ABSTRACT
This 5-year-old male was referred to the hospital child protection team because of circumferential bruising of his wrists and ankles, suspected of being ligature marks. He began complaining of knee pain and swelling, and bruising around his ankles 2 weeks after a viral illness. He then fell off a bunk bed ladder and was evaluated in the emergency centre where foot swelling and bruises on his scrotum, wrists and ankles were noted. The patient and all members of his family denied any abusive trauma. These pictures show the appearance of the patient’s wrists and ankles (Images 50a and 50b).
How should the cutaneous findings in this patient be described and what diagnosis does this suggest?
What laboratory studies, if any, will help make this diagnosis?
Why is the ‘bruising’ in this patient worse around the ankles and wrists? Should this case be reported to Child Protective Services?
https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig50a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig50b.jpg"/> 116 https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig50c.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig50d.jpg"/>These pictures (Images 50c and 50d) show the patient’s legs and buttocks. The pictures show diffuse petechiae and purpura located mostly on the patient’s lower extremities and buttocks. This is the classic appearance of the purpuric ‘rash’ seen in Henoch-Schönlein purpura (HSP). The rash may begin as urticarial wheals that evolve into macules and papules and finally petechiae and purpura which may be palpable. Typically the rash occurs in dependent areas but may also involve the upper extremities, face and trunk.
The diagnosis of HSP is a clinical one, with a history spanning days to weeks. HSP is a small vessel vasculitis and as such may involve multiple organ systems including the joints, liver and kidneys. 1
The rash and bruised appearance may be accentuated over pressure points as in this case where underlying vascular fragility was exacerbated by the patient having worn clothing with elastic at the wrists and ankles. Differentiation from physical abuse is made primarily through history and clinical presentation and the associated multisystem involvement seen in HSP. 2 , 3
