Periorbital petechiae after emesis in a young woman

Dermoscopy showing nonblanching, irregular, and structureless purple areas (10×, polarized light)

Post-vomiting purpura

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PMCID: PMC5038125 PMID: 27730060

We present two cases thatpresented with purpuric lesions over the face,-which developed immediately after a bout of forceful vomiting.

The first patient was a 7-year-old male child who presented with red lesions over the face after a single episode of vomiting [Figure 1]. On examination the lesions were purpuric, but not palpable (except for a few lesions where the petechia seemed to be superimposed over pre-existing milia). The child presented to us on the same day of the vomiting episode. The father mentioned that the vomiting was forceful. The child had been seen by the pediatrician on the same day. The pediatrician had considered a diagnosis of gastritis.

Figure 1.

Petechial lesions on the face after vomiting

The second patient was a 21-year-old male patient who also presented to us with purpuric lesions after a bout of forceful vomiting. The patient presented to us three days after the episode of vomiting and by then the lesions had subsided considerably [Figure 2]. The patient had not taken a medical consultation for the vomiting itself, but had self-diagnosed it as gastritis.

Figure 2.

Resolving petechial lesions on the face

Both patients were otherwise healthy and there was no previous history of any similar lesions in the past in the patient or his family. There were no skin lesions elsewhere, including the oral and conjunctival mucosa There was no history of any significant sun-exposure, trauma, fever, or any associated drug intake. In both the patients all laboratory investigations including bleeding/clotting parameters, and work-up for vascultis were within normal limits and the lesions resolved without any treatment within a week. Vitamin C levels were not measured; however, both the patient did not have any other skin or systemic features suggestive of vitamin C deficiency.

Dermoscopy in both cases revealed nonblanching, structureless purple areas, which is consistent with purpura [Figure 3]. Skin biopsy was not done in either case.

Figure 3.

Dermoscopy showing nonblanching, irregular, and structureless purple areas (10×, polarized light)

We present these two cases to highlight the rare but definite entity called postvomiting purpura/petechiae. Petechial lesions after straining during activities such ascrying, coughing, vomiting, weightlifting, and delivery can occur in otherwise normal individuals. The lesions are self-resolving and require no specific intervention other than patient counseling.[1,2] Although a good hand lens and diascopy is sufficient to make a clear clinical diagnosis, dermoscopy may be a useful diagnostic tool in this condition.

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REFERENCES

• 1. Pitt PW. Purpura associated with vomiting. Br Med J. 1973;2:667. doi: 10.1136/bmj.2.5867.667-d. [DOI] [PMC free article] [PubMed] [Google Scholar]
• 2. Burke M, Marks J. Purpura associated with vomiting in pregnancy. Br Med J. 1973;2:488. doi: 10.1136/bmj.2.5864.488-c. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Indian Dermatology Online Journal are provided here courtesy of Wolters Kluwer — Medknow Publications

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Periorbital petechiae after emesis in a young woman

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

PMCID: PMC10120412 PMID: 36918187

A 27-year-old woman presented to the dermatology clinic with a 1-day history of sudden-onset, painless, nonpruritic, periorbital rash. The patient had several episodes of intense vomiting related to alcohol intake 1 day before onset of the rash. She was previously healthy and had not taken medications around the time of rash onset. On examination, we observed nonpalpable petechiae (1–2 mm in diameter), involving both periorbital regions and cheeks, that did not blanch under direct pressure of a glass slide (Figure 1). The only laboratory investigation we ordered was a complete blood count, which showed a normal platelet count and mean platelet volume. We diagnosed petechiae induced by elevated intravascular pressure from her vomiting. The rash resolved after 1 week without any therapeutic intervention. On a phone follow-up 2 years later, she reported no recurrence of petechiae since her initial presentation.

Figure 1:

Petechiae on both periorbital regions and cheeks of a 27-year-old woman.

Cutaneous purpuric lesions are a result of extravasation of blood into the skin or subcutaneous tissue. Petechiae are small lesions that measure less than 2 mm in diameter. Lesions between 2 mm and 10 mm are purpura and become ecchymoses when they are more than 10 mm in diameter. 1 Periorbital petechiae are a clinical sign of elevated intravascular pressure induced by events such as severe vomiting, coughing, crying, infant delivery and the Valsalva manoeuvre. 1 , 2 Concerning causes of periorbital petechiae include seizures and strangulation. 2 , 3 It is also important to consider the possibility of interpersonal violence as a cause of facial petechiae. A detailed medical and social history, along with physical examination, can help determine subsequent investigations. Petechiae induced by elevated intravascular pressure and no other underlying medical condition usually resolve after 1–2 weeks and do not require further investigation or treatment.

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Footnotes

Competing interests: None declared.

This article has been peer reviewed.

The authors have obtained patient consent.

References

• 1. Ota M. A rash localised around the eyes. BMJ 2017;358:j3148. [DOI] [PubMed] [Google Scholar]
• 2. Bhanja DB, Mondal S, Sil A, et al. Post-emesis periorbital purpura in hyperemesis gravidarum. Int J Dermatol 2021;60:e117–9. [DOI] [PubMed] [Google Scholar]
• 3. Kaufman AR, Oh DJ, Gliksberg A, et al. Conjunctival and periorbital petechiae presumed secondary to self-inflicted asphyxiation in a pediatric patient. Can J Ophthalmol 2021;56:e96–8. [DOI] [PubMed] [Google Scholar]

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