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Bruising

Category: Illness or disabilities

Type

Involuntary

Introduction and description

 

A bruise, also known as a ‘contusion’, is a type of hematoma of tissue, - that is a localised collection of blood outside the blood vessels, which spreads among the tissues including the sacs between tissues – or as Wikipedia would have it “allowing blood to seep, haemorrhage, or extravasate into the surrounding interstitial tissues”.  Elderly skin is often thinner and less elastic and thus more prone to bruising. 

A further classification of types of bruising has been made by the medical profession based on the size of the bruise:

  • Petechia - plural petechiae, are by definition less than 3 mm.  The term is almost always used in the plural, since a single lesion is seldom noticed or significant.
  • Purpura - measure 3–10 mm (1 cm)
  • Ecchymosis - are greater than 1 cm in size

Symptoms

 

Colour of skin - Bruises may be easily recognized in people with light skin colour by characteristic blue or purple appearance (idiomatically described as "black and blue"). In people with darker skin, as you can see above it just appears as a dark area.

First, capillaries break under the skin and blood escapes and builds up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread.  The damaged capillary endothelium releases endothelin, a hormone that causes narrowing of the blood vessel to minimize bleeding. As the endothelium is destroyed, ‘the underlying von Willebrand factor is exposed and initiates coagulation’, which creates a temporary clot to plug the wound and eventually leads to restoration of normal tissue.

During this time, bruises change colour due to the breakdown of hemoglobin from within escaped red blood cells in the extracellular space. “The striking colors of a bruise are caused by the phagocytosis and sequential degradation of hemoglobin to biliverdin to bilirubin to hemosiderin, with hemoglobin itself producing a red-blue color, biliverdin producing a green color, bilirubin producing a yellow color, and hemosiderin producing a golden-brown color.”

As these products are cleared from the area, the bruise disappears. Often the underlying tissue damage has been repaired long before this process is complete.

Swelling - The body may rush protective fluids to the area to protect it from further damage – like a protective cushion.  ‘As vascularity forms one of the prominent signs of inflammation, it follows that bruising more or less merges into examples of an inflammatory condition of the part, attended by swelling, tenderness, and heat’.

Pain – There may be pain caused by whatever caused the bruising, in other words direct nerve impact, but the swelling may affect the nerve endings within the affected tissue by creating increased pressure.

Gangrene - Severe bruising may be dangerous or cause serious complications, as the excess fluid may accumulate causing a hard, fluctuating lump or swelling. This has the potential to cut off blood flow to the tissues resulting in cell death and in extreme cases gangrene.  The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death.

Causes

 

By definition, a bruise is always caused by internal bleeding into the interstitial tissues and does not break through the skin, but it may arise from capillaries at the level of skin, subcutaneous tissue, muscle, or bone, as such one should not assume that a bruise is always a result of some external agent, it may have an internal origin which needs investigating.  Blood can also work its way through tissue and settle in an area remote from the site of trauma or pathology.

In other words, bruising may be the result of some pathogen or trauma internal to the body, and furthermore one that may be remote from the bruise itself.  Or, it may be due to an external agent - physical injury such as a bang or knock, sports injury, physical abuse or surgery; or by radiation.  They can even be caused spontaneously by extreme emotion. 

Example illnesses that may cause bruising

Bruises can be a symptom of some serious other diseases which need to be investigated. 

