AUCTORES
Globalize your Research
Chat with us
Case Report | DOI: https://doi.org/10.31579/2690-4861/059
*Corresponding Author: Jochanan E. Naschitz, Department of Geriatric and Palliative care, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
Citation: J E Naschitz, B B Nesher. (2020) Bruises of the face-two verry different tales. International Journal of Clinical Case Reports and Reviews. 4(2);DOI: 10.31579/2690-4861/059
Copyright: © 2020 Jochanan E. Naschitz, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 14 September 2020 | Accepted: 28 September 2020 | Published: 04 November 2020
Keywords: upper torso; systemic disease; bruises of the face
Bruises of the face, sometimes extending to the neck and upper torso, differ from bruising in systemic disease. Two case histories illustrate their main etiologies: bruising induced by coughing or straining which usually is an innocent occurrence, and bruising caused by rough handling the patient or elder abuse which need to be prevented.
Bruising is the result of bleeding into the skin when blood vessels are damaged and red blood cells escape into the surrounding skin. Bruises may be caused by disruption of the blood vessels (due to trauma, vasculitis, infection, collagen disorder, scurvy), disorders of hemostasis (thrombocytopenia, abnormal platelet function, abnormal clotting), defect of the skin tissues supporting the blood vessels (skin ageing, Ehlers-Danlos syndrome), and increased venous pressure [1]. A blunt trauma of sufficient power always causes bruises. Minor trauma may cause bruises when the blood vessels are fragile. Bruising is prevalent in the elderly and may be a consequence of skin ageing. Systemic or topical corticosteroids can cause bruising by inducing capillary fragility and skin atrophy. Bruising can be triggered or exacerbated by anticoagulant or antiaggregant medications. Bleeding may reflect an underlying bone marrow disorder. A careful medical history and physical examination can narrow the diagnostic possibilities [1-3].
The patient history should focus on the use of nonsteroidal anti-inflammatory drugs, platelet antiaggregant, and anticoagulant medications. Antidepressants also may cause bruises. Platelet dysfunction may be due to systemic disorders such as uremia. Presence of hepatosplenomegaly and lymphadenopathy indicates a need for workup for myeloproliferative disease, malignancy, or aplastic anemia. There may be acquired deficiencies of a coagulation factor, some with an immune underlying mechanism (e.g. acquired factor VIII deficiency, acquired factor V deficiency) or nonimmune. Vitamin K deficiency may result in insufficiency of coagulation factors; it may be the consequence of liver disease or treatment with antagonists of vitamin K. Severe acquired hypofibrinogenemia is caused by advanced liver disease. An acquired deficiency of factor X may occur in amyloidosis. Vitamin C deficiency (scurvy) should be considered when there is lethargy, perifollicular hemorrhages in the skin, gum bleeding and gum swelling; the cause may be a very poor diet or malabsorption. Consumption coagulopathy may occur in cancers. Acquired von Willebrand disease may be associated with a paraprotein or hypothyroidism. Spontaneous bruising may be due to abnormal blood vessels, abnormality of the adjacent skin, impaired platelet function, or a coagulation disorder, but often the trigger remains obscure [1].
Bruising limited to the head, or also extending to the neck and upper torso, differ from the usual distribution of bruises in systemic diseases. Their etiology also differs [4-6]. Two case histories illustrate the main causes of bruising limited to the head, their diagnosis, and avoiding misinterpretation.
Case histories
Case 1
A 84-year-old man was admitted for comprehensive nursing and palliative care, having suffered a traumatic brain hemorrhage 3 months earlier. He was in persistent vegetative state, breathed spontaneously through tracheostomy, and received feeding through gastrostomy. There were abundant secretions from the airways needing frequent suctioning. The patient's daily medications were phenytoin sodium 200 mg, levetiracetam 1500 mg, insulin glargine and transcutaneous fentanyl 12 mcg/72 hours. The BUN was 44 mg/dL, the eGFR 69 mL. The platelet count, prothrombin time and thyrotropin were within the normal range. After eleven months of uneventful nursing in our department, bruises appeared successively in areas adjacent to the right eyelids, the right temporo-parietal skin, and in the vicinity of the right mandibular angle (Figure 1). Overall, bruises occurred over 3 weeks and resolved over another 3 weeks. Other body areas were not affected by bruises. The patient’s skin showed evidence of severe dermatoporosis confined to the extremities, but not involving the head and neck. Neurological examination did not disclose new focal signs.
