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Postictal thoracocervicofacial purpura
  1. Paulo Victor Sgobbi de Souza,
  2. Thiago Bortholin,
  3. Wladimir Bocca Vieira de Rezende Pinto,
  4. Adrialdo José Santos
  1. Neurology and Neurosurgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
  1. Correspondence to Dr Wladimir Bocca Vieira de Rezende Pinto, Department of Neurology and Neurosurgery, UNIFESP - Federal University of São Paulo, Pedro de Toledo Street 650, Sao Paulo 04023-900, Brazil; wladimirbvrpinto{at}

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A 28-year-old Brazilian man presented with a 2-hour history of headache and skin lesions in the shoulder girdle, face and upper trunk. Two hours before, he had a generalised tonic-clonic seizure, his third since being diagnosed with genetic generalised epilepsy 1 year before. Each previous episode had been accompanied by the same pattern of skin lesions, which improved after 48 hours. On examination, he had thoracocervicofacial purpura and petechiae, and bilateral subconjunctival haemorrhages (figure 1). Neurological examination was normal. Basic general laboratory investigations, MR scan of brain and cerebrospinal fluid analysis were normal. We started phenobarbital 100 mg orally per day with good control of seizure recurrence.

Figure 1

Examination findings of thoracocervicofacial purpura in the postictal period. Patient disclosing bilateral subconjunctival haemorrhage (A, B) and marked diffuse purpura and petechiae in the cervical and upper trunk regions (C, D).

Proper recognition of postictal skin and mucous membrane signs is essential to provide correct diagnosis and management for patients presenting with generalised convulsive seizures.1 Postictal subconjunctival haemorrhages, and thoracocervicofacial purpura and petechiae eruptions are common following generalised convulsive seizures, but may be under-recognised or may even prompt unnecessary investigation for infective, metabolic and haematological disorders.1 2 It most likely results from the Valsalva manoeuvre-like autonomic responses during the ictal phase.2

Clinicians must be aware of the likelihood of seizure in patients presenting with thoracocervicofacial purpura.

Key message

Thoracocervicofacial purpura represents a common underdiagnosed clinical finding of patients in the postictal period and may also help clinicians in the differential diagnosis of epileptic seizures from non-epileptic episodes.


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  • Contributors All authors have contributed equally to this manuscript. No other subjects were authors of this manuscript.

  • Competing interests None declared.

  • Ethics approval Full consent was obtained from the patient for the case report. This study was approved by our Ethics Institution.

  • Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Mark Manford, Cambridge, UK.

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    Phil E M Smith Geraint N Fuller