  • Blood circulatory diseases – such as malfunctioning platelets, coagulation deficiencies, or vascular disorders
  • Hypertension - In certain circumstances, if the person has high blood pressure [hypertension] and the capillaries are weak, the bruising may simply occur spontaneously after a spike in pressure has occurred. 
  • Leukemia  - Over 50% of children with leukaemia have palpable livers, palpable spleens, pallor, fever and bruising on diagnosis. Abdominal symptoms such as anorexia, weight loss, abdominal pain and abdominal distension are common. Musculoskeletal symptoms such as limp and joint pain also feature prominently. Thus for a child to have leukemia a great many other symptoms need to be present, but bruising is a symptom.  [PMID:  27647842]
  • Meningoccocal infection – Again this infection comes with enough other very serious symptoms to mean that it is diagnosed by other means, nevertheless bruising can be a complication, along with abnormal platelet count and abnormal white blood cell count.  It is possibly the effect on blood circulation that results in the increased susceptibility to bruising [PMID:25605282]
  • Cancer - bruising can indicate internal bleeding from certain types of cancer.  It is a rare side effect of some melanomas.  According to one study ‘There is a heightened risk of patients with cancer sustaining injuries during diagnosis’. [PMID: 27745037]. 
  • Pancreatitis - bruising present around the navel (belly button) with severe abdominal pain suggests acute pancreatitis.
  • Ehlers-Danlos syndrome may cause relatively easy or spontaneous bruising depending on the severity.
  • Systemic lupus erythematosus (SLE) –In one study, 92% of the patients studied reported the appearance of pigmented lesions, preceded by the occurrence of ecchymotic areas [bruised], which gave way to a localized blue-gray or brown pigmentation that persisted.  On further study, however, they found that the cause appeared to be Hydroxychloroquine -a drug used to treat SLE.   HCQ-induced pigmentation was also associated with previous treatment with oral anticoagulants and/or antiplatelet agents and with higher blood HCQ concentration. [PMID:  23824340]
  • Cushings disease  - is a rare disorder characterized by increased adrenocorticotropic hormone (ACTH) production from the anterior pituitary, leading to excess cortisol release from the adrenal glands. Symptoms include high blood pressure and  bruising.
  • Obesity - patients present more common illnesses to their GP in general, such as common cold (without fever), myalgia of the upper girdle, dermatophytosis and bruise (contusion, haematoma).  [PMID:  18842617]

High extreme emotion

 

Increased vascularity under the influence of Emotion, chiefly when sudden, frequently causes rupture of the small blood-vessels.  The emotion can cause sudden increases in blood pressure that burst the blood vessels, or the emotion may cause the person to violently contract the voluntary muscles thus ‘occasioning injury to the vessels imbedded in their tissue, with consequent effusion of blood’, either way the influence of mental states upon the blood vessels is well proven – in fact one of the expressions in common use when someone gets angry acknowledges the connection -  ‘don’t burst a blood vessel.’  The following case study provides some interesting and somewhat unusual proof.

The Influence Of The Mind Upon The Body In Health And Disease, Designed To Elucidate The Action Of The Imagination - Daniel Hack Tuke, M.D., M.R.C.P

In illustration of the influence of Fear or apprehension upon the vascular system, I shall … give the following example, the case of a highly intelligent lady well known to myself. Although the emotion had for its object another person, it none the less acted upon her own system :

One day she was walking past a public institution, and observed a child, in whom she was particularly interested, coming out through an iron gate. She saw that he let go the gate after opening it, and that it seemed likely to close upon him, and concluded that it would do so with such force as to crush his ankle ; however, this did not happen.

"It was impossible," she says, "by word or act to be quick enough to meet the supposed emergency ; and, in fact, I found I could not move, for such intense pain came on in the ankle, corresponding to the one which I thought the boy would have injured, that I could only put my hand on it to lessen its extreme painfulness. I am sure I did not move so as to strain or sprain it. The walk home — a distance of about a quarter of a mile — was very laborious, and in taking off my stocking I found a circle round the ankle, as if it had been painted with red-currant juice, with a large spot of the same, on the outer part. By morning the whole foot was inflamed, and I was a prisoner to my bed for many days."


And thus we have an example of empathetic bruising.

Toxins

If a product applied to the skin causes an allergic reaction, it can affect the blood vessels near where the product was applied, affecting venous supply.  The reaction can in some cases cause a blockage leading to the formation of purpura and it is the fact that purpura have been formed rather than large scale continuous bruising that is often an indicator.  BUT, this is not always the case.  If the product has been applied over large areas, it may be almost impossible to tell whether this is a bruise caused by impact or a bruise caused by a toxin.  Skin moisturiser creams, sun tan creams, detergents, shampoos, washing up liquid, soap, washing liquids, lotions, perfumes, cosmetics, ointments, and other chemicals that have found their way onto the skin such as pesticides, insecticides or weed killers, may all provoke an allergic reaction that has as a side-effect bruising.

The name sometimes used for this is Allergic purpura (AP), it is actually a form of vasculitis (inflammation of the blood vessels),but the appearance is that of a bruise, because the blood vessels break from the  inflammation.

Pharmaceuticals

 

Some medications result in bruising because they alter the composition of the blood itself.  Thus a medication such as warfarin, because it ‘thins the blood’ can result in bruising in places where a person has had only light pressure exerted from external sources.  In other words there has been no trauma to the area, but pressure on the flesh has simply damaged the capillaries and the blood has rushed out because it is ‘thin’.

