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Nonpalpable purpuras include thrombocytopenic conditions, senile or actinic purpura, blood clotting abnormalities, Schamberg's disease, hypergammaglobulinemic conditions, and disseminated intravascular coagulation. Actinic (senile) purpura is a common problem in older individuals, the result of increased vessel fragility reflecting dermal connective tissue damage from chronic sun exposure and aging. Minor trauma induces ecchymoses, usually on the dorsum of the hands and forearms. The skin in these areas is thin and fragile. Topically or systemically administered steroids can induce similar purpura. Other causes of vascular fragility of the skin include amyloidosis and the Ehlers-Danlos syndrome. Schamberg's disease, or pigmented purpuric dermatitis, is an idiopathic capillaritis that causes petechial lesions of the lower legs (occasionally the arms and trunk) in association with hyperpigmentation. The lesions have the appearance of
Occasionally Schamberg's disease is secondary to a drug reaction. Petechiae and purpura also occur in hypergammaglobulinemic purpura, a syndrome characterized by episodes of fever and arthralgias which appear to be the result of immune complex-mediated damage to small blood vessels. Disseminated intravascular coagulation (DIC) refers to uncontrolled clotting within blood vessels with the formation of diffuse thrombosis. The skin is frequently involved with hemorrhage, ecchymosis, and infarction. DIC occurs in association with bacterial sepsis (particularly meningococcemia), as a postviral or poststreptococcal infection phenomenon (purpura fulminans), or in conjunction with malignancies such as prostatic carcinoma and acute myelocytic leukemia. The most distinctive hemorrhagic skin lesions are stellate (star-shaped) purpuric ecchymoses with necrotic centers. The center of the lesion is dark gray, indicative of necrosis and impending slough. Petechiae are seen, and hemorrhagic bullae, acral cyanosis, mucosal bleeding, and prolonged bleeding from wound sites can occur. Patients may be systemically ill with fever, shock, and
A variety of infectious diseases cause cutaneous petechiae, purpura, or ecchymoses. Already mentioned is meningococcemia, in which the organisms produce acute vasculitis or local Shwartzmanlike reactions with erythematous macules, petechiae, purpura, and ecchymosis on the trunk and legs. These may become confluent, often with central necrosis. Patients with acute meningococcemia are ill with fever, malaise, headache, meningeal signs, and hypotension. The skin lesions of disseminated gonococcemia begin as tiny red papules and petechiae and then evolve into painful purpuric pustules and vesicles scattered on the distal extremities. Fever, polyarthritis, or monoarticular arthritis may be
The rash of Rocky Mountain spotted fever appears between the second and sixth day of the illness, initially as small, erythematous macules that blanch on pressure but then evolving into petechiae, purpura, and ecchymoses. The rash first occurs on the acral areas and then spreads to the extremities and trunk. Small areas of necrosis may occur on the fingers, toes, and ear lobes. Fever, severe headache, toxicity, confusion, and myalgias commonly occur. Infective endocarditis is associated with petechial and purpuric skin lesions. Petechiae appear in crops in the conjunctivae, buccal mucosa, upper chest, and extremities. Splinter hemorrhages (linear, red to brown streaks under the fingernails or toenails); Osler nodes (2- to 15-mm, tender, red nodules on the pads of the fingers and toes); and Janeway lesions (small, painless plaques and palpable, purpuric nodules on the palms or soles) may be seen. The skin lesions are related to immune complex vasculitis or
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