Images in Emergency Medicine
Article Outline
A 42-year-old black woman presented with a 4-four day history of oral lesions, a cutaneous rash, intermittent epistaxis, and vaginal spotting despite a hysterectomy 6 years ago. She had an upper respiratory tract infection 4 weeks before presentation, and her body aches and low-grade fever had persisted. Her vital signs, including oral temperature, were normal. Physical examination was remarkable for the cutaneous rash and oral lesions pictured. Also noted was a large bruise over her forehead, where she had bumped into a table 2 days before.
Diagnosis
Immune thrombocytopenic purpura
This patient had a CBC count that was remarkable for a platelet count of 2,000, and a diagnosis of immune thrombocytopenic purpura was considered. Subsequent study results, including a computed tomography scan of the head, were normal.
Severity of immune thrombocytopenic purpura can range from asymptomatic thrombocytopenia to spontaneous intracranial or other significant internal bleeding. Physical manifestations of immune thrombocytopenic purpura include easy bruising (Figure 1), bleeding gums, palpable purpura (Figure 2), and petechiae (Figure 3, Figure 4). In dark-skinned individuals, cutaneous signs of immune thrombocytopenic purpura can be easily overlooked without close and purposeful inspection of the skin. In these patients, it is important to examine the mucosal membranes, which are less pigmented, to help make a diagnosis of thrombocytopenia. In this patient, inspection of the mucosal membranes revealed significant mucosal hemorrhages (Figure 5).
Figure 1.
Forehead bruise.
Figure 2.
Lower extremity rash.
Figure 3.
Lower extremity rash.
Figure 4.
Lower extremity rash.
Figure 5.
Oral lesions. Used with permission of Blaine Hannafin, MD, of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ.
Immune thrombocytopenic purpura is a diagnosis of exclusion, and a medical evaluation should exclude other causes of thrombocytopenia.1, 2 Acute treatments include prednisone 1 to 2 mg/kg and anti-D immunoglobulin for Rh-positive individuals. Platelet transfusions are indicated for emergency treatment of internal bleeding or preparation for major surgery.1, 2 Some patients require splenectomy if they fail initial interventions.
References
For the diagnosis and teaching points, see page 665.To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com
PII: S0196-0644(07)00382-4
doi:10.1016/j.annemergmed.2007.03.021
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
