My Patient is Getting These Strange Tiny Bruise-Looking Spots

[chris_at_lucas_RN, RN]

I hope someone can enlighten me.

My patient is a 36 year old female with melanoma metastatic to liver, lung ("just spots"), diffusely and generally to all her bones, meninges, brain and "the inside of my skull."

She is still pretty heavy at 185# but has been heavier in the past and has the stretch marks on her belly to prove it. (No babies, never married.)

She has just completed a round of radiation to her skull to slow the brain mets down. As she neared the end of this, she did have an episode where she fell, and among other things (none of them usually significant), she experienced a sore muscle phenomenon on the left side of her belly.

Then the stretch marks went from clear/white to purply blue. They are not spreading, the color stays within the stretch marks, they just looked bruise-y.

Then she noticed she was getting little punctate spots behind both knees, the same color, and punctate spots around those purply stretch marks, also the same color. They almost make you think of goosebumps, except they are flat, have the same texture as the skin around them ("normal"), and they are purply-grayish-blue.

When I called last night, she said the spots are spreading.

They do not itch, do not appear erythematous, do not hurt and are not growing, except in number. She does not have any other s/s such as hematuria or evidence of blood in stool. I don't think anyone has done an occult blood. Appetite is not bad, nausea has subsided with the end of radiation and is managed well with phenergan. She uses oxycodone and hydrocodone for pain management. Drinks plenty of fluids. Is pretty much bedfast in part due to weakness and in part because she likes her bed and bedroom!

Any ideas anybody?

I thought with the bone mets and liver mets she might have some issues with clotting factors. I thought maybe she was getting some leakage from arterioles and/or venules, and that it was just taking longer for those things to clot off, hence the appearance of tiny bruises.

She has had a CBC recently (anemic, got 2 units for comfort and it did help), but to my knowledge no PTT or PT or liver enzymes. I don't have any of those results as they were done by her private doc and you know how they always think of sending results to the hospice, right?

One approach of course could be (and maybe should be) they do not bother her, they are not on her face or anything so it is not a cosmetic issue, and she has other stuff going on that is of more concern.

Plus, this is hospice, we are about comfort, etc. Addressing those little spots decreases the quality of her life, better if she can just write them off as interesting but of no real value as concerns her present condition.

Anything anyone has to offer will be appreciated.

[chris_at_lucas_RN, RN]

(bump)

[leslie :-D]

hi chris! :icon_hug:

are you talking about petechiae?

this would happen if platelets are low...

could also surface on stretch marks.

given the mets to liver, real possibility.

as for the left sides soreness, the melanoma deposits can occur in the spinal cord.

this can cause unilateral tenderness/weakness, w/o alot of sensory loss.

leslie

[chris_at_lucas_RN, RN]

hi chris! :icon_hug:

are you talking about petechiae?

this would happen if platelets are low...

could also surface on stretch marks.

given the mets to liver, real possibility.

as for the left sides soreness, the melanoma deposits can occur in the spinal cord.

this can cause unilateral tenderness/weakness, w/o alot of sensory loss.

leslie

They don't look like the pictures, and they don't look like what I have seen and been told are petechiae, but I suppose it is possible. WHen I look it up, she has a lot of the antecedents.

The soreness is resolving, I do believe that she strained a muscle trying to catch herself when she fell.

No unilateral weakness, pain or sensory loss--yet.

Thanks, leslie :loveya:

[a21chdchic]

What medications is this patient on? If she has brain mets - is she on Dilantin? What other symptoms does she have, she could be having a drug reaction. I'm very curious. Hope to hea from you soon. I always love a mystery to unravel.

Ana

[chris_at_lucas_RN, RN]

They were in fact petechiae.

Her platelets were 50 (yes, 50) post transfusion the week before the petechiae began to appear. They kept spreading.

She had mets to her bones and her liver, so it is safe to assume her clotting factors were piddling away too.

She got weaker and weaker, and slept more and more. She resisted changing position, so she got a nice pressure place with a shear injury on one buttock.

She did not take Dilantin or any antiseizure med because, for some reason, she didn't have seizures. Maybe the radiation to her brain worked. Her cognitive skills never faded, and she was well oriented right to the end. (Although once she awoke from a nap and thought it might be Hallowe'en, but when she was told it was summer and the date, she was reoriented--shoot, I wake up from a nap and am a bit disoriented sometimes!)

She died about two days later. She was aware of a lot of things right to the last minute, asking "what time is it" because she did not want to die past midnight. When she was told "it's a quarter to eleven Monday night," she responded, "good, it's not Katie's birthday yet," closed her eyes, took a nice breath and was gone.

A preschool teacher who had never married and never had children of her own, she cared about children right to the end.

Some of them, I think you don't ever forget.

Thank you for asking, I should have posted "the rest of the story."