Makindo Medical Notes

Purpura is a visible sign of an underlying problem with blood vessels, platelets, or the coagulation system. Causes range from benign trauma to life-threatening disorders like DIC or leukaemia. A good history, exam, and targeted tests are essential to identify the cause and guide management.

🟣 What is Purpura?

• Petechiae: 🔴 Tiny pinpoint red/purple spots (<3 mm).
• Ecchymoses: 💜 Larger patches (>1 cm), commonly called bruises.

❓ Why Does Purpura Happen?

Purpura occurs when blood leaks from small vessels into the skin or mucous membranes. Key categories include:

• 🩸 Vascular causes: Vasculitis, vessel inflammation/damage.
• 🧩 Platelet disorders: Low platelets (ITP, TTP) or dysfunctional platelets.
• ⚖️ Coagulation disorders: Factor deficiencies (e.g., DIC).
• 🤕 Trauma: Direct vessel injury.
• 💊 Medications: Anticoagulants, steroids → fragile vessels/clotting issues.

📋 Common Causes & Features

🧬 Immune Thrombocytopenic Purpura (ITP)

• Features: Easy bruising, petechiae, mucosal bleeding (nose, gums), often post-viral.
• Investigations: FBC → isolated low platelets, smear normal, BM biopsy shows ↑ megakaryocytes.
• Management: Corticosteroids, IVIG for acute bleeds, TPO receptor agonists/splenectomy if refractory.

⚡ Thrombotic Thrombocytopenic Purpura (TTP)

• Features: Fever, neuro symptoms, renal failure, purpura, anaemia, jaundice.
• Investigations: FBC → thrombocytopenia + haemolysis; smear → schistocytes; ADAMTS13 ↓.
• Management: Urgent plasma exchange, steroids/rituximab, supportive care.

👶 Henoch-Schönlein Purpura (HSP)

• Features: Palpable purpura on buttocks/legs, abdominal pain, arthritis, haematuria (renal).
• Investigations: Urinalysis → protein/haematuria; renal tests; skin biopsy shows leukocytoclastic vasculitis.
• Management: Supportive, hydration + analgesia, steroids for severe renal/abdominal disease.

🔥 Disseminated Intravascular Coagulation (DIC)

• Features: Widespread bleeding, petechiae, purpura, shock, multiorgan failure (often in sepsis/trauma/malignancy).
• Investigations: Prolonged PT/aPTT, low fibrinogen, low platelets, ↑ D-dimer.
• Management: Treat cause (e.g., infection), FFP/platelets, heparin in chronic DIC.

🌊 Vasculitis (Small Vessel)

• Features: Palpable purpura, fever, weight loss, joint pain, renal/GI involvement.
• Investigations: ANCA, biopsy (skin/kidney), renal tests.
• Management: Corticosteroids, immunosuppressants (cyclophosphamide), monitor organs.

🧪 Leukaemia

• Features: Pallor, fatigue, infections, bruising, night sweats, bone pain, lymphadenopathy.
• Investigations: FBC → cytopenias; smear → blasts; bone marrow biopsy definitive.
• Management: Chemotherapy, transfusions, bone marrow transplant in some cases.

🍊 Vitamin C Deficiency (Scurvy)

• Features: Purpura, gingival bleeding, corkscrew hairs, joint pain, poor healing.
• Investigations: Clinical diagnosis ± low vitamin C levels.
• Management: Vitamin C supplementation, dietary advice.

💊 Drug-Induced Purpura

• Features: Purpura, bruising, mucosal bleeding; history of anticoagulant/steroid use.
• Investigations: Coagulation profile prolonged, FBC may show thrombocytopenia.
• Management: Stop offending drug, vitamin K/FFP for warfarin, supportive care.

🩺 Clinical History Points

• Onset: sudden (infection, trauma) vs gradual (vasculitis, malignancy).
• Associated: fever, arthralgia, renal involvement, mucosal bleeding.
• Drug history: anticoagulants, steroids.
• Family history: haemophilia, vWD.

👩‍⚕️ Examination

• Distribution: localised vs generalised.
• Type: petechiae vs ecchymoses vs palpable purpura.
• Systemic signs: lymphadenopathy, hepatosplenomegaly, infection signs.

🧪 Investigations

• FBC (platelets, anaemia).
• Coagulation profile (PT, aPTT, fibrinogen).
• Blood smear (schistocytes, blasts).
• Liver and renal function tests.
• Autoimmune markers (ANA, ANCA).

💊 Management Principles

• 🩸 ITP → steroids, IVIG, splenectomy if refractory.
• ⚡ TTP → urgent plasma exchange + steroids.
• 🔥 Vasculitis → corticosteroids + immunosuppressants.
• 💉 DIC → treat cause, give FFP/platelets.
• 🍊 Scurvy → vitamin C replacement.
• 💊 Drug-induced → stop drug, supportive care.