Endgames Spot Diagnosis

A rash localised around the eyes

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3148 (Published 13 July 2017) Cite this as: BMJ 2017;358:j3148

Re: A rash localised around the eyes

I read with interest the 'Spot Diagnosis' in 'Endgames' from Dr Mitsuhito, described as facial purpura caused by emesis and illustrated with a photograph (bearing the caption 'Localised peri-orbital pinpoint rash' in the online version).

Whilst the answer to the question posed in the printed Journal refers only to purpura, the discussion in the online version explains that 'Small purpural lesions of 2mm or less in diameter are called petechia', and goes on to describe the mechanism of the development of facial petechiae, citing several examples in which facial petechiae may be caused.

The 'pinpoint rash' illustrated in the photograph would appear to me to be typical of facial petechiae and, whilst the examples in which they may be observed - such as severe straining during the Valsalva manoeuvre - given by Dr Ota may reinforce the 'Learning Point' given in the online version that 'Most cases of petechiae are benign, therefore it is usually unneccessary to order extra tests', their presence ought to cause some pause for thought about the possibility of inter-personal violence particularly (but not exclusively) when the patient is a young woman.

Facial petechiae (including in the skin, lining of the eyelids, and within the mouth) can be a sign of the application of pressure to the neck, and should prompt the clinician to examine the neck closely for any evidence of injury, as well as to seek further information from the patient about safety concerns at home and the possibility of physical abuse.

The protection of the vulnerable patient (i.e. one who is at risk of abuse or neglect) requires vigilance by all healthcare personnel, and the recognition of the potentially abusive cause of facial petechiae represents an important step in the safeguarding process.

Competing interests: No competing interests

17 July 2017
Richard M Jones
Clinical Senior Lecturer in Forensic Pathology
Wales Institute of Forensic Medicine, Cardiff University School of Medicine
University Hospital of Wales, Heath Park, Cardiff CF14 4XN