The eHealthme site collects adverse health reports in the USA submitted by doctors to the FDA and SEDA.  This LINK   takes you to all the pharmaceuticals that have been implicated in causing bruising.  If the link does not work go to the entry for BRUISING  and then look for the heading ‘Drugs that cause’, pressing this link will give you an up-to-date list of drugs implicated in causing bruising.  Note that list is not necessarily exhaustive, PubMed has other examples:

Lidocaine hydrochloride is the most commonly used anesthetic agent in dermatology. Despite its widespread and frequent use, adverse reactions to lidocaine are uncommon. The majority of side effects include vasovagal reactions and local side effects consisting of bruising and edema at the injection site. PMID: 18189063

Long-term glucocorticoid use [immunosuppressants] can cause easy bruising, but then that is the least of your worries if you are suppressing the immune system.

Dietary supplements

Patient use of dietary supplements that alter coagulation or have an effect on bruising is becoming increasingly common…. The MEDLINE, Cochrane Collaboration, and International Bibliographic Information on Dietary Supplements databases were searched for articles using the search words "bruising," "bleeding," "coagulation," "hemostasis," "herbal medicine," "alternative medicine," and "dietary supplement." Additional sources were obtained from manual searches of recent journal articles.  …….[FINDINGS] In vivo and in vitro evidence supports the notion that many dietary supplements alter coagulation. ……. Surgeons should be aware that many of their patients are taking dietary supplements that may alter coagulation. Because most patients will not readily volunteer this information, specific steps should be taken to obtain it prior to more extensive surgical procedures.  PMID:  16029673

Heavy metals

 

Heavy metals may cause bruising via their effect on the cardiovascular system.  The vascular endothelium plays a vital role in the function of the blood vessels and maintains homeostasis of the circulatory system and normal arterial function. Functional disruption of the endothelium is linked to the development of consequent cardiovascular disease (CVD) including atherosclerosis and coronary heart disease.  Heavy metals are proven to cause endothelial dysfunction, with a knock-on effect of hypertension.   And thus from the hypertension bruising may result.  Fo example:

There is a growing data associating mercury exposure with endothelial dysfunction and higher risk of CVD. This review explores and evaluates the impact of mercury exposure on CVD and endothelial function, highlighting the interplay of nitric oxide and oxidative stress. PMID: 26060268

Remember that both dental amalgam fillings and metal implants may be implicated as well as aluminium, mercury, cadmium, and lead.

Physical Hurt

Bruises can be caused by ‘blunt trauma’, which causes damage through physical compression and deceleration forces.  If it wasn’t a blunt trauma then there is likely to be a skin wound rather than a bruise, as Wikipedia states ‘If the trauma is sufficient to break the skin and allow blood to escape the interstitial tissues, the injury is not a bruise but instead a different variety of haemorrhage called bleeding.’   So there you go.   Surgery can result in bruising in areas other than the wounds, as underlying tissues are often damaged and thus bleed causing surface bruising.

Bacteria

A large number of bacteria are capable of causing bruising if they are able to get to the skin surface via the blood stream and thus attack capillaries close to the skin surface.  Any open wound which has admitted the bacteria may also result in the bacteria spreading across the surface of the skin and giving a bruise like appearance to the skin.  There are also bacteria that are capable of entering the skin without any need for open wounds

Life threatening complications can be caused by staphylococcal infection, even if they appear as a simple pustulosis, via hamatogenous dissemination. … the bacteria is able to penetrate the skin without pre-existing skin lesions and reach the adjacent soft tissue, as was the case with a 9 year old boy who had a contusion of the left shoulder and a consecutive life threatening septicemia.  PMID: 11381766

Contusion: Another name for a bruise.  The presence of bacteria can be dangerous if untreated, leading to sepsis

We present a case of a 30-year-old woman … who was found dead at home by her mother. Her body was …. covered in a number of unusual skin lesions …. These lesions were initially thought to be bruises by the police and by a forensic postmortem instigated. Postmortem examination also identified hepatosplenomegaly, severe lymphadenopathy, and focal patchy colonic ulceration. Histologic examination of the skin and bowel ulcers showed the lesions to be areas of infarction caused by Pseudomonas aeruginosa vasculitis. Pseudomonas was also cultured from the swabs of the abdomen, the spleen, and the blood cultures. …. The cause of death was given as Pseudomonas septicemia secondary to immunocompromise resulting from the undiagnosed peripheral T-cell lymphoma.  PMID:  21030848

Viruses

 

There is evidence that viruses can cause bruising as a side effect, principally via the effect they have on the circulatory system.  For example:

