6/20/16 ZSFG pearls – GGOs and purpura

Thank you to Kenny Petterson for finishing intern year STRONG with an amazing morning report case. He presented a 45 y/o man with diabetes who presented with multisystem organ failure and a petechial rash.

Ground glass opacities

Ddx of ground glass opacities in the lung

•          Water (pulmonary edema)
•          Pus (infection, inflammation)
•          Blood (diffuse alveolar hemorrhage)

 

Now lets talk purpura.

This is an opportunity to highlight some amazing resources from the UCSF dermatology department: the dermatology glossary and the purpura/petechiae online module. Go to the dermatology glossary to demystify specific skin terms. The online modules give you a case-based deep dive into specific dermatologic disorders.

Purpura are defined as red-purple skin lesions that result from blood extravasation into tissue. They are non-blanching. Morphologically they are divided into

   Palpable

•    A sign of vascular inflammation or damage, usually a small or medium vessel vasculitis
• Palpable purpura is the hallmark of a leukocytoclastic vasculitis, but LCV is a histopathologic diagnosis
•    Ddx
  •        Primary rheum
    • ANCA-associated
    •  Cryoglobuinemic vasculitis
    • Polyarteritis nodosa
    • Henoch-schonlein purpura (rare in adults)
    •      Urticarial vasculitiS
    •  SLE

•   Infection
  •          HBV-associated PAN
  •          HCV associated cryoglobulinemia
  •          Purpura fulminans associated with DIC
•   Malignancy-related
•   Medication effect (meds can cause an LCV on their own!)

Lindy Fox’s recommendation for first line w/u of palpable purpura

•          CBC w platelets
•          ESR/CRP
•          ANA
•          ANCAs
•          Complements
•          UA
•          Infectious w/u including HIV, HCV, HBV, +/- ASo or strep throat culture and cryos

Non-palpable or macular purpura

• Usually noninflammatory
• further subdivided by size

Petechiae <3mm in size

•   Ddx
  •          Qualitative and quantitative platelet disorders
  •          DIC and infection (mycoplasma was a strong consideration in our case today)
  •          Increased intravascular venous pressure (due to clot or obstruction)
  •          Inflammatory skin disease
  •          Increased vascular fragility including d/t vitamin deficinecies like scurvy

  Ecchymosis >5mm in size

•   External trauma
•   DIC and infection
•   Coagulopathy
•   Skin weakness/fragility
•   Waldenstrom’s

https://www.evernote.com/shard/s192/sh/5eb3d7b4-29c1-456d-9819-61d24fd26bfc/a966a8c330dc9314df0f3e591855bd38

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