Morning Report

Morning Report: Henoch-Schonlein Purpura

Resident Presenter: Chris Norris PGY-1

Case Summary: 
6 y.o. female presenting to the ED for rash on the lower extremities. Pt’s mother reports pt 2 weeks ago had an URI that was treated supportively, has had some residual cough and rhinorrhea, and starting 8 days ago began having a small erythematous non blanching rash that began on her ankles, and has now progressed to her BLE and ascended to her buttocks. Pt has no fever, but went to her pediatrician who did lab work and found she has an elevated WBC greater than 17,000, and no blood in her urine, pt has been complaining of belly pain all day and has vomited non bloody vomit x 4. Pt has no constipation, no diarrhea, no current jelly stools, no abdominal swelling, no CP, SOB, no nuchal rigidity, no vision changes. Pt is up to date on her vaccines.

Learning Points:

  • IgA mediated small vessel vasculitis
  • Presents with:
    • Rash (95-100% of cases), especially involving the legs & buttocks
    • Abdominal pain and vomiting (35-85%)
    • Joint pain (60-84%), especially involving the knees and ankles
    • Subcutaneous edema (20-50%)
    • Scrotal edema (2-35%)
    • Bloody stools
    • An URI precedes the onset of symptoms by 1-3 weeks in ½ to 2/3rds of patients!
  • Order:
    • CBC esp. for WBC and platelet count (to r/o TTP/HUS, ITP, DIC)
    • CMP esp. for BUN/Cr for renal involvement, bilirubin to r/o hemolytic causes, potassium for hemolytic causes
    • Lactate for possible bowel perforation or ischemia
    • UA for hematuria/proteinuria for renal involvement (can be nephritic or nephrotic)
    • Consider ASO titer, stool guaiac, lipase
    • US abd for intussusception (usually ileoileal!!!)
  • Rx:
    • IV Fluids
    • NSAIDs for joint and abd pain
      Steroids if disease is severe
    • Usually benign, with supportive care, but can rarely be fatal.

EBM Article:
Reamy, Brian; Lindsey, Tammy; “Henoch-Schönlein Purpura” American Family Physician 10/2009. http://www.aafp.org/afp/2009/1001/p697.html

References:
Noah S Scheinfeld; “Henoch-Schonlein Purpura”. Medscape 11/2016. http://emedicine.medscape.com/article/984105-overview

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