Homoeopathy

Description
Purpura is a purplish discoloration of the skin produced by small bleeding vessels near the surface. Purpura may also occur in the mucous membranes, especially of the mouth, and in the internal organs. Purpura is not a disease per se but is indicative of an underlying cause of bleeding.
When purpura spots are very small (<1 cm in diameter), they are called petechiae or petechial haemorrhages. Larger, deeper purpura are referred to as ecchymoses or bruising.
Purpura may occur with either normal platelet counts (non-thrombocytopenic purpuras) or decreased platelet counts (thrombocytopenic purpuras). Platelets help maintain the integrity of the capillary lining as well as being important in the clotting process. As a general rule, purpura indicates a problem of the platelet system whilst a deficiency of clotting factors will cause haematomas or haemarthrosis as in haemophilia. Nevertheless, clotting factor deficiency must be considered.
History
 Note the age of the patient. Henoch-Schönlein purpura tends to occur in children.[4] Senile purpura is confined to the elderly.[5] Leukaemia and myeloproliferative disorders can occur at any age.
    How long has the rash been present? Is it changing noticeably? Meningococcal septicaemia will be very recent in origin and changing almost visibly.
    Is the patient otherwise well? If a child has developed a purpuric, possibly meningococcal, rash but does not seem unwell, do not be lured into a false sense of security. That child may be moribund just 20 minutes later.
    Has general easy bruising been noticed? Other components of a routine history should be gone through (past medical history, medical and allergic history - including any over-the-counter drugs - and social history are all relevant).

Investigations
This will be guided by the differential diagnosis, much of which will already have been excluded.
FBC, ESR, platelets. The platelet count is fundamental. Leukaemia or related diseases may produce anaemia and leukocytopenia. ESR may indicate an inflammatory process. It is very nonspecific.
LFTs to check for liver disease.
A coagulation screen will screen for clotting factor deficiencies.
If the patient is on warfarin, check INR.
Plasma electrophoresis may show hypergammaglobulinaemia, paraproteinaemia and cryoglobulinaemia.
Autoantibody screen for connective tissue disorders.
The clinical condition may indicate further investigations, including blood culture and lumbar puncture.

Associated diseases
These have been outlined in 'Differential diagnosis', above. Here are some points you may wish to bear in mind.

Bacterial infections
Those that cause purpuric rashes include meningococcal septicaemia, streptococcal septicaemia and diphtheria. Several acute viral infections also cause purpuric rashes. These include smallpox, chickenpox, measles, parvovirus B19 and haemorrhagic fevers caused by Ebola virus, Rift Valley virus and Lassa fever.

Allergic vasculitic purpura
This is caused by inflammation and infiltration of the blood vessel wall as an anaphylactic reaction to a number of physical and chemical stimuli, including infections. Henoch-Schönlein purpura is one of the most common. Is often preceded by an upper respiratory tract infection due to beta-haemolytic streptococcal infection. It can occur in epidemics in young children with a fever followed by a purpuric rash, that may be slightly raised. Typically, it affects the fronts of the legs and the buttocks. There may be associated acute arthritis, gastrointestinal pain and nephritis with proteinuria. The rash may continue to form over several weeks. Serious acute complications include central nervous system (CNS) bleeding, acute intussusception or acute renal failure. Usually it is a self-limiting condition but it may respond to steroids.

Strong steroids
Long-term use of strong steroids can cause widespread purpura and bruising, normally on extensor surfaces of the hands, arms and thighs. It is caused by atrophy of the collagen fibres supporting blood vessels in the skin. A similar appearance is also found in senile-type purpura.

Blood transfusions
Severe thrombocytopenia 5 to 12 days after receiving a blood product containing platelets is a rare complication, usually confined to multiparous[9] women. It is due to the production of an antibody to a specific platelet antigen that the woman normally lacks. The patient normally recovers within 1 to 3 weeks but the condition can be lethal and may need treatment with plasmapheresis or intravenous (IV) immunoglobulins.

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