Petechial rash inflicted by self-damage in a pre-teen

 Corresponding author: Elda Skenderi Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Petechial rash inflicted by self-damage in a pre-teen Elda Skenderi 1, *, Alberta Shkembi 1, Gjeorgjina Kuli-Lito 2, Megina Muco 1, Ergena Neziri 1, Uendi Dermyshi 1 and Admir Sulovari 3 1 General Pediatric Ward, University Hospital Center “Mother Tereza”, Tirana, Albania. 2 Pediatric Infectious Diseases Ward, University Hospital Center “Mother Tereza”, Tirana, Albania. 3 American Hospital, Tirana, Albania. World Journal of Advanced Research and Reviews, 2025, 26(03), 1894-1897 Publication history: Received on 09 May 2025; revised on 16 June 2025; accepted on 18 June 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.3.2378 Abstract A petechial rash in children is characterized by small, pinpoint, less than 2mm in diameter, non-blanching spots appearing over the skin and mucous membranes. They result from areas of hemorrhage into the dermis. Petechial rash is common in children and result from infections, trauma and blood and clotting disorders. Here is presented the case of pre-teen girl with a petechial rash inflicted by self-damage. Keywords: Petechial Rash; Trauma; Self-Damage; Psychologic Evaluation; Family Therapy. 1. Introduction A petechial rash in children is characterized by small, pinpoint, less than 2mm in diameter, non-blanching spots appearing over the skin and mucous membranes. Petechial rashes result from areas of hemorrhage into the dermis, the main pathophysiological causes are thrombocytopenia, platelet dysfunction, disorders of coagulation, and loss of vascular integrity, or a combination of these mechanisms [1, 2]. There are many causes of a petechial rash in children ranging from infections, to trauma, hematologic, malignant and drug reactions. Viral illnesses as enterovirus, adenovirus; bacterial infections as Neisseria meningitidis, group A Streptococcus; and less commonly fungal infections cause petechiae. Blood and clotting disorders as thrombocytopenia and other coagulation disorders can cause petechiae. Trauma inflicting skin injuries or straining can lead to petechiae [3, 4]. Non-blanching rashes, such as petechial rash, are a great cause of concern for parents and physicians, so a careful assessment and evaluation are necessary to detect the etiologic cause and formulate an appropriate management plan. 2. Case report A 12 years old female B.T. admitted to the University Hospital Center of Tirana after the appearance of a petechial rash on the skin. The parents stated that the rash erupted suddenly, was not companied by other symptoms, and was not evolving. They denied that the girl had taken any medication or drug. The girl lived in a rural area with her family, the parents and a little brother of 3-years old. All the family members were healthy and the girl had been health till then. She was fully vaccinated. The family did not keep domestic animals at home and consumed safe foods. World Journal of Advanced Research and Reviews, 2025, 26(03), 1894-1897 1895 On physical examination the girl did not appear ill, she was adequately responsive and conscious. A petechial rash was visible on her skin in the face, anterior thorax and abdomen. The rash followed a kind of symmetric pattern, and was absent on the upper and lower extremities and was absent on the back too (Fig.1). No weight loss was observed. Sclera were normally, no pharyngeal injection, no petechiae in the oral mucosa, or cervical lymphadenopathy were observed. Pulmonary and cardio-vascular systems were normal, no tachycardia nor tachypnea were observed. The abdomen was soft, not distended, bowel sounds were present, liver and spleen were not palpable. Although the patient did not appear ill on physical examination, a petechial rash in children requires a complete evaluation to determine the underlying cause. Laboratory investigations; complete blood count, C-reactive protein, urine microscopy, renal, liver and coagulation profile were performed. Laboratory examinations revealed; normal blood cell count (normal white blood cells, normal red blood cells, normal platelets), normal values of C-reactive protein, normal urine examination, normal renal and liver function, and normal coagulation tests. In this conditions, as infectious causes, and blood and clotting disorders were excluded, suspicion was raised on traumatic causes. The patient was referred to the psychological consult. Figure 1 Petechial rash 3. Discussion 3.1. Reason for Psychologic Referral The patient has been referred for a clinical psychological evaluation due to the presence of bodily injuries (multiple skin lesions), which are suspected to be self-inflicted. The girl is 12 years old and lives with her parents and younger brother. Her academic performance is assessed as