Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2025;15(1):4738 1

Petechiae and Limb Weakness in a 12-Year-Old Boy
Eline Vandersteen1, Katrien Smets1, Sophie Bravo2, Valerie Reynaert1,  

Sherief R. Janmohammed1, Dirk Van Gysel1,3

1 Department of Dermatology, Interdisciplinary Unit of Pediatric Dermatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis 

Brussel (UZ Brussel), Brussels, Belgium

2 Department of Pediatrics, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium

3 Department of Pediatrics, O.L. Vrouw Hospital Aalst, Aalst, Belgium

Citation: Vandersteen E, Smets K, Bravo S, Reynaert V, Janmohammed SR, Van Gysel D. Petechiae and Limb Weakness in a 12-Year-Old 
Boy. Dermatol Pract Concept. 2025;15(1):4738. DOI: https://doi.org/10.5826/dpc.1501a4738

Accepted: August 19, 2024; Published: January 2025

Copyright: © Vandersteen et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, 
distribution, and reproduction in any medium, provided the original authors and source are credited.

Funding: None.

Competing Interests: None.

Authorship: All authors have contributed significantly to this publication.

Corresponding Author: Dirk Van Gysel, M.D, Ph.D., Department of Pediatrics, O.L. Vrouw Hospital, Moorselbaan 164, B-9300 Aalst, 
Belgium. E-mail: dirk.van.gysel@olvz-aalst.be

Case Presentation

A 12-year-old boy presented to the Emergency Department 

with a skin rash and weakness in the limbs. History revealed 

fever for one day, followed by redness and edema of the legs 

two days later. Clinical examination showed petechiae on 

the distal lower legs (Figure 1) and on pressure points of 

buttocks and neck. Lower limb muscle strength was normal 

(Medical Research Council (MRC) Scale for Muscle Strength 

Grade 5). He had bathed in a cold water stream the day be-

fore onset of skin symptoms.

Laboratory tests demonstrated low hemoglobin (12.3 g/dl),  

low red blood cell count (4.2 × 106/mm3), low platelet count 

(138 × 103/mm3), and normal white blood cell count and  

C-reactive protein. Urinalysis showed hemoglobinuria +++.

Based on history and clinical picture, which resembled 

papular-purpuric “gloves and socks” syndrome [1], par-

vovirus B19 serology was performed, revealing a positive  

IgM (>48.00) and IgG (4 UI/ml). This finding, combined 

with the presence of transient hemoglobinuria, led to the di-

agnosis of parvovirus B19-induced paroxysmal cold hemo-

globinuria (PCH).

Teaching Point

PCH is an uncommon autoimmune hemolytic anemia, gen-

erally afflicting children after an acute infection; it is caused 

by autoantibodies directed against red blood cells, triggered 

by cold exposure, and causes intravascular hemolysis. Pa-

tients classically present with hemoglobinuria, fever, jaun-

dice, pallor, and fatigue. Diagnosis can be confirmed by 

Donath-Landsteiner autoantibody detection [2]. Although 

this was not performed in our case, the clinical presentation 

and laboratory findings were highly indicative of PCH fol-

lowing parvovirus B19 infection. While severe anemia ne-

cessitating blood transfusion can occur, our patient received 

supportive care and experienced spontaneous resolution of 

hemoglobinuria.



2 Image Letter | Dermatol Pract Concept. 2025;15(1):4738

References

1. Gutermuth J, Nadas K, Zirbs M, et al. Papular-purpuric gloves 

and socks syndrome. Lancet. 2011;378(9786):198. DOI:10.1016 

/S0140-6736(11)60554-0.

2. Jacobs JW, Figueroa Villalba CA, Booth GS, Woo JS, Stephens LD, 

Adkins BD. Clinical and epidemiological features of paroxysmal 

cold hemoglobinuria: a systematic review. Blood Adv. 2023;7(11): 

2520-2527. DOI:10.1182/bloodadvances.2022009516.

Figure 1. Clinical picture of a 12-year-old boy presenting with 

 petechiae on the lower legs and feet.