An 11-year-old boy presented with epistaxis, petechial hemorrhages, easy bruising, and purpuric rash. He was diagnosed to have immune thrombocytopenic purpura and evidence of concomitant parvovirus B19 and dengue viral infection.  PMID:  22544695

Other viruses implicated and for which papers exist include HIV, Hepatitis and Cytomegalovirus (CMV)

We reviewed 62 patients with HCV infection who were from 3 months and 19 years of age (M +/- SD, 12.5 +/- 5.8 years). Sixty percent presented with clinical symptoms of fatigue, joint-abdominal pain, bruising/bleeding, or other non-specific symptoms. PMID:  19593250

Fungal infection

Generally speaking, although fungal infections do cause skin diseases, there appear to be [according to the papers on PubMed] few if any that cause bruising.  In general the symptoms are normally spots, itching and flaking, or ulceration.  For example, Sporothrix schenckii, is the causative agent of Sporotrichosis  - the most common subcutaneous mycosis in Latin America.  Symptoms include nodular lesions or bumps in the skin, which start off small and painless, and range in colour from pink to purple. Left untreated, the lesion then becomes larger and eventually a chronic ulcer develops.

Hypoxia

Reduction of adequate oxygen intake can lead long term to cell death in the skin and in the cells of the capillaries leading to spontaneous bruising.

Parasites

 

Parasites both internal and external can be a source of bruising, the following appears an unusual case:

Acquired platelet dysfunction with eosinophilia is a rare, benign self-limiting disorder characterised by platelet dysfunction and an association with parasitic infections. A 20-year-old national serviceman who presented with easy bruising and spontaneous epistaxis is reported. Investigations revealed eosinophilia and an abnormal platelet function … He also had evidence of hookworm infestation. …… this disorder of acquired platelet dysfunction with eosinophilia should be considered in patients with bleeding disorders secondary to platelet dysfunction. PMID: 10741194

But it appears that parasite infestation causes platelet dysfunction, which in turn leads to bruising

One hundred and sixty-eight children aged 13 months to 12.6 years with acquired platelet dysfunction with eosinophilia (APDE) were studied. …. no history of any drug ingestion was detected. All of the children had widespread spontaneous bruising on the extremities, body and face off and on. ….. The number of platelets in these children was within the normal range but the platelet morphology was abnormal in all of them. Eosinophilia was detected in 86% of these children. ….. Parasitic infection was detected in 56% of these children.PMID: 11281630

Radiation

 

The effects of radiation depend on its frequency.  Although high frequencies have been proven to cause burns [analogously like a microwave oven cooking the water filled cells] and low frequency radiation does its damage via resonance of the organs, there is no specific indication of which frequencies of radiation cause the capillaries to burst causing bruising

During recent years there has been increasing public concern on potential health risks from power-frequency fields (extremely low frequency electromagnetic fields; ELF) and from radiofrequency/microwave radiation emissions (RF) from wireless communications. Non-thermal (low-intensity) biological effects have not been considered for regulation of microwave exposure, although numerous scientific reports indicate such effects. …. Health endpoints reported to be associated with ELF and/or RF include childhood leukaemia, brain tumours, genotoxic effects, neurological effects and neurodegenerative diseases, immune system deregulation, allergic and inflammatory responses, breast cancer, miscarriage and some cardiovascular effects. The BioInitiative Report concluded that a reasonable suspicion of risk exists based on clear evidence of bioeffects at environmentally relevant levels, which, with prolonged exposures may reasonably be presumed to result in health impacts. … Other health impacts associated with exposure to electromagnetic fields not summarized here may be found in the BioInitiative Report at www.bioinitiative.org.  PMID:  18242044

 

Nutritional deprivation

Vitamin K deficiency or hypovitaminosis K results from insufficient vitamin K1 or vitamin K2 or both.  Symptoms include bruising, petechiae, hematomas, oozing of blood at surgical or puncture sites, stomach pains; risk of massive uncontrolled bleeding; cartilage calcification; and severe malformation of developing bone or deposition of insoluble calcium salts in the walls of arteries. In infants, it can cause some birth defects such as underdeveloped face, nose, bones, and fingers.  Vitamin K deficiency may be caused by

  • Intestinal problems - Vitamin K1-deficiency may occur by disturbed intestinal uptake, so those who have undergone bowel surgery of any sort run the risk of this occurring.  Bacteria in the gut flora can convert K1 into vitamin K2, but if the intestinal flora have been disrupted this process
  • Pharmaceuticals - There are a number of pharmaceuticals that are vitamin K1-antagonists -  warfarin, all Coumarins. 
  • Rodenticides - Pindone, chlorophacinone, and diphacinone used as rodenticides, are also vitamin K1-antagonists
  • Inherited genes - It is often very challenging for clinicians to distinguish between accidental, intentional, and other causes of bruising such as an underlying bleeding disorder in a child with extensive bruising. When children present to an emergency department with multiple unexplained bruises they need to be checked, as they may have congenital vitamin K-dependent clotting factor deficiency. PMID: 25186509

It is rare for a person to be Vitamin K deficient from a poor diet in countries where access to good food is available, as Vitamin K1, also known as phylloquinone, is made by plants, and is found in highest amounts in green leafy vegetables because it is directly involved in photosynthesis.