average. From the clinical interview with the patient, a difficult family history is revealed, marked by emotional burdens, problems within the family environment, and a lack of emotional support. She was initially hospitalized due to suspicions of a physical illness. World Journal of Advanced Research and Reviews, 2025, 26(03), 1894-1897 1896 3.2. Psychosocial History • Family history: Frequent family conflicts, presence of emotional/verbal abuse, lack of emotional support from parental figures. • School and social functioning: Difficulties in social adaptation, withdrawal from peers, pronounced isolation. • Self-harming behavior: Presence of multiple injuries on the front part of the body, in areas accessible to the patient. • Other symptoms: Prolonged states of sadness, apathy, anxiety, feelings of emptiness, and periods of irritability. 3.3. Clinical Observation During the assessment session, the patient appeared quiet, with low visual contact and limited responses. Physical signs of self-harm were evident. There was a presence of passive expressions indicating low self-esteem and feelings of helplessness. She did not express active suicidal thoughts at the time of the evaluation, but such risks cannot be ruled out without further monitoring. 3.3.1. Factitious Disorder Imposed on Self (F54/DSM-5; 300.19) Individuals with this disorder fabricate or simulate physical symptoms with an unconscious intent to adopt the sick role [5]. • The physical signs are often self-inflicted, but the individual does not acknowledge this. • There is often a history of emotional abuse or trauma. 3.3.2. Non-Suicidal Self-Injury (NSSI) – (Z91.5) Deliberate behaviors aimed at harming the body without suicidal intent [6]. • Often used as a coping mechanism to deal with anxiety, emotional pain, or feelings of emptiness. 3.4. Psychological Intervention • Individual psychological therapy focused on trauma, aimed at processing emotional experiences and building healthier coping mechanisms [7]. • Play therapy intervention, considering the patient has difficulty verbalizing trauma, allowing emotional processing through play [8]. • Family therapy to address toxic family dynamics and involve parents in the therapeutic process. Therapy focused on restructuring hierarchical roles within the family, as the patient was found to be in a chaotic family system with unclear emotional boundaries [9]. • Family therapy also aimed to intervene at three levels: individual, family, and social — with goals to build communication, emotional support, and improve healthy parenting [10]. • A multidisciplinary treatment approach, including ongoing monitoring of self-harming behaviors. 4. Conclusions • Immediate follow-up with a child/adolescent psychiatrist. • Individual therapy using a Trauma-Focused CBT approach. • Family therapy. • Active monitoring for self-harming behaviors. Recommendations Clinical findings suggest the presence of a severe emotional disorder with manifestations through self-harming behavior. World Journal of Advanced Research and Reviews, 2025, 26(03), 1894-1897 1897 Compliance with ethical standards Acknowledgments We thank the medical staff of the General Pediatric Ward for the precious support! Disclosure of conflict of interest No conflict of interest to be disclosed. Statement of informed consent Informed Consent was taken from the parents of the hospitalized girl, reported in the study, for using the data of the medical records, providing anonymity. References [1] Galera P, Dulau-Florea A, Calvo KR. Inherited thrombocytopenia and platelet disorders with germline predisposition to myeloid neoplasia. Int J Lab Hematol. 2019 May;41 Suppl 1:131-141. [PubMed] [2] Pilania RK, Singh S. Rheumatology Panel in Pediatric Practice. Indian Pediatr. 2019 May 15;56(5):407414. [PubMed] [3] Joly BS, Coppo P, Veyradier A. An update on pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol. 2019 Jun;12(6):383-395. [PubMed] [4] Wells LC, Smith JC, Weston VC, Collier J, Rutter N. The child with a non-blanching rash: how likely is meningococcal disease? Arch Dis Child. 2001 Sep;85(3):218-22. [PMC free article] [PubMed] [5] American Psychiatric Association. Diagnostic and Staticticial Manual of Mental Disorders (DSM-5), 2013. [6] Klonsky, E. D., & Muehlenkamp, J.J. (2007). Selfinjury ; A research review for the practitioner. Journal of Clinical Psychology, 63(11), 1045-1056. [7] Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Trauma-Focused CBT for Children and Adolescents. Guilford Press. [8] Landreth, G. L. (2012). Play Therapy: The Art of the Relationship. Routledge. [9] Minuchin, S. (1974). Families and Family Therapy. Harvard University Press. [10] Liddle, H. A. (2010). Multidimensional Family Therapy: A science-based treatment for adolescent drug abuse. Counseling and Psychotherapy Research, 10(3), 208–216.