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Petechiae Cite this Page

Ailbhe McGrath; Michael J. Barrett.

Author Information and Affiliations In this Page
Last Update: September 4, 2023. Continuing Education Activity

Introduction
Continuing Education Activity Go to:
Etiology
Petechiae are pinpoint non-blanching spots that measure less than 2 mm in size and affect the
Epidemiology
skin and mucous membranes. Petechial rashes are common and can be a significant cause for
concern for parents and the interprofessional team. Petechial rashes result from areas of Pathophysiology
hemorrhage into the dermis. The primary pathophysiological causes of petechiae are History and Physical
thrombocytopenia, platelet dysfunction, disorders of coagulation, and loss of vascular integrity.
Evaluation
Though there are many causes of a petechial rash in a child, invasive meningococcal disease
(IMD) caused by Neisseria meningitidis is one of the most concerning reasons. A child with a Treatment / Management
fever and a petechial rash requires an urgent and comprehensive assessment. This activity Differential Diagnosis
reviews the causes of petechiae and highlights the role of the interprofessional team in the
Pearls and Other Issues
management of patients with petechiae.
Enhancing Healthcare Team Outcomes
Objectives:
Review Questions
Identify the etiology of petechiae. References

Describe the evaluation of petechiae.

Summarize the treatment options available for petechiae. Bulk Download

Bulk download StatPearls data from FTP
Review interprofessional team strategies for optimizing care coordination and
communication to advance the evaluation and management of petechiae to improve
outcomes.
Related information
Access free multiple choice questions on this topic. PMC

PubMed
Introduction Go to:

Petechiae are pinpoint non-blanching spots that measure less than 2 mm in size, which affects
Similar articles in PubMed
the skin and mucous membranes. A non-blanching spot is one that does not disappear after
Evaluation of febrile children with petechial rashes: is
applying brief pressure to the area. Purpura is a non-blanching spot that measures greater than 2
there consensus among pediatricians?
[Pediatr Infect Dis J. 1998]
mm. Petechial rashes are a common presentation to the pediatric emergency department (PED).
Non-blanching rashes can be a great cause for concern for parents and physicians alike. Prevalence and location of petechial spots in well
infants. [Arch Dis Child. 2010]
Therefore, careful assessment and evaluation are necessary to formulate a sensible management
plan.[1][2][3] Validating clinical practice guidelines for the
management of children with non-blanching
[Lancet Infect rashes
Dis. 2021]
in
the UK (PiC): a prospective, multicentre cohort study.
Etiology Go to: Review Emergency department management of rash
and fever in the pediatric
[Pediatr
patient.
Emerg Med Pract. 2020]
There are many causes of a petechial rash in a child to be considered. Invasive meningococcal
Review Intrathoracic petechial hemorrhages: a clue
disease (IMD) caused by Neisseria meningitidis, is the priority in the differential diagnosis to
to the mechanism of death in [Ann
sudden
N Yinfant
Acaddeath
Sci. 1988]
consider on the initial presentation. Consequently, a child with a fever and a petechial rash syndrome?
requires urgent and comprehensive assessment. Multiple studies have shown that the rate of See reviews...

IMD has reduced following the introduction of meningococcal vaccines into childhood See all...
immunization schedules and that the low prevalence of IMD suggests that most children
presenting with a petechial rash have less serious pathologies. However, given its associated
morbidity and mortality, it should remain at the forefront of the clinician's mind when assessing Recent Activity
Turn Off Clear
the child with pyrexia and petechiae.[4][5]
Petechiae - StatPearls
Causes can classify into the following categories:

Infective Discoid Lupus Erythematosus - StatPearls

Viral: Enterovirus, parvovirus B19, dengue Malar Rash - StatPearls

Bacterial: Meningococcal, scarlet fever, infective endocarditis

See more...
Rickettsial: Rocky Mountain Spotted fever

Congenital: TORCH

Trauma

Accidental injury

Non-accidental injury

Increased pressure following bouts of coughing, vomiting or straining

Hematological and Malignant

Leukemia

Idiopathic thrombocytopenic purpura (ITP)

Thrombocytopenia with absent radius (TAR) syndrome

Fanconi anemia

Disseminated intravascular coagulation (DIC)

Haemolytic uraemic syndrome (HUS)

Splenomegaly

Neonatal alloimmune thrombocytopenia (NAIT)

Vasculitis and Inflammatory Conditions

Henoch-Schonlein purpura (HSP)

Systemic lupus erythematosus (SLE)

Connective Tissue Disorder

Ehlers-Danlos syndrome

Congenital

Wiscott-Aldrich syndrome

Glanzmann thrombasthenia

Bernard-Soulier syndrome

Other

Drug reaction

Vitamin K deficiency

Chronic liver disease

Epidemiology Go to:

