Case 5: A 15 year old girl with a purpuric skin rash
Written by: Ezzeldin Saleh, MD, FAAP, Pediatrician, Franciscan Skemp-Mayo Health System, La Crosse, WI, USA Reviewed by: Haleem Rasool, MD, Chairman Department of Oncology, Franciscan Skemp-Mayo Health System, La Crosse, WI, USA
History:
A previously healthy 15-year-old girl develops a rash on her legs and easy bruising that started 5 days prior to presentation. She has had multiple bruises on her shins from bumping against the stairway at home. Her mother noted on the day of presentation that she has many tiny purple/red spots on her chest, neck, and the rest of her body. She denies any nosebleeds, bleeding per rectum or black tarry stools. She has no headaches, or fever. She had mild cold symptoms two days ago. There is no joint pain or swelling. Review of other systems is within normal limits. Menarche started at 13 years of age. Her periods have been irregular but with normal flow and without clots or significant bleeding. Last menstrual period was 2 ½ months ago. She takes no medications or supplements, and has no allergies to any medications.
Past Medical History: No history of chronic conditions or recurrent illnesses. No previous hospitalization or surgeries. She had received immunizations till the age of 6.
Family/Social History: There is no significant family medical history, including no history of cancer. There is no history of easy bruising or bleeding problems in her family. She lives with her parents and ten siblings on a dairy farm. She is home schooled and finished her eighth grade. No smoke exposure.
Physical Examination:
Vital Signs: Weight is 55.8 kg. Height 158 cm. Temperature 37.5 C. Pulse 105. Respirations 20. Blood pressure 128/80. Oxygen saturation 100% on room air.
General: The patient is awake, alert, pleasant, and cooperative.
Head, Eyes,Ear, Nose, and Throat (HEENT): Normocephalic. Conjunctivae and sclerae are clear. Pupils are equally responsive and reactive. Tympanic membranes are clear bilaterally. No hemotympanium. Nares: crusted blood in the right nostril. Oropharynx: She has petechiae on her lips, tongue and oral mucosa with minimal gingival bleeding.
Neck: supple without lymphadenopathy.
Lungs/Heart: Normal exam.
Abdomen: soft, nontender, and nondistended. No hepatosplenomegaly. No masses.
Skin: She has a petechial rash and purpuric lesions on her neck, upper chest, her back, and abdomen, and also extending to her lower extremities. She has bruises and ecchymoses on her shins. Rest of her exam is normal.
© Sudanese American Medical Association, 2010
Investigations
| Laboratory Test |
Value |
Normal Range |
| Hemoglobin |
13.5mg/dl |
12.0-15.5 |
| Hematocrit |
38.2% |
34.9-44.5 |
| White Blood Cell Count |
9,300/ µL |
3.5-10.5 |
| Platelet Count |
1000/ µL |
150,000-450,000 |
| Manual differential |
67% neutrophils |
42-75 |
|
1% bands |
0-3 |
|
|
28% lymphocytes |
16-52 |
|
|
2% monocytes |
1-11 |
|
|
1% eosinophils |
0-7 |
|
|
1% basophils |
0-4 |
|
| Peripheral Smear | normocytic and normochromic red blood cells, the platelets are markedly reduced in number and unremarkable in morphology. The platelet count is close to zero. There are only rare schistocytes noted on the peripheral smear | |
| Sodium |
136 mmol/L |
136-144 |
| Potassium |
4.0 mmol/l |
3.5-5.0 |
| Chloride |
102 mmol/l |
101-111 |
| Bicarbonate |
27 mmol/l |
22-32 |
| Glucose |
129 mg/dl |
70-100 |
| Creatinine |
0.59 mg/dl |
0.40- 1.2 |
| Blood Urea Nitrogen |
10 mg/dl |
8-20 |
| Calcium |
9.5 mg/dl |
8.6-10.6 |