Vitamin K2 or menaquinoneis found inanimal livers, meat, eggs, and dairy products, and the richest dietary source of long-chain menaquinones are fermented foods (from bacteria) fermented soybeans (nattō), and in most fermented cheeses.  Sauerkraut contains vitamin K2.

Treatment

Find the cause.

 

Note that advice to apply ice packs or any other form of treatment is very ill advised.  If anything the best advice is to keep the area warm and well protected, for example by a loose bandage and cotton wool round the wound [thus ensuring no new injuries take place and pain from further impact is minimised] and to leave the body to heal itself.  As long as the area is warm, the body is able to rush skin and cell repair substances to the area and the bruise should be repaired quickly.  Being in the sun helps a great deal with the wound exposed, as Vitamin D helps the repair process and the warmth helps.  Sleep, lots of it, and rest gives the body time to repair itself

Applying ice packs or cold water to the area simply slows the healing process and is very ill advised as it may cause cell death and thus encourage gangrene.  It may numb the area, and thus lessen the pain, but in the long term it will simply prolong the agony.

References and further reading

  • Acad Emerg Med. 1997 Sep;4(9):916-7; 922-5.  Bilateral leg pain and bruising. Hypersensitivity vasculitis.- Miller DW1, Norton VC.  Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA. PMID: 9305435
  • Blood Coagul Fibrinolysis. 2004 May;15 Suppl 1:S41-8.  Non-accidental injury and the haematologist: the causes and investigation of easy bruising.  Liesner R1, Hann I, Khair K.  Department of Haematology & Oncology and Children's Haemophilia Comprehensive Care Centre, Great Ormond Street Children's Hospital & Institute of Child Health, London, UK.
  • Arch Dis Child. 2016 Oct;101(10):894-901. doi: 10.1136/archdischild-2016-311251.  Clinical presentation of childhood leukaemia: a systematic review and meta-analysis.  Clarke RT1, Van den Bruel A1, Bankhead C1, Mitchell CD2, Phillips B3, Thompson MJ4.
  • Clin Infect Dis. 2015 Apr 15;60(8):e27-35. doi: 10.1093/cid/civ028. Epub 2015 Jan 20.  Outcomes of invasive meningococcal disease in adults and children in Canada between 2002 and 2011: a prospective cohort study.  Sadarangani M1, Scheifele DW2, Halperin SA3, Vaudry W4, Le Saux N5, Tsang R6, Bettinger JA2; investigators of the Canadian Immunization Monitoring Program, ACTive (IMPACT).
  • J Plast Reconstr Aesthet Surg. 2010 Jan;63(1):e90-1. doi: 10.1016/j.bjps.2008.08.051. Epub 2009 Jan 10.  Sentinel bruising in metastatic malignant melanoma.  Paton L, Rannan-Eliya SV, Ahmed OA.  PMID:  19136323 [A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting]
  • Dermatol Surg. 2005 Jul;31(7 Pt 2):819-26; discussion 826.  Dietary supplements: altered coagulation and effects on bruising.  Dinehart SM1, Henry L.
  • Am J Forensic Med Pathol. 2012 Sep;33(3):276-9. Unusual skin lesions mimicking bruises caused by Pseudomonas septicemia secondary to undiagnosed peripheral T-cell lymphoma in a young woman.  Saunders S1, Jeffery A, Hew R.
  • Rev Med Interne. 2005 Dec;26(12):984-5.  [Spontaneous bruising in an HIV-positive patient].  [Article in French] Khonsari H1, Grandière-Pérez L, Caumes E.  PMID:  15927310
  • J Clin Pathol. 1992 Nov;45(11):1037-8.  Severe thrombocytopenia secondary to asymptomatic cytomegalovirus infection in an immunocompetent host.  Wright JG1. [Thrombocytopenia is a condition characterized by abnormally low levels of thrombocytes, also known as platelets, in the blood]

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