One study reported that 2.5% of presentations to the pediatric emergency department were
patients with a petechial rash.[6]

Pathophysiology Go to:

Petechial rashes result from areas of hemorrhage into the dermis. Derangements in the normal
hemostasis can result in petechiae along with a variety of other clinical findings. The primary
pathophysiological causes of petechiae and purpura are thrombocytopenia, platelet dysfunction,
disorders of coagulation, and loss of vascular integrity. Some clinical pictures result in petechial
lesions from a combination of these mechanisms.[7][8]

History and Physical Go to:

A detailed history and physical examination are paramount for every child presenting with
petechiae. Key features in the history include the time of onset, anatomical pattern and a detailed
chronological account of any other symptoms, e.g., fever, coughing, vomiting, any recent URTI
or gastroenteritis, and any sick contacts. A rapidly spreading rash is more concerning for IMD in
an unwell child with a fever. A recent viral infection (URTI or gastroenteritis) is common in ITP,
HSP, and HUS. Petechiae confined to above the nipple line are associated with bouts of
vomiting or coughing. It is also important to ask about any bleeding from mucosal surfaces such
as gingival bleeding, epistaxis, melena, among others. As always, the clinician should confirm
vaccination status.

On examination, a complete set of observations and neurological status requires monitoring. A

full systemic examination should be completed, including cardiac, respiratory, abdominal,
otorhinolaryngological, and neurological (if concerns of IMD). The skin should undergo
thorough examination from head to toe, and the pattern of rash requires clear documentation.
Demarcating areas of petechiae with a skin marker can help monitor the progression of the rash
in clinical practice.

The age of the child can be useful in reaching the most likely diagnosis, for example, a neonate
with petechiae could have a NAIT or a TORCH infection, and HSP is more common in the 2 to
5 year age range.

Patterns of concerning symptoms and signs presenting with petechiae include but are not limited
to:

Pyrexia, tachycardia, reduced level of consciousness and rapidly spreading petechiae:

IMD

Pallor, bruising, weight loss, lymphadenopathy: Malignancy

Hypertension: Renal disease associated with HUS, HSP or SLE

Unusual patterns of petechiae with bruising, an inconsistent history or signs of injury or

neglect: NAI

Evaluation Go to:

Investigations to diagnose the cause of a petechial rash depend on the clinical presentation and
can differ from one PED to another. Adhering to the local protocol is advised. In general,
investigations will depend on the location of petechiae, associated pyrexia, or clinical suspicion
for any of the concerning patterns of signs and symptoms for particular illnesses such as IMD,
HSP and HUS. A healthy child with scattered petechiae of obvious causation, e.g., known
trauma or petechiae confined to above the nipple line, may not require any investigations, and a
period of observation in the PED may be sufficient. Petechia and fever is often concerning for
IMD and poses as a clinical dilemma, though IMD accounted for only 1.4% of cases with fever
and petechiae in a recent large-scale prospective UK cohort study. [9] Many clinical guidelines
pre-date the introduction of meningococcal B and C vaccination (for example, the NICE clinical
guidelines) and a cautious approach can lead to many children undergoing painful procedures
and receiving unnecessary antibiotics in populations with high vaccination rates.

Investigations may include:

Complete blood count (CBC) to check platelet number, a raised or decreased white cell
count or decreased hemoglobin.

If concerns about IMD or other infection: C-reactive protein, blood culture and
procalcitonin if available, along with blood gas, renal, liver and coagulation profiles.

Renal, liver and coagulation profiles may also be necessary in other cases (DIC, IMD,
HSP, HUS). A prolonged prothrombin time can indicate factor deficiencies, vitamin K
deficiency, DIC, liver, or renal disease.

Urine dipstick and microscopy are useful when renal causes are part of the differential
(HSP, HUS, SLE), to check for proteinuria in particular.

Further tests may be later requested when narrowed down to a more specific diagnosis.

Treatment / Management Go to:

Many patients attending the PED with petechial rashes will not require any specific treatment. If
a child remains well after a period of observation, with no spreading of the rash, a normal
platelet count and no physical signs or signs of infection on blood tests (raised white cell count
and inflammatory markers), they may be discharged home. If IMD is likely, urgent intravenous
antibiotics as per local guidelines should be administered, with close observations after
admission to the ward or intensive care unit. Some patients may receive a dose of
antibiotics pre-hospital if high clinical suspicion of IMD is present. If there are specific
diagnoses, for example, HSP or ITP, and the child remains well, they may be discharged with an
appointment to return to the appropriate outpatient department and condition-specific education.
Other conditions will require admission and treatment, for example, urgent referral to oncology
inpatient services for a patient with pancytopenia and probable malignant diagnosis.[10][11]

Differential Diagnosis Go to:

Ecchymosis

Palpable purpura

Retiform purpura

Pearls and Other Issues Go to:

Recognizing the full range of possible diagnoses for a child presenting with petechiae is
essential for any clinician working in the PED. Public health sepsis campaigns have increased
recognition of petechiae, therefore, allaying parents' fears and concerns is a crucial role, in
addition to educating them on red flag signs that should prompt return to the PED. Senior
clinicians should be involved in decision-making to avoid both unnecessary tests or antibiotics
and to avoid missing cases of IMD.

