Rosen & Barkin's 5-Minute Emergency Medicine Consult (590 page)

• Obtain a complete medical history
  
• Previous bleeding problems
  
• Deep venous thrombosis/pulmonary embolism suggesting factor V Leiden mutation
  
• Splenectomy
  
• Alcohol and drug abuse
  
• Family history of bleeding disorders
  
• High-risk medications
  

• Platelet count: Abnormal counts must be verified by manual exam of a peripheral smear
  
• DIC screen: Indicated when patient appears toxic
  
• PT/PTT
  
• Chemistry panel including liver function tests
  
• Rapid strep test
  
• Urinalysis
  
• Studies for outpatient management:
  
  • Bleeding time
    
  • Hepatitis B and C serologies
    
  • Strep throat culture or anti–streptolysin O titer
    
  • Antinuclear antibodies
    
  • Cryoglobulins
    
  • Platelet function studies
    
  • Serum complements
    
  • Serum protein electrophoresis
    
  • von Willebrand disease screen
    

• Disorders with telangiectasias:
  
  • Cherry angiomas
    
  • Hereditary hemorrhagic telangiectasia
    
  • Chronic actinic telangiectasia
    
  • Scleroderma
    
  • CREST syndrome
    
  • Ataxia-telangiectasia
    
  • Chronic liver disease
    
  • Pregnancy-related telangiectasia
    
• Kaposi sarcoma and other vascular sarcomas
  
• Fabry disease
  
• Neonatal extramedullary hematopoiesis
  
• Angioma serpiginosum
  

TREATMENT

• IV access
  
• Monitor for:
  
  • Fever
    
  • Hypotension
    
  • Altered mental status
    

• For fever, hypotension, altered mental status, or generalized ecchymoses:
  
  • Airway support
    
  • IV access
    
  • Fluid resuscitation
    
  • IV antibiotics as soon as possible
    

• Presumptive treatment of infectious etiology:
  
  • Meningococcus
    : Ceftriaxone (Prophylaxis: Rifampin or Ciprofloxacin)
    
  • Pneumococcus
    : Ceftriaxone, consider penicillin
    
  • Rickettsia rickettsii
    : Doxycycline, Chloramphenicol in pregnancy
    

• Ceftriaxone: 2 g (peds: 100 mg/kg/24h) IV BID
  
• Ciprofloxacin (prophylaxis): 500 mg PO once
  
• Chloramphenicol: 75 mg/kg/24h PO or IV QID
  
• Doxycycline 100 mg (peds: 4 mg/kg/24h) PO or IV BID
  
• Penicillin G: 4 million U (peds: 240,000 U/kg/24h) IV q4h
  
• Rifampin (prophylaxis): 600 mg PO BID for 2 days
  
• Neonatal sepsis: Ampicillin 100 mg/kg/24h IV q6h
  and
  gentamicin 7.5 mg/kg/24h IV q8h (or cefotaxime 200 mg/kg/24h IV q6h)
  

FOLLOW-UP

• Unstable vital signs
  
• Altered mental status
  
• Fever
  

Exclusion of life-threatening etiologies:

• Serious bacterial infections
  
• Critical thrombocytopenia
  

• Serious hematologic, rheumatologic features and malignancies require an in-depth outpatient assessment if the patient is not admitted
  
• No contact sports or antiplatelet agents until cleared by a physician
  

• Appropriate close follow-up scheduled
  
• Consider follow-up with dermatology (skin biopsy) and hematology
  

Consider empiric antibiotics to cover for meningococcemia, Rocky Mountain Spotted fever, and/or sepsis if any doubt of underlying infection

• Baselga E. Purpura in infants and children.
  J Am Acad Dermatol
  . 1997;37:673–705.
  
• Coller BS, Schneiderman PI. Clinical evaluation of hemorrhagic disorders: The bleeding history and differential diagnosis of purpura. In: Hoffman R, et al.
  Hematology: Basic Principles and Practice
  . 5th ed. New York, NY: Churchill Livingstone; 2008:1975–2000.
  
• Lee KC, Ladizinski B, Nutan FN. Systemic complications of levasimole toxicity.
  J Am Acad Dermatol.
  2012;67(4):791–792.
  
• Piette WW. Hematologic Diseases. In: Goldsmith LA, et al.
  Fitzpatrick’s Dermatology in General Medicine
  . 8th ed. New York, NY: McGraw-Hill; 2012.
  www.accessmedicine.com
  

See Also (Topic, Algorithm, Electronic Media Element)

Rash, Pediatric

CODES

• 287.0 Allergic purpura
  
• 287.2 Other nonthrombocytopenic purpuras
  
• 287.31 Immune thrombocytopenic purpura
  

BASICS

• Complication of a lower UTI by bacterial ascension into the upper urinary tract
  
• Primarily a clinical diagnosis
  
• Incidence lower in males in every age group
  
• Male/female ratio:
  
  • 1:10 in 1st years of life
    
  • 1:5 in children
    
  • 1:50 in reproductive years
    
  • 1:1 in 5th decade and later
    
• Bilateral infection in up to 25% of cases, hence no lateralizing signs (in some studies)
  

• Bacteriology:
  
  • Escherichia coli
    80–95% predominates
    
  • Uropathogens:
    
    • Klebsiella
      species
      
    • Citrobacter
      species
      
    • Enterobacter
      species
      
  • Others:
    
    • Staphylococcus saprophyticus
      5–15%
      
    • Proteus mirabilis
      
    • Serratia
      species
      
    • Pseudomonas
      species
      
    • Staphylococcus aureus
      (increasing)
      
• Predisposing factors (consider complicated infections):
  
  • Recent instrumentation:
    
    • Catheterization
      
    • Cystoscopy
      
  • Urinary retention:
    
    • Mechanical (see Obstruction below)
      
    • Medications (e.g., anticholinergics)
      
    • Other infections (e.g., herpes simplex)
      
  • Urinary obstruction:
    
    • Stricture
      
    • Renal calculi
      
    • Prostatic hypertrophy
      
  • Anatomic abnormalities:
    
    • Hypospadias
      
    • Ureteral ectopia
      
    • Bifid ureter
      
    • Renal scarring
      
    • Ureterovesicular reflux (UVR)
      
    • Posterior urethral valves
      
  • Neurologic conditions:
    
    • Neurogenic bladder
      
    • Spinal cord injury
      
  • Abnormal urodynamics
    
  • Previous UTIs (in childhood, >3 in last year)
    
  • Recent pyelonephritis (within 1 yr)
    
  • Diabetes mellitus
    
  • Immunosuppression
    
  • Pregnancy
    

DIAGNOSIS