Purpura
(Approach: Establish purpura, rule out anaemia and neutropenia, establish
cause)
Examination
 Introduce, thank pt, ask for pain and request to undress, note any nasal speech
(Wegener’s)
 General inspection
 Age
 Cushingoid
 Renal failure, CLD
 Extent – ULs, LLs trunk
 Examine individual lesions in the ULs or LLs
 Palpable = vasculitis
 Central hemorrhagic necrosis of HSP
 Petechiae, ecchymosis
 Cockscrew hair, perifollicular haemorrhages
 Thin skin
 Upper limbs
 Hands
 RA/SLE/Scleroderma
 IE signs – Osler’s nodes, splinters, clubbing
 Nails involvement
 CLD stigmata
 Elbows

RA nodules, thickened nerves (leprosy)
 Face
 Jaundice
 Conjunctival pallor (haematological disease)
 Malar rash
 Mouth – Ulcers, rashes, bleeding gums (scurvy for elderly patient)
 Chest
 CLD stigmata
 Lower limbs
 Arthritis of knees and ankles
 Examine the feet
 Requests
 LNs
 Abdominal examination – hepatosplenomegaly
 Peripheral neuropathy
 Temperature chart
 Urine dipstik – hematuria in vascultis with renal involvement
 Drug history
Presentation
Sir, this patient has
 Purpura/palpable purpura as evidenced by non blanchable, well-demarcated
reddish/purplish patches
 Presence/absence of petechiae, ecchymosis



Distribution and extent
Anaemia and mouth ulcers (neutropenia)
Cause (purpura)
 Age (Mention perifollicular haemorrhages and cockscrew hair if elderly)
 Cushingoid
 renal failure
 Liver failure
 Chest scars – anticoagulation
 Obvious haemarthrosis (haemophilia)
 Ehlers Danlos

Cause (palpable purpura)
 AI conditions
 Infections
 Malignancy
 Drugs
Treatment (Cushingoid – can be cause of purpura or treatment for vasculitic rash)
Complete examination for spleen, liver and LNs


Questions
What are your differential diagnoses for purpura?
 Thrombocytopenia
o ITP
o BM infiltration – haematological malignancies
o BM aplasia
o CLD
 Capillary fragility
o Senile purpura
o Chronic steroid ingestion
o Vasculitis eg HSP
o Renal failure
 Coagulation factors (ecchymoses)
o Haemophilia
o Christmas disease
o Anticoagulation
o CLD
What are the causes of a palpable purpura/vasculitis rash?
 Autoimmune
o SLE/RA/SSc
o Churg-Strauss/PAN/Wegener’s
o PBC/UC/Cryoglobulinaemia
 Mitotic
o Solid
o Haematological – Lymphoproliferative, paraproteinaemia
 Infective
o Viral – HIV, Hep B, Hep C, EBV, influenzae
o Bacterial – IE, TB, leprosy, Streptococcal
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Drug

o
o
o
o
o
Idiopathic
Aspirin
Antibiotics (penicillins, sulphonamide)
Allopurinol
Anticoagulant
Phenytoin, Gold
What are the common causes of purpura?
 Senile purpura
 Secondary to steroids and anticoagulants
 Thrombocytopenia from leukaemia or marrow aplasia
How would you investigate this patient?
 After taking a detailed drug history
 Blood Ix – FBC, biochemistry, liver function test, coagulation profile and protein
electrophoresis (rule out paraproteinaemia), ANAs, dsDNA, ANCAs
 Skin Bx – small vessel vasculitis
 Others – Bone marrow biopsy, trephine biopsy of the iliac crest