Bruising

Last Updated on by frcemuser

The term ‘purpura’ describes a purplish discolouration of the skin produced by small bleeding vessels near the surface. Purpura may also occur in the mucous membranes, especially of the mouth and in the internal organs. Purpura is not a disease but is indicative of an underlying cause of bleeding.

When purpura spots are very small (<1 cm in diameter), they are called petechiae or petechial haemorrhages. Larger, deeper purpura are referred to as ecchymoses or bruising.

Differential diagnosis

  • Trauma (accidental)
  • Non-accidental injury
  • Meningococcal septicaemia
  • Vascular disorders
    • Senile purpura
      • Common benign condition resulting from impaired collagen production and capillary fragility in elderly people.
      • Manifests as bruises which are usually bilateral on extensor surface son hands/forearms/face/neck.
    • Simple purpura (‘easy bruising syndrome)
    • Hereditary haemorrhagic telangiectasia (HHT)
      • Rare autosomal dominant genetic disorder which leads to mucocutaneous telangiectasia of the skin, mucous membranes and organs.
      • May be a positive family history, recurrent nosebleeds, fatigue, nail changes and hair loss.
    • Ehlers-Danlos syndrome
      • This causes joint hypermobility and skin translucency and hyperextensibility.
      • It may present with gingival bleeding, prolonged bleeding after surgical procedures, and menorrhagia.
      • Abnormalities in capillary structure and deficiencies of perivascular collagen cause vascular fragility, and blood vessels may rupture when subjected to shearing forces.
    • Osteogenesis imperfecta
      • This is characterised by blue sclerae, short stature, bone fragility, dentinogenesis imperfecta, and adult hearing loss.
      • Easy bruising after minimal or no trauma is thought to occur due to platelet dysfunction and capillary fragility.
    • Vitamin C deficiency (scurvy)
      • May occur following a lack of fresh fruit and vegetables over prolonged periods of time.
      • May present with perifollicular haemorrhage and bruising, dental deterioration, impaired wound healing, and coiled hairs.
  • Platelet disorders
    • Acute idiopathic thrombocytopenic purpura (ITP)
      • Usually seen in children
      • Caused by a reaction to a viral infection resulting in the production of antibodies against platelets
      • Sx: easy bruising, sudden onset of petechiae, nosebleeds, menorrhagia
      • Splenomegaly may be seen on examination but this is rare
      • Usually self–limiting, with about 90% of children recovering within 6 months
    • Chronic ITP
      • Most common in adult women.
    • Henoch-Schonlein purpura
    • Aplastic anaemia
      • This is a bone marrow disorder which commonly presents with fatigue, recurrent infections, and mucosal bleeding due to anaemia, leukopenia, and thrombocytopenia.
    • Malignancy with bone marrow involvement
      • Acute lymphocytic or myelogenous leukaemia often present with fatigue, recurrent infections, and mucosal bleeding or bruising. Full blood count may show a pancytopenia with thrombocytopenia, neutropenia, anaemia, and an elevated white blood cell count.
      • Neuroblastoma in a child, where tumour infiltration of the bone may present with periorbital bruising. The child is likely to be systemically unwell and may have a palpable abdominal mass.
      • Myeloma or myeloproliferative disorders may present with bone pain, fatigue, and anaemia.
    • End-stage chronic kidney disease
      • May cause abnormalities of platelet aggregation and prolongation of bleeding time.
    • Liver disease
      • May cause abnormalities of platelet function and number, the quality of clotting factors and proteins, and the quality of the skin and connective tissues.
  • Coagulation disorders
    • Haemophilia A (factor VIII deficiency) and B (factor IX deficiency)
      • X-linked conditions
      • Features depend on the level of clotting activity, and include spontaneous haemarthrosis, especially of the knees, ankles, and elbows; and muscle haematomas in severe haemophilia. Increased or delayed bleeding with injury or postoperatively is typical of milder disease.
    • Liver disease
      • Liver disease can cause impaired synthesis of clotting factors.
    • Vitamin K deficiency
      • This can result in functional deficiencies of factors II, VII, IX, and X, and proteins C and S, and can cause bleeding in an infant in the first weeks of life, when it is known as Haemorrhagic Disease of the Newborn (HDN).
      • Vitamin K deficiency can also occur due to malnutrition, and in older children and adults as a result of malabsorption, caused by conditions such as coeliac disease and cystic fibrosis.
    • Von Willebrand disease (VWD)
      • The most common inherited coagulation disorder, with an incidence of up to 1% in the general population.
      • Inherited as an autosomal dominant disorder (equally common in males and females).
      • Typically presents with mild to moderate mucocutaneous bleeding, such as nosebleeds, menorrhagia, or prolonged bleeding after surgical incisions or dental procedures.
    • Amyloidosis
      • This condition may be associated with decreased factor X levels as amyloid light chain fibrils in the liver and spleen absorb this clotting factor. Bleeding symptoms may be exacerbated by vascular fragility.
  • Drugs
    • Corticosteroids
    • Drugs which impair platelet function
      • Aspirin, NSAIDs, clopidogrel, SSRIs
    • Drugs which cause low platelets
      • Alcohol, antibiotics (cephalosporins, nitrofurantoin, penicillins, sulfonamides), carbamazepine and valproate, quinine, propranolol, thiazides
    • Drugs which inhibit coagulation
      • Warfarin, heparin, NOAC medications (apixaban, dabigatran, and rivaroxaban)

Suspecting non-accidental injury in children with bruising

Suspect non-accidental injury and physical abuse when:

  • Bruises are on a child who is not yet independently mobile (crawling, cruising, or walking).
    • Bruising appropriate to learning to walk is common from around 1 year of age when most children have started ‘cruising’. It is typically distributed on the anterior tibia and knee, followed by the upper legs and forehead.
  • Bruises have indicative features.
    • Disproportionate to the explanation of injury sustained.
    • Unusually large.
    • Present in multiple sites or in clusters.
    • Of a similar shape and size.
    • Patterned in the shape of a hand print, ligature, stick, tooth (or teeth marks), grip, or implement (such as a belt). Fingertip bruising is often found in children with a bleeding disorder.
    • Associated with petechiae.
  • Bruises are found in indicative places.
    • Sites that are not typical for the age of the child.
    • Any non-bony part of the body or face (including the eyes, ears, cheeks, back, abdomen, buttocks, arms, and genitalia).
    • On both sides of the face or head.
    • On the neck (consistent with strangulation).
    • On the ankles and wrists (consistent with use of a ligature).
  • The explanation for the bruising is implausible, inadequate, or inconsistent:
    • With the child’s presentation, normal activities, existing medical condition, age or developmental stage, or account — compared with that given by parents or carers.
    • Between parents or carers.
    • Between accounts over time.
  • There is a delay in presentation.

 

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