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Child Health Guideline Identifier

Petechiae and purpura with/without fever

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Management flow chart

Petechiae

Introduction

Purpura/petechiae is the name given to the discolouration of the skin or mucous membranes due to haemorrhage from small blood vessels.

  • Petechiae are small, purpuric lesions up to 2mm across
  • Palpable purpura is purpura than can be felt, due to inflammation of the blood vessels (vasculitis)
  • Ecchymoses or bruises are larger extravasations of blood.

Aetiology

There are many causes of fever and petechiae. These include:

  • Viral infections including enteroviruses and influenza
  • Neisseria meningitidis (meningococcal) disease
  • Other causes of bacteremia including Streptococcus pneumoniae and Haemophilus influenzae
  • Other diseases including Henoch Schonlein purpura, ITP and leukaemia
  • Illness characterised by vomiting or coughing causing petechiae around the head and neck region
  • All children with fever and petechiae should be reviewed by a registrar or consultant.

Additionally:

  • The majority of children with fever and petechiae do not have an identifiable cause - they are presumably due to viral infections.
  • At least 90% of children with fever and petechiae will NOT have meningococcal disease. However, recognition and early treatment of the child with meningococcal disease is paramount.
  • Clinical signs and laboratory investigations may help determine those who should be treated for suspected meningococcal disease

Unwell children with fever and petechiae

All unwell children with fever and petechiae should be treated for meningococcaemia. See Meningococcaemia Guideline for details on the management of a child with suspected meningococcal disease.

Important principles in the management of meningococcal disease include immediate fluid resuscitation, early administration of antibiotics (3rd generation cephalosporin) and involvement of intensive care staff.

Children should be considered unwell when they have the following features:

Abnormal vital signs

  • Tachycardia
  • Tachypnoea and or hypoxia in air
  • Increasing systolic to diastolic difference in blood pressure (i.e. widened pulse pressure)

Poor peripheral perfusion

  • Cold extremities
  • Prolonged capillary refill

Altered conscious state

  • Irritability (inconsolable crying or screaming)
  • Lethargy (including as reported by family or other staff)

Petechiae in well children due to mechanical causes

Children who are well and have a clear history of a mechanical cause for their petechiae do not require investigation and may be discharged with clinical review planned within 24 hours. This can be with the GP.

Mechanical causes of petechiae are:

  • Coughing or vomiting leading to petechiae around the head and neck region only.
  • Local physical pressure such as a tight tourniquet, being held tightly for procedures, stroller straps, car seats, leg caught in cots.

If there is any doubt about the aetiology of the petechiae, children should be managed as below.

Well children with petechiae with/without fever

Purpura in well children

  • Purpura > 2mm may be an indicator of meningococcal disease.
  • A period of observation is required for these children.
  • Prior antibiotic administration does not change the management of these children.

These children should ideally be reviewed by a senior medical officer prior to any disposition decisions being made.

If there is any clinical deterioration or progression of the petechial rash during the period of observation, treat as per Meningococcaemia Guidelines.

Children with petechiae with/without fever who do not have a mechanical reason for their petechiae and remain well during their period of observation MAY warrant blood tests as part of their management. Blood tests are useful to help in excluding other diagnoses such as ITP (see ITP Guideline) and leukaemia. They are also a way of stratifying risk.

If Henoch Schonlein Purpura (HSP) becomes the most likely clinical diagnosis, obtain urine specimen to look for renal involvement (usually red cells).

Children with ALL of the following features have a very low risk of meningococcal disease and may be discharged from the emergency department after 4 hours observation:

  • Well, and
  • No deterioration in clinical state or progression of the rash.

If there is any clinical deterioration or progression of the petechial rash, consider meningococcal disease and treat as per Meningococcaemia Guidelines.

References

  • Royal Children's Hospital Melbourne Clinical Practice Guidelines.
  • Dermnet New Zealand

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Document Control

  • Date last published: 26 June 2017
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Author(s): Kiran Singh
  • Owner: Sarah Jamison
  • Editor: Greg Williams
  • Review frequency: 2 years

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