Tuesday, January 10, 2012

Puzzling Purpura

Abstract: 11 yo with three week history of localized purpura

HPI: This is a healthy, stable 11 year old who has had two episodes of purpura on the upper arms. Mildly pruritic. Her pediatrician reported the family to social services. She's on no meds.

O/E: There are purpuric bruises on both upper arms. The remainder of the cutaneous examination if unremarkable.

Laboratory: All hematologic studies are normal

Pathology: A biopsy was performed. Results pending

Impression: Puzzling Purpura. Her pediatricians were concerned about child-abuse and referred her to social services. Their report found no evidence of this. It is likely that this is due to some kind of intentional or unintentional trauma. See a similar case "Diagnostic Challenge" presented by Dr. Amanda Oakley in 2007. I am also considering Gardner-Diamond syndrome (whatever that really is). Further reading raises the question of a purpuric contact dermatitis from azo and other clothing dyes.

Question: What are your thoughts?
One Week Follow-up:

Note: Cleared completely after one week. This argues for factitial disease (as our readers' felt)


1. Rasmussen JE. Puzzling purpuras in children and young adults. J Am Acad Dermatol. 1982 Jan;6(1):67-72.
2. Meeder R, Bannister S. Gardner-Diamond syndrome: Difficulties in the management of patients with unexplained medical symptoms. Paediatr Child Health. 2006 Sep;11(7):416-9. Available full text.


  1. If not a fixed drug reaction Dave, it is likely to be artefactual on this site. Pinching purpura perhaps.
    Best wishes
    Ian McColl FACD

  2. I can't wait to see what the biopsy shows. Looking at it and the distribution makes me think it's factitious- but I hate to call something factitious if I can't figure out how she's causing the marks. Any marks on the back of her arms, any recent travel? ( it doesn't look like phytophotodermatitis from the pics) (from a pediatrician)

  3. The distribution of the lesions point to an etiology of local trauma, self-inflicted or otherwise. Negative hematological studies rule out a disorder of coagulation.

    Does the child have a psychiatric history? Any evidence of trichotillomania or cutting behavior?

  4. from DW Johnson, Honolulu
    "Looks factitial. Possibly self induced."

  5. Gardner-Diamond syndrome


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