SAEM Clinical Image Series: Sudden Onset of Facial Petechiae in Kindergartener


A 6-year-old boy with no past medical history presented when his parents noticed facial petechiae after picking him up from school. He had a series of four recent upper respiratory infections within four months since starting public kindergarten. He occasionally also complains of leg pain.

General: Non-toxic, cooperative child

Skin: Petechial rash in periorbital and infra-auricular areas

HEENT: Normal; no lymphadenopathy

Musculoskeletal: Normal strength and range of motion

Hemoglobin: 12.6 g/dL

White blood cell (WBC) count: 6.7×103/mL

Platelets: 352,000/mL

Increased pressure in the dermis from actions such as extended Valsalva maneuver, vomiting, crying, or coughing.

This child had a stressful day in kindergarten. He was holding his breath for extended periods of time to suppress crying. The increased pressure caused the facial petechiae, which was completely unrelated to his recent viral infection or growing pains

Take-Home Points

  • Fine petechiae around the eyes, cheeks, and ears are most often caused by crying or similar behaviors that cause increased pressure in the subcutaneous vessels of the face.
  • Mucosal and cutaneous capillaries are fragile and can easily rupture, even with minor trauma. Usually, platelets can seal these immediately, so when petechiae show up, consider a problem with primary hemostasis.
  1. Kumar V, Abbas A, Aster J. Hemodynamic Disorders, Thromboembolic Disease, and Shock. Robbins & Cotran Pathologic Basis of Disease, 10th edition. 2021. Marcdante K, Kliegman R. Immunological Assessment. Nelson Essentials of Pediatrics, 8th edition. 2019