I read over her chart and saw that my 15-year-old patient had already seen her pediatrician, a pediatric hematologist, an infectious-disease physician, and had extensive lab testing. But no one knew what was causing her bruises.
I was a confident third-year resident at the pediatric hospital that was her next stop. Her expensively dressed father looked at me impatiently, seeing he would have to tell the whole story to yet another young doctor who likely couldn't help. His daughter avoided my gaze.
"For the past six months, she bruises with the slightest touch," he said as he pointed to bruises on her legs, arms, and abdomen. I asked her about each bruise - they were all due to things like gently bumping into a table, or a slight encounter with a tennis ball.
Her platelet count and tests for easy bruising came back negative on several occasions, and I could see the bruising on her inner arms where phlebotomists had penetrated her skin.
A comprehensive physical exam came up empty, though I did observe that she even had bruises in areas without bony prominences. I spoke to her with her father out of the room, and she was teary, but she denied any abuse.
As her father had assumed, I didn't know what was going on. I presented her story to our pediatric rheumatologist, who agreed to examine her.
He handed me a few alcohol pads and told me to give them to him when he asked. I was utterly perplexed.
All children get bruises, but multiple bruises in areas that usually do not bruise is ominous. Conditions such as idiopathic thrombocytopenia, in which the body attacks its own platelets, can cause bruising, but this girl's platelet count was normal. Infections can cause bleeding under the skin, as can leukemia and other cancers, but she had none of those. Autoimmune diseases can also cause bruising, and we hadn't yet ruled those out.
Our rheumatologist looked the girl's father in the eye and apologized for all that his family had been through. He did his own physical exam, looking closely at the bruises with the ophthalmoscope.
"Please give me the alcohol pads," he said, and he approached an area that was bruised. "No, no," the girl protested. "What are you doing?" Before her father could intervene, the rheumatologist had wiped the pad over one of the bruises and held it up for all to see. On it were bluish streaks.
"You two need to talk" the rheumatologist said to father and daughter.
The diagnosis was factitious purpura, a bruise intentionally or inadvertently inflicted by the patient. When intentional, the goal is to gain attention, sympathy, or nurturance.
Together with a social worker, we reentered the room to find daughter and father in a teary embrace. She admitted to us she had studied how to make ink look like bruises. We learned that her parents' relationship was strained and that her father traveled extensively for work.
We arranged for family and individual therapy as they shook the rheumatologist's hand in appreciation. As I walked out of the exam room realizing how much I had still to learn, I noticed a discarded alcohol pad, the blue ink absorbed into its core.
Daniel R. Taylor, D.O., is an associate professor at Drexel University College of Medicine and director of community pediatrics and child advocacy at St. Christopher's Hospital for Children.