Seizure-Induced Periorbital Petechiae

Dear Editor, Petechiae are small, non-blanching hemorrhagic spots that can occur in various clinical contexts. While often linked to hematologic or dermatologic conditions, their occurrence following seizures is less commonly emphasized in clinical practice. The most common causes are platelet dysfunction and congenital or acquired thrombocytopenia. Petechiae may also result from trauma, inflammatory dermatoses, or sudden increases in vascular pressure, such as those caused by coughing or vomiting (1). A range of cutaneous and systemic manifestations has been reported following seizures, including automatisms, hypersalivation, traumatic ecchymosis, skin abrasions, choroidal venous congestion, subconjunctival hemorrhage, and tongue ulcerations (2). To highlight the diagnostic importance of postictal petechiae, we report the case of a 17-year-old boy who was admitted following a generalized tonic-clonic seizure. The patient had been seizure-free for 2.5 years, during which time sodium valproate was gradually tapered over three months. One month after discontinuing antiepileptic therapy, the patient experienced a seizure. Neurological and physical examinations were normal, except for bilateral periorbital petechial rash (Figure 1). He had no prior history of periorbital rash during earlier seizures. Blood pressure, cranial magnetic resonance imaging, and routine laboratory tests—including platelet count and prothrombin/partial thromboplastin time—were within normal limits. The petechiae resolved spontaneously. In epilepsy, petechiae may result from antiepileptic drug-induced thrombocytopenia. Postictal petechiae may also occur, thought to result from capillary rupture due to sudden elevations in intrathoracic and venous pressure, similar to the Valsalva maneuver (3). During a seizure, involuntary muscle contractions and impaired breathing can transiently increase central venous pressure, leading to facial venous congestion. This elevated pressure may cause fragile periorbital capillaries to rupture, resulting in petechial rash. In cases where patients experience seizures in isolation and no other objective findings are present, petechial rash may serve as an auxiliary clue supporting a diagnosis of epileptic seizure when other causes are excluded. As conclusion, Periorbital petechiae are an uncommon but benign manifestation that may occur following generalized tonic-clonic seizures due to sudden elevations in venous pressure. Recognizing this subtle clinical sign can support the diagnosis of epileptic seizures, particularly in cases lacking objective findings on neurological examination or imaging. Awareness of this phenomenon may help clinicians avoid unnecessary diagnostic procedures and provide reassurance regarding its self-limiting nature.