determine whether this is thrombocytopenic (ITP or leukemia) or non-thrombocytopenic purpura (HSP).

hemoglobin and leukocyte count for leukemia.

determine if there is renal involvement in HSP
urinalysis will detect hematuria and/or proteinuria. BUN and creatinine are indicated to determine the extent of renal disease.

ESR and ANA too non-specific
not support blood culture or PT/PTT

Front 15

Intussusception

Back 15

most common form of bowel obstruction in children 6 mos-6y/o (80% under 2)
boys> girls

proximal segment of bowel invaginates or telescopes into the distal segment adjacent. accompanying mesentery becomes entrapped, causing vascular compression and eventual ischemia.

classic triad (minority):
- Paroxysms of severe abdominal pain with inconsolable crying
- Passage of “currant jelly" stool containing blood and mucus
- Palpation of a “sausage-shaped" mass in the right abdomen

Additional signs and symptoms: vomiting (bilious or non-bilious), lethargy and a toxic appearance, with or without signs of pain.

Most cases do not involve a discrete, identifiable lead point. Hypertrophied intestinal lymphoid tissue (e.g., in response to a concurrent viral infection) has been suggested as a possible trigger.

Occasionally, a pathological lead point (e.g., polyp, Meckel's diverticulum) starts the telescoping process. Intussusception in HSP likely begins at points of intestinal edema or submucosal hemorrhage.

Idiopathic intussusception (in which there is no identifiable lead point) occurs in otherwise healthy infants and toddlers.
majority ileocecal junction
dx w air or barium enema. Ultrasound initial eval
tx: telescoped segment of bowel reduced by air or hydrostatic pressure. Occasionally, procedure is unsuccessful and require surgical reduction.

Intussusception occurring in HSP is usually ileo-ileal, not ileo-colic, and will not be reduced by air or barium enema. Diagnosis requires abdominal ultrasound, and treatment is generally surgical.

Front 16

XR with intussusception

Back 16

Central ring of hypoattenuation (arrow heads) corresponds to mesenteric fat in the intussusceptum. There is no small bowel dilatation or radiographic evidence of small bowel obstruction

Front 17

recurrent HSP

Back 17

recurrence rate for HSP is about 30%. Symptoms may return weeks to many months after the first episode. Recurrences (like the initial episode) may start with abdominal pain, rather than rash

always check urine for renal involv