Periorbital Ecchymosis Secondary to Severe Coughing- A Valsalva Associated Phenomenon.

Abstract

Sir, A 70-year-old woman presented with chief complaints of sudden onset of asymptomatic red-colored lesions over the periorbital region since the previous night. There was no history of insect bite, trauma, fever, or bleeding from any site. Patient was a known case of asthma and there was a history of increase in the severity of coughing with nocturnal exacerbation for 1 week. On systemic examination, rhonchi were present in the bilateral lung fields. On dermatological examination, well-defined, ecchymotic patch was present in the left periorbital area extending vertically from the brow to 1 cm below the lower eyelid and horizontally from the side of the nose to the left temple area with involvement of tarsal plate of eyelid medially [Figure 1]. A similar well-defined, oval ecchymotic patch of size 3 × 2cm was present on the medial canthus of the right eye [Figure 2]. Ophthalmological examination was unremarkable.Figure 1: Periorbital purpura with tarsal plate involvementFigure 2: Purpura along medial aspect of right eyeRoutine investigations including complete hemogram, bleeding time, prothrombin time and activated partial thromboplastin time, liver and renal function tests, and serum electrophoresis were normal. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were normal with no evidence of skull base fracture, and there was no abnormality in the intracranial or periorbital vasculature. Based on the above mentioned findings and in the absence of any underlying coagulation disorder, the diagnosis of periorbital ecchymosis secondary to severe coughing was made. Patient was advised a topical emollient and asked to follow-up after 2 weeks. Periorbital ecchymosis can be caused by coagulopathies, disorders involving orbital vasculature, and intracranial or extracranial pathologies, as outlined in Table 1.[1] Periorbital ecchymosis secondary to severe coughing has been rarely reported in the literature. Paysee et al. have reported bilateral eyelid ecchymosis and subconjuctival hemorrhage associated with coughing paroxysms in pertussis infection.[2] Reid et al. have described Panda sign in a patient secondary to coughing due to asthma exacerbation.[3]“Panda sign” is a distinctive type of periorbital ecchymosis where bruising is characterized by tarsal sparing. This sparing is caused by an anatomical structure called the orbital septum, which limits the spread of the discoloration beyond the tarsal plate. Hence, “panda sign” description should be limited to orbital ecchymosis due to basal skull fractures, as bilateral bruising caused by non traumatic medical conditions can spread beyond the tarsal plate, as in our case.[1] Sudden onset of lesions at night can be explained by the nocturnal exacerbation of cough and increased fragility of vessels because of old age of the patient; left lateral positioning of the patient while sleeping can explain ecchymosis limited to the left eye and extending to the temples and cheek as well as the medial canthus of the right eye. The facial veins receive tributaries from the side of the nose and from the inferior palpebral, superior, and inferior labial veins, the buccinators, parotid and masseteric veins, as well as other tributaries which join it below the mandible. The facial veins communicate to the cavernous veins via the superior and inferior ophthalmic veins which drain either separately or by a common trunk to the cavernous sinus.[1] Coughing leads to an increase in cerebral venous pressure which is transmitted via cavernous sinus to orbital and facial venous system resulting in bruising.[4] Al-Sardar reported perioral involvement caused by vomiting which can be explained by the drainage of superior and inferior labial veins into facial venous system, which further communicates to cavernous system by ophthalmic veins.[1] Hence, the transmission of increased cerebral venous pressure during Valsalva maneuver to facial venous system may also lead to perioral ecchymosis but our patient had no other site involvement on face due to ecchymosis except periorbital area.Table 1: Causes of Periorbital PurpuraFacial ecchymosis has also been reported with other benign conditions associated with valsalva maneuver such as coughing, vomiting, sneezing, and power lifting.[1256] Hence, we would like to stress that these benign conditions should be considered in the differential diagnosis of periorbital purpura on excluding bleeding disorders, trauma, and intracranial pathologies after appropriate investigations. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.