Pallor
Mark T. Kinirons, Harold Ellis in French’s Index of Differential Diagnosis an A–Z, 2016
Pallor is a very subjective sign indicating a reduction in skin or mucous membrane colouring. It usually refers to a generalized reduction rather than to localized depigmentation, as in vitiligo. Pallor may be a congenital characteristic resulting in an individual always looking pale even when healthy. Anaemia, for any reason, is the most common cause of pallor. Pallor of the conjunctivae or mucous membranes is a very unreliable indication of a reduced haemoglobin, except when there is severe anaemia. Pallor may be accentuated in hypopituitarism when, in addition to the anaemia, there is a reduction in skin pigmentation. A reduction in blood flow to the skin will result in acute pallor. This can arise either due to hypotension, as in shock, or due to hypothermia or low cardiac output states. Similarly, profound vasoconstriction (as seen in phaeochromocytoma) will also lead to pallor and is the mechanism by which emotional shock or stress can be responsible for pallor. Any increase in the thickness of the skin, particularly the epidermis, will tend to obscure the haemoglobin in the capillaries, resulting in pallor. Skin thickness is increased in acromegaly and myxoedema.
Epistaxis
John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed in Paediatrics, The Ear, Skull Base, 2018
Anterior rhinoscopy can also be performed with a well-illuminated otoscope with a large speculum. The most common findings are crusting (two-thirds of children) and visible vessels (40–50% of children) on the anterior septum. , Hallmarks of allergic rhinitis may be present including a transverse nasal skin crease (‘the allergic salute’), and periorbital markers such as ‘allergic shiners’ and ‘Dennie–Morgan lines’. Pale or bluish nasal mucosa and turbinates are also typical in allergic rhinitis. A nasal foreign body should be excluded. Distortion of nasal anatomy, an intranasal mass, polyps or cervical lymphadenopathy should raise the suspicion of tumour and also prompt a screen for cranial nerve palsies. Rigid nasendoscopy is not tolerated well by children and, if a more posterior view of the nasal cavity and nasopharynx is required, a fine 2.2 mm flexible nasendoscope can be used after application of topical anaesthetic and vasoconstricting agent. Given the low yield of nasal endoscopy findings in younger children in particular, routine use is probably not warranted. As the diagnosis of a nasal mass is most likely in adolescent males, nasal endoscopy should continue to be routine in their assessment. Stigmata of systemic causes of bleeding, such as bruising, petechiae, cutaneous or mucocutaneous telangiectasia, should be looked for. Pallor may indicate significant blood loss or anaemia. The jaundiced child may have liver disease with a secondary coagulopathy. In some circumstances, if an adequate view cannot be obtained or the child is not sufficiently cooperative, examination under general anaesthesia may be required.
The abdomen
Kevin G Burnand, John Black, Steven A Corbett, William EG Thomas, Norman L Browse in Browse’s Introduction to the Symptoms & Signs of Surgical Disease, 2014
General appearance The most noticeable features are wasting and pallor. The wasting is often most apparent in the face and hands. The pallor is usually caused by an iron deficiency anaemia that is the result of chronic bleeding and lack of iron in the diet. Many patients present at an advanced stage with multiple hepatic metastases or metastases in the lymph glands around the porta hepatis. Mild jaundice suggests the latter. Neck The supraclavicular fossa must be carefully examined, as secondary deposits in the supraclavicular lymph glands are common. A palpable supraclavicular gland in a patient with a carcinoma of the stomach is called Virchow’s gland, and its presence is referred to as Troisier’s sign. Lungs The presence of a pleural effusion suggests pulmonary metastases. Abdomen Inspection. The abdomen is often scaphoid as a consequence of weight loss but, paradoxically, there may be generalized abdominal distension if ascites is present. Pyloric obstruction causes epigastric distension and visible peristalsis. These physical signs can only be seen in thin patients. In the majority, the primary tumour is too small, too high or too deep to be seen.
Two Cases of Segmental Disc Oedema and Normal Visual Acuity in Giant Cell Arteritis
Published in Neuro-Ophthalmology, 2019
Laura Donaldson, Ari Aharon Shemesh, Edward Margolin
Giant cell arteritis (GCA) frequently involves the ocular circulation. Arteritic anterior ischemic optic neuropathy (AAION) is the most common presentation, producing severe vision loss with a characteristic waxy pallor of the optic disc. Optic disc ischemia in AAION is related to underlying systemic vasculitis, which must be treated aggressively with systemic steroids in order to minimize the risk of fellow eye involvement. In contrast, non-arteritic AION (NAION) is thought to result from localized hypoperfusion of the posterior ciliary arteries and mainly presents with segmental optic disc oedema. This condition is usually seen in individuals with crowded optic discs as well as predisposing vascular risk factors and does not require specific treatment. Distinguishing these two entities is important and often challenging. We describe two cases of biopsy-confirmed AAION presenting as segmental disc oedema with the absence of pallor, suggesting specific and isolated involvement of the posterior ciliary arteries in GCA affecting the ophthalmic circulation. This emphasizes the importance of maintaining a high index of suspicion for GCA, particularly when atypical features are present or systemic findings accompany acute vision loss.
Bruch’s Membrane Opening Minimum Rim Width in the Differential Diagnosis of Optic Neuropathies
Published in Neuro-Ophthalmology, 2020
Joana Braga, Ricardo Soares, Mónica Loureiro, Lígia Ribeiro, Dália Meira
Observing optic disc pallor during a patient’s first visit frequently raises a diagnostic challenge, particularly in regards to whether the cause is due to glaucoma or another form of optic neuropathy. Bruch’s membrane opening (BMO) was recently discovered as the anatomical border of the optic disc. BMO minimum rim width (BMO-MRW) seems to be a reliable representation of the neuroretinal rim. In our study, we demonstrate the ability of BMO-MRWs to differentiate between glaucomatous and non-glaucomatous. Additionally, we propose an MRW ratio which may allow discrimination of open angle glaucoma from either non-arteritic anterior ischaemic optic neuropathy or compressive optic neuropathy.
Leber Hereditary Optic Neuropathy with Interval of Visual Loss Greater Than 12 Months
Published in Neuro-Ophthalmology, 2016
Renata Cristina Ferreira Prado, Frederico Castelo Moura
A 28-year-old man presented with severe left visual loss and normal right visual acuity. The left fundus examination showed temporal pallor and complete absence of the nerve fibre layer (NFL) of papillomacular bundle. Right fundus examination showed focal loss of inferotemporal NFL. Magnetic resonance and serum aquaporin-4 antibody were negative. After 14 months of the initial visual involvement, the patient suffered subacute visual loss in contralateral eye. Genetic study revealed the 11778 point mitochondrial DNA (mtDNA) mutation associated with Leber hereditary optic neuropathy (LHON). Although very rare, interval of involvement of second eye greater than 12 months can occurs in LHON. Detailed optic nerve examination and careful interpretation of optical coherence tomography (OCT) printout support the diagnosis.