Thoracocervicofacial purpura as the single manifestation of epileptic seizure

A 44 year old woman who underwent ovariectomy due to bilateral ovarian cysts at the age of 29 followed by hormone replacement therapy for several years, was admitted to hospital after a generalised grand mal seizure. The patient had no history of epilepsy. Neurological examination on admission was negative; however, purpura of the thoracocervicofacial region was seen (figure). Routine blood chemistry (platelet count on FBC) and chest radiography were normal. Cranial CT and MRI did not show any parenchymal pathology. An EEG trace was within normal limits. Purpura was described in association with generalised seizures by Bychowski.1 Guillaume proposed that this type of purpura was of mechanical origin5, due to intense contraction of the chest and abdominal muscles with the glottis closed during the tonic-clonic phase, as in the Valsalva manoeuvre.