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April 20, 2017

Easy Bruising: Symptom and  Differential Diagnosis - Isabel Healthcare

15147116356_308e205509_m.jpgEasy bruising is a common complaint which medical professionals  often come across in their everyday work. The frequency of easy bruising among patients attending health care appointments has been reported as ranging from 12% to 55% and is commonly seen more frequently in women and the elderly. The definition of easy bruising is bruising without a history of trauma, or bruising after minor trauma that would not have caused bruising in the past.  The medical professional needs to evaluate the patient and work out what is normal versus what is clinically significant, and this can be quite difficult due to there not being specific symptoms.

How a bruise develops

A bruise (ecchymosis) is caused by bleeding beneath the skin due to extravasation of blood leaking from surrounding blood vessels.  It may develop due to hemostatic abnormalities or due to the blood vessel wall being altered structurally.

Easy bruising causes

There are many causes of easy bruising, ranging from those which are clinically insignificant, to those where underlying diseases could be life-threatening such as severe bleeding disorders or malignancies of the bone marrow. This means appropriate evaluation is crucial to reach the correct diagnosis and offer the best treatment.  A structured approach to assessing a patient with easy bruising is therefore essential, incorporating a history, physical examination and ordering correct laboratory studies.  A clinical decision support system can also help you research which conditions could be causing the easy bruising in different age groups.


Differential diagnosis of easy bruising in a child

Ehlers-Danlos Syndrome

Is a heritable collagen disorder where easy bruising is a characteristic manifestation.  EDS is a heterogeneous group of connective tissue diseases sharing clinical manifestations in skin, ligaments and joints, blood vessels and internal organs. Easy bruising can be seen in all subtypes of EDS and is due to vascular fragility affecting capillaries, perivascular connective tissues. In the vascular subtype of EDS it also affects the medium-sized and large arteries, causing larger and more severe bruises which may require treatment in hospital.

Aplastic anemia

This develops when bone marrow stem cells, which normally grow into healthy blood cells, are damaged, resulting in patients experiencing anemia, neutropenia and thrombocytopenia. This then leads to the symptom of easy bruising in the patient along with other symptoms including fatigue, shortness of breath and dizziness.

Vitamin C deficiency (Scurvy)

Vitamin C cannot be made by the human body and is an essential component of a healthy diet as is needed to repair tissues in the body.  A prominent symptom of Vitamin C deficiency is easy bruising along with joint and muscle pains.  If a patient presents with evidence of a poor diet or if they have travelled from a less developed country where a balanced diet has been an issue then Vitamin C deficiency should be considered if they have easy bruising.

Acute myeloid leukemia or acute lymphoblastic leukemia

This could present with a rapid onset of fatigue, shortness of breath, fever, rigors and pancytopenia.  The patient may also demonstrate easy bruising due to the blood abnormalities which they are experiencing. This is much more common in younger children, and is a red flag diagnosis for that age group.

Easy bruising in Adults:

Easy bruising is commonly seen as a symptom in the older population.  As a patient ages the skin becomes thinner and loses some of the protective fatty layer which helps cushion the blood vessels from injury.  Therefore, in the older generation a small knock to the arm or leg can result in a substantial bruise forming.

Medications and supplements such as aspirin, anticoagulant medications and anti-platelet agents also reduce the blood’s ability to clot.  Some antibiotics have also been associated with clotting problems.  As the older generation tend to be on more medications it is also another reason why easy bruising is commonly seen in this age group.  The bleeding from capillary damage from a knock may take longer than usual to stop which means more blood leaks out and causes a bigger bruise.

In adults taking topical and systemic corticosteroids for allergies, asthma or eczema easy bruising can occur as the skin is thinner than normal.  Therefore, it is important to ensure you have taken a thorough history both in terms of physical, past medical history of conditions the patient has or has experienced and any current medications they are when working up their differential diagnosis.

Life-threatening complications of easy bruising

As well as the leukemias and aplastic anemia mentioned earlier, which can all be life threatening causes of easy bruising, the symptom may be a sign of a life-threatening decrease in platelet count or factor levels. Early recognition of this may prevent severe bleeding complications. The following diagnoses may be life-threatening:

  • Thrombotic thrombocytopenic purpura - classically presents with microangiopathic hemolytic anemia, thromobcytopenia, renal insufficiency, neurological symptoms and fever.
  • Disseminated intravascular coagulation (DIC) – Abnormal bleeding, small vessel thrombosis and tissue ischemia as well as macroangiopathic hemolytic anemia and thrombocytopenia.
  • Immune thrombocytopenia (ITP) – Patient presents with severe thrombocytopenia, sudden onset of petechia and mucosal bleeding.  Severe thrombocytopenia may be associated with life-threatening bleeding including intracranial bleeding.
  • Myelodysplastic syndrome – commonly presents with symptoms of anemia, leukopenia and thrombocytopenia in patients older than 65 years.
  • Coagulation factor deficiencies – recurrent or severe bleeding or bruising can occur in coagulation disorders such as hemophilia, von willebrand disease and other coagulation disorders.

Bruising is a difficult symptom to work up, as causes can be benign or life threatening. A thorough workup and differential diagnosis list is essential to get the best and correct outcomes for a patient.  Clinical decision support systems like Isabel may help determine a thorough clinical workup and early recognition of the cause may prevent severe bleeding complications from arising.




Image Attribution:

Mandy Tomlinson

Mandy Tomlinson

Mandy has worked for Isabel Healthcare since 2000. Prior to this, she was a Senior Staff Nurse on the Pediatric Infectious disease ward and high dependency unit at one of London's top hospitals, St Mary’s in Paddington which is part of Imperial College Healthcare NHS Trust. Her experience in the healthcare industry for the past 28 years in both the UK and USA means she's a vital resource for our organization. Mandy currently lives and works in Scottsdale, Arizona.


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