Purpura

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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151 Purpura

Instruction

Examine this patient’s skin.

Salient features

History

• Take a drug history: steroids, anticoagulants, carbimazole, phenylbutazone, chloramphenicol, gold salts

• Age (senile purpura)

• History of chronic liver disease

• History of mouth ulcers (severe neutropenia).

Examination

• Small circumscribed bleeding into the skin, purpura, or larger lesions, bruises or ecchymoses (Fig. 151.1). Lesions begin as 1–3 mm papules, which increase in size and become palpable. They may coalesce to form plaques; in some instances, they may ulcerate.

image

Fig. 151.1 Purpura.

Proceed as follows:

• Look for an underlying cause

• Comment on the patient’s age: consider senile purpura

• Comment on the distribution: Henoch-Schönlein purpura is seen over the buttocks and lower limbs (p. 566)

• Look for the following signs:

• Rheumatoid arthritis where purpura is drug induced (steroids, gold)
• Anaemia (leukaemia, marrow aplasia or infiltration)
• Chronic liver disease
• Ulcers in the mouth (severe neutropenia)
• Bleeding gums, corkscrew hair and perifollicular haemorrhages of scurvy (particularly in the elderly)
• Stigmata of Ehlers–Danlos syndrome.
• Bleeding from multiple venepuncture sites (disseminated intravascular coagulation).

• Tell the examiner that you would like toexamine spleen, liver and lymph nodes.

Diagnosis

This patient has purpura (lesion) that is caused by ingestion of steroids (aetiology) and is cosmetically unacceptable to the patient (functional status).

Questions

What are the common causes of purpura?

• Senile purpura, as a result of senile changes in the vessel walls

• Purpura induced by steroids or anticoagulants

• Thrombocytopenia as a result of leukaemia and marrow aplasia.

What are causes of bruising?

• Thrombocytopenia: idiopathic thrombocytopenic purpura, marrow replacement by leukaemia or secondary infiltration

• Vascular defects: senile purpura, steroid-induced purpura, Henoch–Schönlein purpura, scurvy, von Willebrand’s disease, uraemia

• Coagulation defects: haemophilia, anticoagulants, Christmas disease

• Drugs: thiazides, sulphonamides, phenylbutazone, sulphonylureas, sulindac, barbiturates.

Advanced-level question

What do you know about Moschcowitz syndrome?

Moschcowitz syndrome or thrombotic thrombocytopenic purpura is an acute disorder characterized by thrombocytopenic purpura, microangiopathic haemolytic anaemia, transient and fluctuating neurological features, fever and renal impairment.

E Moschcowitz (1879–1964), New York physician.

In 1951 William Harrington, then a trainee in haematology at the Barnes Hospital in St Louis, Missouri, had severe thrombocytopenia immediately after voluntarily receiving plasma from a patient with the disease, establishing beyond doubt that a plasma factor causes the destruction of platelets in chronic idiopathic thrombocytopenic purpura.

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