Purpura

DIAGNOSTIC :

Purpura is a red spot is not erasing the vitropression. It is due to the extravasation of red blood cells in the dermis.

The diagnosis is obvious.

The diagnosis is crucial. Indeed, purpura may be the call sign of a very serious infection (purpura fulminans of meningococcemia), a significant thrombocytopenia or systemic vasculitis.

There are several types of purpura

– Petechial purpura: red tasks are not erasing the vitropression are punctate form lens. This is the most common case;

– Ecchymotic purpura: these blue-purple tablecloths large;

– Purpura vibices: linear streaks.

HSP

It also distinguishes clinically infiltrated purpura (vascular purpura, associated vasculitis or vascular thrombosis) non infiltrated purpura (plans, for example purpura hematological associated with thrombocytopenia).

Purpura predominates usually on the lower limbs and changes taking shades of biligénie. Several elements of different ages may exist and progress can be made toward healing without scars, atrophic scars or brown spots according to etiology.

ELIMINATE THE URGENT:

The diagnosis of purpura is, as we have seen, mostly clear, on pain of having bothered to undress the patient.

Two major emergencies must be recognized:

– Purpura associated with fever or sepsis;

– Purpura associated with hemorrhagic syndrome.

Other signs of severity are necrotic or extensive purpura, an achievement of ends, signs of organ involvement (neurological, cardiac, renal, blood pressure, abdominal pain under severe systemic vasculitis).

All purpura associated with sepsis in mucosal bleeding, easy bruising or extensive necrotic thrombocytopenic is an emergency requiring immediate hospitalization. The practitioner should call an ambulance and the nearest hospital to organize the hospital immediately.

Purpura with sepsis:

The major fear is the purpura fulminans, the most often at méningococoque, which can take a few hours an individual previously healthy.

Purpura is usually easy bruising or extensive, but can be limited to a few petechiae, especially in children. Septic or meningeal syndrome can be discreet.

Besides ménigocoque, rarely are involved pneumococcus, Staphylococcus Haemophilus or other gram-negative bacilli.

Treatment should be started urgently if there is a necrotic or ecchymotic element of at least 3 mm in diameter associated with infectious signs: 1 to 2 g of IV Rocéphine® otherwise IM or Clamoxyl® 1 to 2 g. In children, it gives 50 to 100 mg / kg Rocéphine® or 25 to 50 mg / kg Clamoxyl®.

The patient will be transferred to emergency by ambulance to the nearest hospital to be warned of his arrival.

Purpura with haemorrhagic syndrome:

The risk is linked to severe visceral bleeding, especially meningitis. Hemorrhagic bullae mucous membranes, conjunctival haemorrhage, epistaxis, gingival bleeding of a macroscopic haematuria should be investigated.

Headache, retinal hemorrhages have to fear the possibility of subarachnoid hemorrhage.

Again, the patient should be hospitalized immediately by the SAMU.

Other necrotic purpura:

Purpura of DIC is sudden onset; large closets Ecchymotic appear on the ends with risk of necrosis. Bubbles may be.Support is réanimatoire, including administration of fresh frozen plasma heparin and low dose, and reconstructive surgery at a later stage.

Purpura deficits congenital or acquired protein C, particularly during the administration of anticoagulants can give identical tables.

Purpura disease cholesterol emboli mainly affects men over fifty years atheromatous. It typically appears in suites endovascular operation, an anticoagulant treatment. This is the classic picture of blue toes. The fundus, skin biopsy may help diagnose.

Renal failure progressively worsening appears secondarily. An array of pseudo-PAN can be observed. The prognosis is poor. It will stop anticoagulants and sometimes give corticosteroids to average dose.

OUTSIDE EMERGENCY MAJOR:

The diagnostic orientation is given by the clinical appearance of purpura: is it infiltrated or not? and the platelet count (thrombocytopenia purpura).

Hematological purpura:

Thrombocytopenia is most often involved, with a platelet count less most often at 50,000 platelets / mm3. Purpura is not infiltrated. Bleeding should be investigated, and lymphadenopathy, hepatomegaly, or splenomegaly.

Thrombocytopenia should be confi rmed by a levy without EDTA, especially if there is no sign of bleeding. A bone marrow aspiration should be done, despite the same thrombocytopenia.

It differentiates thrombocytopenic purpura Central origne (anemia, leukemia) or peripheral (idiopathic thrombocytopenic purpura most often, connectivity, drugs, DIC, hypersplenism) (cf. on thrombocytopenia).

More rarely, purpura are associated with a platelet disorder or are thrombocytémiques.

The vascular purpura:

Vascular purpura are often infiltrated. We distinguish purpuras by vasculitis (cutaneous or systemic) and purpura reached by content (intraluminal thrombosis).

