Workup and Differential Diagnosis for Ecchymoses
Initial Diagnostic Approach
Begin with a focused history assessing for spontaneous versus traumatic bruising, medication use (especially anticoagulants, antiplatelet agents, NSAIDs), family history of bleeding disorders, associated symptoms (epistaxis, menorrhagia, hematuria, gastrointestinal bleeding), nutritional status, alcohol use, and recent infections or travel. 1
Essential Laboratory Testing
Order the following initial laboratory panel:
- Complete blood count with differential to assess platelet count and identify cytopenias 2
- Prothrombin time (PT) and activated partial thromboplastin time (aPTT) 1
- Comprehensive metabolic panel including liver function tests 2, 1
- Lactate dehydrogenase (LDH) 2
Critical pitfall: Normal PT and aPTT do not rule out bleeding disorders—these tests detect only approximately 50% of coagulation disorders. 1
Specific Testing Based on Initial Results
If aPTT is mildly prolonged with normal PT and normal platelet count, immediately order von Willebrand disease (VWD) testing including:
- Von Willebrand antigen
- Ristocetin cofactor activity
- Factor VIII coagulant activity 1
This pattern suggests intrinsic pathway factor deficiency, and VWD should be the first diagnostic consideration even with mild aPTT prolongation, as VWD often does not significantly prolong aPTT. 1
Differential Diagnosis by Clinical Context
Hematologic Disorders (Primary Consideration)
Von Willebrand Disease:
- Most common inherited bleeding disorder
- Presents with mucocutaneous bleeding (bruising, epistaxis, menorrhagia)
- May be acquired (AVWS) especially without family history 1
- Requires specialized testing as basic coagulation tests are unreliable 1
Mild Factor VIII or IX Deficiency:
- May not significantly prolong aPTT but causes spontaneous bruising 1
Thrombocytopenia:
- Ruled out by normal platelet count 1
Nutritional Deficiencies
Vitamin C Deficiency (Scurvy):
- Presents with follicular hyperkeratosis, perifollicular hemorrhages, confluent ecchymoses particularly on lower extremities 3, 4
- Associated with poor dietary intake, alcoholism 4
- May present with progressive weakness or paraparesis 4
- Serum ascorbic acid level confirms diagnosis 4
Multiple Vitamin Deficiencies:
- Combined deficiencies of vitamins C, K, B12, and E can cause extensive ecchymoses 3
- Consider in malnourished patients 3
Infectious/Immunocompromised States
In neutropenic or immunocompromised patients, consider:
- Ecthyma gangrenosum (Pseudomonas, other gram-negatives, fungi) 2
- Necrotizing fasciitis or myonecrosis 2
- These require urgent biopsy and broad-spectrum antibiotics 2
Anatomic Location-Specific Diagnoses
Periorbital ecchymosis: Base of skull fracture 5, 6
Abdominal wall ecchymosis (Cullen's sign, Grey Turner's sign): Retroperitoneal hemorrhage, pancreatitis 5, 6
Groin/scrotal ecchymosis (Bryant's sign): Pelvic fracture 5, 6
Lower extremity ecchymosis: Consider nutritional deficiency, vascular disorders, or trauma 5, 6, 4
Psychogenic Purpura
Rare entity characterized by:
- Spontaneous recurrent bruising preceded by burning/stinging sensation 7
- Normal coagulation studies 7
- Associated emotional disorders 7
- Diagnosis of exclusion after ruling out organic causes 7
Management During Workup
While awaiting specialized test results:
- Avoid NSAIDs and antiplatelet agents 1
- Postpone invasive procedures until definitive diagnosis 1
- Refer to hematology for specialized evaluation 1
If nutritional deficiency suspected:
- Begin oral vitamin C supplementation empirically in appropriate clinical context 4
- Symptoms resolve rapidly with treatment 4
If infectious etiology suspected in immunocompromised patient: