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Probability diagnosis

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Simple purpura (easy bruising syndrome)

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Senile purpura

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Corticosteroid-induced purpura

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Immune thrombocytopenic purpura

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Henoch–Schönlein purpura

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Serious disorders not to be missed

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Malignant disease:

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  • leukaemia

  • myeloma

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Aplastic anaemia

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Myelofibrosis

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Infection:

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  • septicaemia

  • meningococcal infection

  • infective endocarditis

  • measles

  • typhoid

  • dengue/chikungunya

  • other tropical haemorrhagic viral infections

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Disseminated intravascular coagulation

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Thrombotic thrombocytopenic purpura

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Fat embolism

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Kidney failure

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Pitfalls (often missed)

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Haemophilia A, B

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von Willebrand disease (vW)

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Post-transfusion purpura

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Trauma (e.g. domestic violence, child abuse)

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Rarities:

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  • hereditary telangiectasia (Osler–Weber–Rendu syndrome)

  • Ehlers–Danlos syndrome

  • scurvy

  • Fanconi syndrome

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Masquerades checklist

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Drugs:

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  • chloramphenicol

  • corticosteroids

  • sulphonamides

  • quinine/quinidine

  • thiazide diuretics

  • NSAIDs

  • cytotoxics

  • oral anticoagulants/heparin

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Anaemia:

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  • aplastic anaemia

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Psychogenic factors

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Factitious purpura (intentionally pinching skin)

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Key history

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Include family history, drug history and features of the purpura such as post trauma or spontaneous, recurrent episodes of bleeding and whether any bleeding is out of proportion to the trauma.

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Key examination

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  • Detailed examination of the skin, lips and oral mucosa, lymph node areas, abdominal examination with emphasis on spleen and liver

  • Urinalysis searching for blood (microscopic or macroscopic) is important

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Key investigations

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FBE and blood film

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  • If coagulation defect suspected:

    • - prothrombin time i.e. INR

    • - activated partial thromboplastin time

    • - fibrinogen level

    • - thrombin time.

  • If platelet pathology suspected:

    • - platelet count

    • - platelet function analyser (PFA-100).

  • If inherited disorders suspected:

    • - factor VIII

    • - vW factory activity

    • - vW factor antigen.

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Diagnostic tips

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  • Platelet abnormalities present as early bleeding following trauma.

  • Coagulation factor deficiencies present with delayed bleeding after initial haemostasis is achieved by normal platelets.

  • A normal response to previous coagulation stresses (e.g. dental extraction, circumcision or pregnancy) indicates an acquired problem.

  • If acquired, look for evidence of MILD: malignancy, infection, liver disease and drugs.

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