For a vasculitis, character infiltrated purpura is associated with skin lesions polymorphic (maculopapular edematous, vesicoureteral bubbles may become necrotic, nodules, livedo …) and the visceral (with central neurological signs, mono or polyneuropathy, heart, kidney (hematuria, proteinuria, hypertension, renal failure), stomach (abdominal pain, melena …), Raynaud’s syndrome, arthralgias.

Purpura is readily triggered by Trendelenburg and orthostatic (purpura rheumatoid example).

Vasculitis can be pure cutaneous or systemic. In this case, the distinction is made according to the preferential involvement of certain types of vessels (classification Chappel Hill, Table I). The balance practicing is shown in Table II.

The most common causes of vasculitis in adults are:

– Bacterial, viral or parasitic, emphasizing endocarditis (especially if the ends purpura);

– Systemic vasculitis (see table);

– Cryoglobulinemia (usually as part of a type II cryoglobulinemia in HCV with purpura, arthralgias and asthenia), other hematological malignancies (lymphoma, hairy cell leukemia …)

– Drugs (often accused by excess);

– Hypersensitivity vasculitis (without etiology found, with isolated skin involvement).

GCA:

GCA affects people aged over 55. The major risk is blindness.

The clinical signs are unusual headache with hyperesthesia of the scalp (especially when the comb-over), pain when chewing, induration and pain of the superficial temporal arteries, inflammatory pain shoulder and PPR type belts .There is an inflammatory syndrome and often cholestasis year icteric. The biopsy of the temporal arteries (inconsistently positive due to focal segmental nature of injuries) strongly directs the diagnosis. The treatment is described in the headache part.

Takayasu’s arteritis:

Takayasu’s arteritis affects young women, is more common in Asia, Mexico and Africa. It is an inflammatory aortoaortite touching the aorta, the large artery that are born and pulmonary arteries.

Clinical manifestations are ischemic (blood pressure asymmetry to the upper extremities, postural syndrome, renovascular hypertension, coronary artery disease, cough, hemoptysis and PAH by achieving the pulmonary artery).

TB history, Crohn, SPA will be sought.

Polyarteritis nodosa:

Polyarteritis nodosa associated with general signs (fever, weight loss), mononeuritis, myalgia elevated CPK, arthralgia, subcutaneous nodules on arterial routes, livedo, vascular nephropathy with hypertension, gastrointestinal damage and cardiomyopathy . Testicular pain can be. Infection with hepatitis B is conventionally associated. There is no ANCA.

Microscopic polyangiitis:

Microscopic polyangiitis conventionally associated rapidly progressive glomerulonephritis, alveolar haemorrhage and the presence of p-ANCA.

Kawasaki disease:

Kawasaki disease usually occurs in children. The risk is that coronary attacks.

Wegener:

Wegener’s disease combines ORL reached with crusting rhinitis, chondrites, chronic sinusitis, otitis, under gottique stenosis, pulmonary nodular opacities with excavated, rapidly progressive glomerulonephritis, mononeuritis, episcleritis or pseudotumor of the orbit. ANCA are typically c-ANCA. Eosinophilia is possible.

Churg-Strauss:

Churg-Strauss syndrome combines a late asthma, severe, steroid-resistant, eosinophilia and pulmonary infiltrates labile.

ANCA are conventionally p-ANCA.

Rheumatoid purpura:

The HSP is more common in children than in adults. After a nasopharyngeal infection, appears an undercover purpura especially affecting the lower limbs, which may go back on the buttocks and lower back.

segmental edema can see. Arthralgia are frequent. Abdominal pain is frequent (risk of gastrointestinal bleeding and intussusception); renal disease is serious, especially in adults. Skin biopsy found deposits of IgA; there may be an increase in their blood levels.

The patient should be hospitalized. In the absence of visceral involvement signs, bed rest (decubitus increases lesions) and colchicine are sufficient. If visceral involvement in adults, the treatment is not well codified (corticosteroids, immunosuppressants such Endoxan®).

Purpura capillary fragility:

Less serious, the purpura group by capillary fragility.

Purpura or senile purpura Bateman key

the elderly or in long-term corticosteroid. There are bruises, in particular on the dorsal surfaces of the hands and forearms, stellar scars and skin atrophy.

There is no specific treatment.

Purpura scurvy purpura associated with perifollicular sometimes available, hematoma of the lower limbs and gingivitis.Psychiatric, socio-economic is evocative.

The administration of 1 g of vitamin C per os per day for one month allows healing.

Purpura may occur after exercise (vomiting) or the installation of the pressure cuff. Include the eyelid ecchymotic purpura AL amyloidosis.

Several types of dermatological purely purpura localized in the lower limbs have been described, with hyperpigmentation. The best known is the stasis dermatitis. These purpura are usually bilateral and symmetrical.There is no effective treatment.