A rare cause of facial purpura: endoscopy.

stomach endoscopy due to gastritis was referred to our department because of an eruption on her face, which had started during the procedure. Due to the fright− ening appearance of the lesions, the pa− tient and the endoscopist failed to com− plete the procedure. On dermatologic ex− amination, hundreds of pin−head−sized red macules on the face, oral mucosa, and neck were seen (l" Figure 1). Subcon− junctival hemorrhage was also observed (l" Figure 2). There was no pruritus or constitutional symptoms. The patient was otherwise healthy. Hematologic cau− ses were excluded, with normal complete blood count, prothrombin time, and par− tial thromboplastin time. The rash started to fade spontaneously within 24 hours, and had disappeared completely after 4 days without treatment. Several factors may contribute towards purpura on the face and neck. The most challenging step in identifying the cause of purpura is to decide whether the pur− pura presents a sign of an underlying life−threatening disorder or not. The dif− ferential diagnosis of purpura can be con− fusing, and consists of a long list of factors including rheumatologic, dermatologic, infectious, and traumatic entities [1]. In some circumstances, facial purpura is caused by a valsalva maneuver that raises intrathoracic or abdominal pressure and results in rupture of capillaries within the dermis. Alcalay et al. [2] suggested the name “mask phenomenon” to de− scribe this condition. Rare occurrence of purpura on the face is thought to be relat− ed to the rich anastomotic vascular sup− ply to face, or the lack of end−artery ves− sels in this area [1]. Giving birth, emesis, and vigorous coughing are examples of this kind, and are well−known causes of facial purpura [1,2]. Prolonged hand− standing [3] and epileptic seizure [4, 5] are also other benign conditions that lead to facial purpura, as reported in the literature. In our patient, the endoscopy probe triggered the retch reflex and caused vigorous coughing. We want to remind physicians of this be− nign cause of facial purpura in order to avoid unnecessary investigation. Endo− scopic procedures are not easy to tolerate, and internists should be aware of this complication of the procedure. This kind of eruption should be added to the list of procedure−related complications of en− doscopy.