Non-blanching rash in a child
A quick visual on the common causes of a non-blanching rash ( NBR ) in childhood. NBR is any rash in which the colour does not change with direct pressure.
A NBR can be petechiae or purpura or both. It happens due to extravasation of blood from the vasculature into the skin or mucus membranes. It does not fade with pressure. It can happen due to-physical trauma to capillaries , inflammatory injury to capillary wall , low circulating levels of platelets
Causes can be
Infective-Viral – several viral infections as ◘ Enterovirus ◘ Parvovirus B19 ◘ Dengue ◘ Cytomegalovirus ( CMV ) ◘ Respiratory synctical virus ( RSV ) ◘ Epstein-Barr virus ( EBV ) ◘ Rotavirus ◘ Adenovirus ◘ Influenza rhinovirus Bacterial ◘ Meningococcal ◘ Scarlet fever ◘ Infective endocarditis
Trauma – Accidental injury NAI e.g child abuse Increased pressure following bouts of coughing , vomiting or straining Seat belt compression in RTAs
Haematological and malignancy – Leukaemia Platelet disorders e.g Idiopathic thrombocytopenic purpura Fanconi anaemia Disseminated intravascular coagulation ( DIC ) Haemoltyic uraemic syndrome ( HUS ) Splenomegaly Neuroblastoma Neonatal alloimmune thrombocytopenia ( NAIT )
Vasculitic and Inflammatory- HSP and SLE
Others –Ehler Danlos Drug reactions Vitamin K deficiency
Idiopathic immune thrombocytopenic purpura Autoantibody mediated destruction of platelets leading to isolated thrombocytopenia Commonest reason for thrombocytopenia in childhood ( age 2-10 yrs ) level at which petechiae appear are usually in range of 10-20 A h/o viral URTI or vaccination is common Child is otherwise well – but may present with sudden onset of bruises , purpura , mucosal haemorrhage and petechiae Runs a benign self limiting course but platelet count platelet count recovers in 6-12 wks
Acute Leukaemia –ALL ( acute lymphatic leukaemia ) most common malignancy seen in children Presentation depends on ○ how bad are the blood counts – marrow infiltration leading to for e.g pancytopenia ○ extramedullary and organ inflitration ( hepatosplenomegaly , lymphadenopathy , bony pains ) ○ systemic symptoms due to cytokine release Based on above ○ may not be acutely unwell ○ may have widespread petechial haemorrhage or ecchymoses on limbs and trunks ○ lethargy, pallor , fever ○ bony pain or limp ○ recurrent infection , sepsis ○ lymphadenopathy and hepatosplenomegaly Prognosis has improved dramatically now and almost 85 % of childhood leukaemias can be now cured
henoch-Schonlen purpura –Acute vasculitis of unknown cause Commonest childhood vasculitic disease- in children aged 3-10 yrs Characterized by ○ cutaneous palpable purpura ( not thrombocytopenic ) symmetric distribution dependent parts , extensors of both legs , buttocks , around ankles painful s/c oedema ○ arthralgia / arthritis ○ gastrointestinal involvement abdominal pain , vomiting , intussception ○ renal involvement which can include microscopic haematuria , proteinuria , nephrotic syndrome , nephritis , hypertension and renal impairment Seasonal variations – most cases in autumn and winter A preceding h/o URTI is common Rash may be be urticarial at onset which becomes maculopapular with petechiae and purpura Diagnosis is clinical – no biomarker Management is supportive – runs a self limiting course BP and urine dipstick in 1° care to monitor for renal damage in uncomplicated cases
Image from Public health image Library ( PHIL ) content provider CDC / Mr.Gust This image depicts an anterior view of the lower legs of an 8-year-old patient, who presented with numerous erythematous lesions, which had been identified as anaphylactoid purpura, also known as Henoch–Schönlein purpura (HSP). The precise cause for this reaction is unknown, but HSP involves an inflammatory process of small blood vessels, including the deposition of immune complexes, specifically antibody IgA. This reaction is self-limited, resolving itself within a few weeks. However, statistics show that there can be a secondary onset in one-third of cases, with 1% of cases including permanent kidney damage.