A rare cause of facial purpura: endoscopy

A 43-year-old woman who underwent stomach endoscopy due to gastritis was referred to our department because of an eruption on her face, which had started during the procedure. Due to the frightening appearance of the lesions, the patient and the endoscopist failed to complete the procedure. On dermatologic examination, hundreds of pin-head-sized red macules on the face, oral mucosa, and neck were seen ([Figure 1]). Subconjunctival hemorrhage was also observed ([Figure 2]). There was no pruritus or constitutional symptoms. The patient was otherwise healthy. Hematologic causes were excluded, with normal complete blood count, prothrombin time, and partial thromboplastin time. The rash started to fade spontaneously within 24 hours, and had disappeared completely after 4 days without treatment.

Figure 1 Pin-head-sized red macules on patient’s face and neck.

Figure 2 Subconjunctival hemorrhage.

Several factors may contribute towards purpura on the face and neck. The most challenging step in identifying the cause of purpura is to decide whether the purpura presents a sign of an underlying life-threatening disorder or not. The differential diagnosis of purpura can be confusing, and consists of a long list of factors including rheumatologic, dermatologic, infectious, and traumatic entities [1].

In some circumstances, facial purpura is caused by a valsalva maneuver that raises intrathoracic or abdominal pressure and results in rupture of capillaries within the dermis. Alcalay et al. [2] suggested the name “mask phenomenon” to describe this condition. Rare occurrence of purpura on the face is thought to be related to the rich anastomotic vascular supply to face, or the lack of end-artery vessels in this area [1]. Giving birth, emesis, and vigorous coughing are examples of this kind, and are well-known causes of facial purpura [1] [2]. Prolonged handstanding [3] and epileptic seizure [4] [5] are also other benign conditions that lead to facial purpura, as reported in the literature. In our patient, the endoscopy probe triggered the retch reflex and caused vigorous coughing.

We want to remind physicians of this benign cause of facial purpura in order to avoid unnecessary investigation. Endoscopic procedures are not easy to tolerate, and internists should be aware of this complication of the procedure. This kind of eruption should be added to the list of procedure-related complications of endoscopy.

Endoscopy_UCTN_Code_CPL_1AH_2AB

References

• 1 Goldman A C, Govindaraj S, Franco Jr R A. et al . Facial purpura.  Laryngoscope. 2001;  111 207-212
• 2 Alcalay J, Ingber A, Sandbank M. Mask phenomenon: postemesis facial purpura.  Cutis. 1986;  38 28
• 3 Bartunek C, Brodell R T, Brodell L P. Self-assessment quiz. Valsalva purpura.  J Ophthalmic Nurs Technol. 1998;  17 23-24
• 4 Reis J J, Kaplan P W. Postictal hemifacial purpura.  Seizure. 1998;  7 337-339
• 5 Rubegni P, Fimiani M, De Aloe G. et al . Thoracocervicofacial purpura as the single manifestation of epileptic seizure.  J Neurol Neurosurg Psychiatry. 1998;  65 365