Prevalence and distribution of petechiae in well babies

Congenital Cytomegalovirus Infection Presenting with Hyperbilirubinemia and Splenomegaly in a Term Infant with Trisomy 21

Congenital cytomegalovirus infection (cCMV) is very common, yet the presentation can be varied, making the diagnosis challenging. However, early diagnosis for treatment with medication in symptomatic cases within the first month of life is critical. Hyperbilirubinemia and splenomegaly are less common manifestations at birth and may be overlooked in the setting of other symptoms, especially in a critically ill neonate. We present a case of a term infant with trisomy 21 who presented with isolated hyperbilirubinemia and splenomegaly and was later diagnosed with congenital CMV.

Inherited Platelet Disorders: A Modern Approach to Evaluation and Treatment

The inherited platelet disorders are a heterogeneous group of disorders that can be pleotropic in their clinical presentations. They may present with variable platelet counts and bleeding, making their diagnosis difficult. New diagnostic tools range from flow cytometric platelet function assessments to next-generation sequencing. Several platelet disorders may now be treated with gene therapy or bone marrow transplant. Improved understanding of the molecular and biologic mechanisms of the inherited platelet disorders may lead to novel targeted therapies.

Validation of two algorithms for managing children with a non-blanching rash

BACKGROUND

Paediatricians are concerned that children who present with a non-blanching rash (NBR) may have meningococcal disease (MCD). Two algorithms have been devised to help identify which children with an NBR have MCD.

AIM

To evaluate the NBR algorithms' ability to identify children with MCD.

METHODS

The Newcastle-Birmingham-Liverpool (NBL) algorithm was applied retrospectively to three cohorts of children who had presented with NBRs. This algorithm was also piloted in four hospitals, and then used prospectively for 12 months in one hospital. The National Institute for Health and Care Excellence (NICE) algorithm was validated retrospectively using data from all cohorts.

RESULTS

The cohorts included 625 children, 145 (23%) of whom had confirmed or probable MCD. Paediatricians empirically treated 324 (52%) children with antibiotics. The NBL algorithm identified all children with MCD and suggested treatment for a further 86 children (sensitivity 100%, specificity 82%). One child with MCD did not receive immediate antibiotic treatment, despite this being suggested by the algorithm. The NICE algorithm suggested 382 children (61%) who should be treated with antibiotics. This included 141 of the 145 children with MCD (sensitivity 97%, specificity 50%).

CONCLUSIONS

These algorithms may help paediatricians identify children with MCD who present with NBRs. The NBL algorithm may be more specific than the NICE algorithm as it includes fewer features suggesting MCD. The only significant delay in treatment of MCD occurred when the algorithms were not followed.

Clinical characteristics of children with viral single- and co-infections and a petechial rash

BACKGROUND

Children with petechial rash are more likely to undergo invasive diagnostics, to be treated with antibiotics for potential bacterial infection and to be hospitalized. However, viruses have also been associated with petechial rash. Nonetheless, a systematic analysis of viral infections with modern available techniques as quantitative real-time polymerase chain reaction in the context of petechial rash is lacking. The purpose of this pediatric study was to prospectively uncover viral pathogens that may promote the emergence of petechiae and to analyze the correlation with the clinical characteristics and course.

METHODS

We conducted a prospective study in children (0 to 18 years) presenting with petechiae and signs or symptoms of infection at the emergency department between November 2009 and March 2012. In nasopharyngeal aspirates the following viruses were analyzed by quantitative real-time polymerase chain reaction: cytomegalovirus, Epstein-Barr virus, parvovirus B19, influenza A and B, parainfluenza viruses, human respiratory syncytial virus A and B, human metapneumovirus, rhinovirus, enterovirus, adenovirus, human coronavirus OC43, 229E, NL63 and human bocavirus.

RESULTS

A viral pathogen was identified in 67% of the analyzed 58 cases with petechial rash. Virus positive patients showed a significantly higher incidence of lower respiratory tract infections. Forty-one percent were viral coinfections, which were significantly younger than virus negative patients, had a higher leukocyte count and were hospitalized for a longer time.

CONCLUSIONS

A petechial rash is frequently associated viral single- and coinfections and can rapidly be identified via quantitative real-time polymerase chain reaction.

Petechiae/purpura in well-appearing infants

BACKGROUND

Well infants with petechiae and/or purpura can present to emergency departments, and their management can be difficult. Many will have extensive investigations and treatment that may not be necessary.

METHODS

This was a retrospective and descriptive audit investigating well infants (<8 months of age) presenting with petechiae or purpura in the absence of fever to a pediatric emergency department over a 9½-year period. All presenting problems of petechiae or purpura were reviewed. Patients were excluded if they appeared unwell, were febrile or have a history of fever, or had eccyhmoses on presentation.

RESULTS

Thirty-six babies were identified. The average age was 3.8 months (range, 1-7 months). The majority of the infants had localized purpura/petechiae to the lower limbs (92%) with two thirds of these patients having bilateral signs. None had generalized signs. Most infants had a full blood count (94%), coagulation profile (59%) and C-reactive protein (59%), and blood cultures (59%), with all being normal (except for mild elevation in platelets). Nine patients were admitted for observation, with only 1 patient having progression of signs. This patient had a diagnosis of acute hemorrhagic edema of infancy. The rest of the patients were thought to have either a mechanical reason for their petechiae/purpura (tourniquet phenomena) or a formal diagnosis was not specified.

CONCLUSIONS

Well infants with localized purpura and/or petechiae with an absence of fever are more likely to have a benign etiology. Further study is required to determine if a full blood count and coagulation profile is necessary, or a period of observation (4 hours) is all that is required. If there is no progression of signs, it is likely that they can be safely discharged. The likely cause may be due to a tourniquet phenomenon (eg, diaper).

Caput succedaneum and facial petechiae--birth-associated injuries in healthy newborns under forensic aspects

In cases of suspected neonaticide, the results of a forensic autopsy might be important for conviction or acquittal. But autopsy findings in dead newborns are often unspecific and can rarely provide corroborative evidence of inflicted injury, as they are known to occur during normal birth as well. In our study, we examined 59 vaginally delivered, healthy newborns within the first 30 min after birth to know more about the prevalence and possible correlations of a caput succedaneum and facial petechiae. Caput succedaneum occurred in 33.9%, facial petechiae in 20.3%. As for the occurrence of caput succedaneum, statistically significant differences could be shown for the duration of delivery and the mother's parity. These correlations could not be shown for the occurrence of facial petechiae. Within the scope of our study, we could demonstrate that neither caput succedaneum nor facial petechiae are rare findings in healthy newborns. In the forensic investigation of suspected neonaticide, their potential significance can only be ascertained together with further investigations of the circumstances of death and a thorough forensic pathological autopsy.