CLIPP case 21. 6yo with bruising rash

Question 1

6yo B presents to clinic with pain in his legs and a petechial rash since morning. With the exception of a recent URI, has otherwise been well. On exam there is palpable purpura and petechiae on his buttocks and legs, and mild tenderness with passive ankle flexion.

Answer 1

DDx:

• HSP
• ITP
• Leukemia
• Sepsis, meningococcemia
• SLE
• Coagulation disorder

Question 2

Boy diagnosed with HSP yesterday presents to ED with severe abdominal pain.

Answer 2

US to assess for intussusception

Guaiac test to assess for GIB

Question 3

Causes of petechiae and purpura

Answer 3

• Trauma, coughing
• Platelet deficiency or dysfunction (ITP, bone marrow infiltration or suppression, malignancy)
• Coagulation abnormalities
• Vascular fragility (vasculitis)
• Combinations of the above (e.g., infection causing coagulation abnormalities, vascular fragility, platelet consumption)

Question 4

HSP

Answer 4

• Self-limited, IgA-mediated, small vessel vasculitis
• Hallmark is non-thrombocytopenic petechiae and purpura
• RAP: renal, arthritis/abdominal, purpura
• Most common form of vasculitis in children
• Boys:girls 2:1
• Tx: NSAIDs for pain; corticosteroids to maybe reduce GI cx (not renal)
• 30% recurrence rate

Question 5

ITP

Answer 5

• Usually asymptomatic petechiae and bruising; mucosal bleed; rare ICH
• Most common cause thrombocytopenia
• Anti-platelet ab -> binds platelet surface -> removal and destruction of platelets in spleen and liver (but no HSM)
• Often preceded by nonspecific viral infection
• Tx: observation, oral corticosteroids, IVIG, RhoGAM

Question 6

Intussusception

Answer 6

-Proximal bowel segment invaginates into
distal -> entrapment of mesentery -> ischemia
-Most common form bowel obstruction 6 mo - 6 yrs; Boys > girls
-Classic triad: abdominal pain spells, “currant jelly” stool, “sausage” mass in R abdomen
-Dx and Tx: Air or contrast enema; HSP-related often requires ultrasound for Dx and surgery for tx

Question 7

Liver exam

Answer 7

Causes of hepatomegaly (>3.5cm below rib in newborns; >2cm in kids):

• Inflammation (e.g., viral hepatitis)
• Infiltration (e.g., leukemia/lymphoma)
• Accumulation of storage products (e.g., glycogen storage disease)
• Congestion (e.g., congestive heart failure)
• Obstruction (e.g., biliary atresia)

Question 8

Spleen exam

Answer 8

Causes of splenomegaly (>2cm below):

• Infection (EBV, CMV, bacterial sepsis, endocarditis)
• Hemolysis (sickle cell disease)
• Malignancy (leukemia, lymphoma)
• Storage diseases (Gaucher disease)
• SLE, JIA
• Congestion (related to portal hypertension)
• (No ITP or HSP)

Question 9

LN exam

Answer 9

Abnormal if…

• Larger than 2 cm
• Palpable in areas other than the cervical, axillary, and inguinal regions
• Tender, warm, fluctuant, erythematous
• Hard, rubbery, matted together, fixed/immobile
• Supraclavicular nodes (lymphoma)
• Diffuse adenopathy (generalized)