Bruises restricted to the head, sometimes extending to the neck and upper torso, differ from the usual distribution of bruises in systemic diseases and trauma. It has been described in the context of paroxysmal coughing, vomiting, Valsalva maneuver, epileptic seizure, myocardial infarction, proctoscopy, chest trauma, bungee jumping, yoga, and power lifting [4-14]. It was attributed to bursts of high intrathoracic pressure, as high as 300 mmHg, occurring during coughing [15]. Comparable high intrathoracic pressures but lasting much longer occur under vomiting, spontaneous straining, Valsalva maneuver and asphyxia [10]. Clinical and experimental studies have shown that the high intrathoracic pressure is transmitted to the vena cava, resulting in reversal of the venous flow, stasis in the venous tributaries and capillaries, and bleeding by break of small vessels [10]. Bruising confined to the head, neck and upper torso is usually an innocent occurrence [4-14)]. The proposito was heavily straining during suctioning the tracheal secretions, which could cause high intrathoracic pressures and produce bruises.The patient's relatives were concerned and questioning about the possibility of physical abuse of the patient. Supervision of the caregivers during washing and nursing the patient revealed no evidence of an unprofessional conduct. Neither did the appearance of the bruises match the patterns typically observed under patient abuse [16, 17]. The worries of the family could be relieved.
Case 2
A 71-year-old woman was admitted for treatment of stage 4, paratrochanteric pressure injury. She had been diagnosed with dementia CDR 3.0, i.e. severe memory loss and no significant function outside of the house, extrapyramidal syndrome, type 2 diabetes mellitus complicated by neuropathy, and osteoporosis. Her usual medications were insulin glargine, gabapentin, and laxatives. There was direct bone contact in the depth of the pressure ulcer. In suspecting osteomyelitis empirical antibiotic treatment was initiated. Because of insufficient eating enteral feeding was initiated through nasogastric tube. When she inadvertently pulled out the nasogastric tube, and then opposed to it being reinserted there was need to hold her head forcedly. Bruising on her jaw and face became apparent on the following days (Figure 2). At this time the platelet count was 412000/mm3, PT INR 1, aPTT 25.7 secconds, eGFR 111 mL/min/1.73m2, and C reactive protein 1 mg/dL.Rough handling the person with the hand or the fingertips may cause bruising at the site of impact. Bruises caused by physical mistreatment are often large (>5 cm) and are often found on the face, lateral right arm, or posterior torso [16, 17]. Rough handling this patient induced a sequence of inquiries, penalty, and measures to prevent recurrence of the accident.
Discussion
Bruises limited to the head, sometimes extending to the neck and upper torso, differ from the usual distribution of bruises in systemic diseases. Two case histories illustrate their main etiologies: bursts of high intrathoracic pressure during coughing or straining in Case 1, and rough physical treatment in Case 2.
Clinical and experimental studies showed that high intrathoracic pressure is transmitted to the vena cava, resulting in reversal of the venous flow, stasis in the dependent venous tributaries and capillaries, and bleeding by break of small vessels [10]. Intrathoracic pressures as high as 300 mmHg may occur during coughing, vomiting, spontaneous straining, Valsalva maneuver, or chest trauma [4-14, 18]. The reason why high intrathoracic pressure affects selectively capillaries in upper but not the lower body segments could not be found in the literature. We proposed the following explanation based on the equation Energy = Pressure x Volume. Equally exposed to bursts of high intrathoracic pressure are the superior and inferior vena cava. However, the thoracic segment of the inferior vena cava is merely a small segment while the superior vena cava is entirely intrathoracic. Therefore, the blood volume exposed to intrathoracic pressure in the superior vena cava is several times larger than the blood volume exposed to intrathoracic pressure in the inferior vena cava. So, the energy conveyed by high thoracic pressure to the tributaries of the superior vena cava is many-fold higher than the energy conveyed to the tributaries of the inferior vena cava [18]. In theory as well as in practice bruising caused by high intrathoracic pressure affects with predilection the upper body parts.The differential diagnosis of bruising caused by forceful handling in Case 2 was straightforward, in observing the pattern of the bruises and the circumstances of their appearance. They differed from the pattern of bruises caused by coughing or straining, differed from senile purpura which is usually superimposed on dermatoporosis [19], and also from bruising in systemic diseases which is predominantly localized in dependent body areas [1]. The differential diagnosis with an ecchymosis expanding from an internal organ to the skin is paramount, but should not be difficult based on associated acute pain and hypotension, clinical context, the different pattern and large extent of the bruise [20]. Avoidance of rough physical treatment by medical personnel is a must. If detected it is sanctioned. Rough physical treatment, mistreatment, and elder abuse, though differing by intent, may have similar consequences. Vigilance is needed to avoid, detect, and condemn either [16, 17, 21, 22]. Elder abuse is common but infrequently identified. It may have serious medical and social consequences. Suspected or confirmed elder abuse or neglect needs intervention to handle medical, traumatic, and psychological issues, ensure patient safety, and reporting to the authorities. Not so, spontaneous bruising in the area of the head, and/or the upper torso.
In conclusion, bruising limited to the face, neck and/or thoracic outlet is an innocent occurrence, usually, devoid of clinical consequences. It might be attributed to bouts of high intrathoracic pressure during straining and coughing. This benign occurrence should be distinguished from ecchymosis expanding from an internal organ to the neck or chest wall, the latter needing urgent diagnostic imaging and treatment. It should also be distinguished from bruising caused by physical mistreatment, which needs inquiries, penalty, and measures to prevent the misconduct.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
