SAEM Clinical Image Series: Rash with Blood Pressure Cuff Inflation

Rash with blood pressure cuff inflation - petechiae

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Chief Complaint: Possible seizure, Left arm rash

History of Present Illness: A 29-year-old with a history of migraine headaches, thalassemia of unknown phenotype, and no history of hypertension or epilepsy arrived to the emergency department via ambulance after possible seizure. The patient had nausea and vomiting the morning after a night of heavy drinking. After several rounds of vomiting, she felt shaky, lightheaded and experienced paresthesia in both of her hands and feet. There was no loss of consciousness, confusion or incontinence. EMS reported hypertension and tremors with upper extremity spasms. The patient developed a left upper extremity rash distal to the blood pressure cuff after paramedics did the first blood pressure measurement.

Physical Exam

General: 162/103, otherwise normal vital signs

HENT: Oropharynx clear, no sign of tongue biting

Skin: Petechial rash that covered the distal left upper extremity to the proximal arm, with a sharp line of demarcation where the blood pressure cuff was located.

Neurologic: GCS 15, unremarkable.

Laboratory Data

BMP: Hypokalemia

CBC: Hemoglobin 12.2 g/dL with MCV of 65.5 FL. Platelet count 258,000 platelets/µL.

Coagulation studies: Within normal limits

Creatine kinase: 914 U/L

Urine dip: Positive for hematuria with scant red blood cells

Case Question: What is the name of the clinical finding displayed in these images, which were obtained after inflation of a blood pressure cuff?

Rumpel-Leede phenomenon

Case Answer/Discussion

The Rumpel-Leede phenomenon is a rare condition in which the small dermal capillaries rupture in response to compression of the extremity, leading to the development of a petechial rash distal to the site of compression. This phenomenon commonly presents in the setting of thrombocytopenia or microvascular fragility that is due to hypertension (hypothesized to be due to elevated venous pressures) or diabetes (due to microvascular injury).

Also seen in patients with:

Ehlers-Danlos
Platelet dysfunction
Intravenous drug use
Chronic steroid use
Mechanical trauma
Infections (e.g. Dengue fever)

The high red blood cell turnover in thalassemia causes an overall increase in bodily absorption of iron. Increased amounts of iron can lead to the creation of reactive oxygen species, such as via the Fenton Reaction. These reactive oxygen species are believed to be involved in various vascular disorders, possibly predisposing the patient to this phenomenon.

The patient’s vessel injury due to thalassemia, her hypertensive state, and the blood pressure cuff inflation together could have led to the occurrence of the Rumpel-Leede phenomenon.

There are no known consequences of the Rumpel-Leede phenomenon. The patient’s petechiae resolved in just over one week, consistent with the typical spontaneous resolution of the rash within 6 to 14 days.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2019 SAEM Annual Meeting | Copyrighted by SAEM 2019 – all rights reserved. View other other cases from this series on ALiEM.