Enhancing Healthcare Team Outcomes Go to:

There are many causes of petechiae, and condition management is optimally by an

interprofessional team that includes clinicians, specialists as indicated, hematology nurses, and
pharmacists. The key is to determine the primary cause. Most patients with a benign cause or
drug-induced petechiae have a good outcome when discontinuing the offending agent. However,
when petechiae are due to heparin, paradoxical thrombosis can occur.[12] Cross-disciplinary
communication and collaboration of the entire interprofessional healthcare team will guide these
cases to the optimal outcome. [Level 5]

Review Questions Go to:

Access free multiple choice questions on this topic.

Comment on this article.

Figure

Petechiae over the legs with close up. Contributed by Rian

Kabir, MD

References Go to:

1. Ranganathan D, John GT. Therapeutic Plasma Exchange in Renal Disorders. Indian J

Nephrol. 2019 May-Jun;29(3):151-159. [PMC free article] [PubMed]
2. Iba T, Watanabe E, Umemura Y, Wada T, Hayashida K, Kushimoto S, Japanese Surviving
Sepsis Campaign Guideline Working Group for disseminated intravascular coagulation.
Wada H. Sepsis-associated disseminated intravascular coagulation and its differential
diagnoses. J Intensive Care. 2019;7:32. [PMC free article] [PubMed]
3. Clark WF, Huang SS. Introduction to therapeutic plasma exchange. Transfus Apher Sci.
2019 Jun;58(3):228-229. [PubMed]
4. Sargentini-Maier ML, De Decker P, Tersteeg C, Canvin J, Callewaert F, De Winter H.
Clinical pharmacology of caplacizumab for the treatment of patients with acquired
thrombotic thrombocytopenic purpura. Expert Rev Clin Pharmacol. 2019 Jun;12(6):537-545.
[PubMed]
5. Joly BS, Coppo P, Veyradier A. An update on pathogenesis and diagnosis of thrombotic
thrombocytopenic purpura. Expert Rev Hematol. 2019 Jun;12(6):383-395. [PubMed]
6. Wells LC, Smith JC, Weston VC, Collier J, Rutter N. The child with a non-blanching rash:
how likely is meningococcal disease? Arch Dis Child. 2001 Sep;85(3):218-22. [PMC free
article] [PubMed]
7. Galera P, Dulau-Florea A, Calvo KR. Inherited thrombocytopenia and platelet disorders with
germline predisposition to myeloid neoplasia. Int J Lab Hematol. 2019 May;41 Suppl 1:131-
141. [PubMed]
8. Pilania RK, Singh S. Rheumatology Panel in Pediatric Practice. Indian Pediatr. 2019 May
15;56(5):407-414. [PubMed]
9. Waterfield T, Maney JA, Fairley D, Lyttle MD, McKenna JP, Roland D, Corr M, McFetridge
L, Mitchell H, Woolfall K, Lynn F, Patenall B, Shields MD., Paediatric Emergency Research
in the UK and Ireland (PERUKI) Group. Validating clinical practice guidelines for the
management of children with non-blanching rashes in the UK (PiC): a prospective,
multicentre cohort study. Lancet Infect Dis. 2021 Apr;21(4):569-577. [PubMed]
10. Blickstein D. [TREATMENT OF IMMUNE THROMBOCYTOPENIC PURPURA IN
ADULTS: UPDATE]. Harefuah. 2019 Mar;158(3):196-199. [PubMed]
11. Jelusic M, Sestan M, Cimaz R, Ozen S. Different histological classifications for Henoch-
Schönlein purpura nephritis: which one should be used? Pediatr Rheumatol Online J. 2019
Feb 28;17(1):10. [PMC free article] [PubMed]
12. Obara H, Matsubara K, Kitagawa Y. Acute Limb Ischemia. Ann Vasc Dis. 2018 Dec
25;11(4):443-448. [PMC free article] [PubMed]

Disclosure: Ailbhe McGrath declares no relevant financial relationships with ineligible companies.

Disclosure: Michael Barrett declares no relevant financial relationships with ineligible companies.

Copyright © 2023, StatPearls Publishing LLC.

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