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Acute-onset, localized petechiae and purpura of the lower extremities occurred in 3 otherwise healthy infants following recent exposure to baby carriers. This case series identifies tourniquet-like forces associated with baby carriers as a mechanical cause of the Rumpel-Leede phenomenon.
The index patient’s father—a pediatric dermatologist—had taken his infant son on a 2-hour hike using a “legs out,” forward-facing baby carrier. At the hike’s conclusion, the cloth material of the baby carrier was noted to have cinched tight around the infant’s lower extremities. Almost immediately after release of tension on the cloth material, a showering of petechiae and purpura was observed on the infant’s legs, with a sharp, symmetric cutoff at the proximal thighs (Figure). Pulses were normal, and edema was absent. The patient remained afebrile, and the lesions spontaneously resolved over several days.
Note the sharp, symmetric cutoff at the proximal thighs.
Subsequently, 2 healthy-appearing infants presented with eruptions of petechiae and purpura limited solely to the lower extremities in the setting of recent exposure to baby carriers, one with mildly elevated levels of aspartate transaminase (AST) (65 U/L), alanine transaminase (ALT) (55 U/L), platelets (504 × 103/μL), and creatine kinase (CK) (177 U/L) and the other with a mildly elevated AST value (59 U/L). (To convert ALT, AST, and CK to microkatals per liter, multiply by 0.0167.) Multiple laboratory investigations in consultation with a hematology service failed to reveal an underlying bleeding diathesis (tests included complete blood cell count, comprehensive metabolic panel, fibrinogen measure, activated partial thromboplastin time, prothrombin time, blood cultures, and skeletal survey). Lesions completely resolved within several weeks, and all 3 children remained well through follow-up.
Acute-onset petechiae and purpura can be alarming, accounting for approximately 2.6% of all pediatric emergency department visits.1 Given the life-threatening conditions associated with these lesions, extensive evaluations are often implemented. A more benign cause may be the Rumpel-Leede phenomenon, a self-limited clinical finding characterized by acute dermal capillary rupture caused by tourniquet-like forces leading to distal petechiae and purpura on release of pressure.2 A 2012 retrospective review of 36 well-appearing infants presenting to emergency departments with petechiae and purpura in the absence of fever postulated an association with “mechanical forces,” but no specific cause was confirmed.3
Initially reported in association with scarlet fever, the Rumpel-Leede phenomenon has been associated with conditions predisposing patients to capillary fragility, such as diabetic microangiopathy and thrombocytopenia, after ambulatory blood pressure monitoring.4,5 Medications such as calcium channel blockers have also been implicated. In children, the finding has been associated with leukemia, liver disease, and infantile scurvy.5
Excessively tight baby carriers may induce a Rumpel-Leede phenomenon in susceptible infants. Certain viral infections causing thrombocytopenia, including Epstein-Barr virus, may help lower the threshold for occurrence2; notably, 2 patients in this series had mild transaminitis, suggesting a predisposing viral cause. Alternatively, the slightly elevated CK and AST levels may be secondary to trauma to myocytes from sustained mechanical pressure.
Acute onset of petechiae and purpura requires careful investigation to exclude serious underlying causes. At a minimum, direct observation and screening laboratory tests (eg, complete blood cell count, comprehensive metabolic panel, coagulation profile) may be warranted. In the specific setting of a supporting history and physical examination with well-demarcated localized findings, however, recognition of the Rumpel-Leede phenomenon presenting as “baby carrier purpura” may help spare infants from unnecessary, costly, and invasive evaluations and treatments.
Given the ubiquity of baby carriers in today’s society, it is unclear why more cases of this phenomenon have yet to be documented. Similar presentations may simply be unrecognized, and factors such as duration of exposure, carrier type, infant positioning, and local terrain may play roles. Consequently, the true incidence and overall long-term clinical significance of baby carrier purpura should be investigated. Larger, prospective studies would also help elucidate the utility of “muscle markers” (eg, AST and CK) as potential screening tools when tourniquet-like forces are considered as a possible causal agent for this specific presentation.
Corresponding Author: Andrew C. Krakowski, MD, Four Tower Bridge, 200 Barr Harbor Dr, Ste 200, West Conshohocken, PA 19428 (AndrewKrakowski@DermOne.com).
Published Online: February 17, 2016. doi:10.1001/jamadermatol.2015.6270.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the index patient’s parents for granting permission to publish this information. We are also indebted to Colette Grant, MD, and Jennifer Davis, MD, who contributed substantially to the information in this case series. They received no compensation for their contributions.
Nguyen TA, Garcia D, Wang AS, Friedlander SF, Krakowski AC. Rumpel-Leede Phenomenon Associated With Tourniquet-like Forces of Baby Carriers in Otherwise Healthy Infants: Baby Carrier Purpura. JAMA Dermatol. 2016;152(6):728–730. doi:10.1001/jamadermatol.2015.6270
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