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García-Porrúa C, González-Gay MA, Botana M, Sanchez-Andrade A. Henoch-Schönlein purpura in adults and autoimmune thyroiditis. J Rheumatol 2000; 27:1326-7. [PMID: 10813317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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202
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Redett RJ, Bury TF, McClinton MA. The use of simultaneous free latissimus dorsi tissue transfers for reconstruction of bilateral upper extremities in a case of purpura fulminans. J Hand Surg Am 2000; 25:559-64. [PMID: 10811762 DOI: 10.1053/jhsu.2000.6926] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We report a case of extensive purpura fulminans destroying the soft tissue over the posterior aspect of both elbows. Simultaneous, bilateral free latissimus dorsi muscle transfers were used to close both wounds in a single procedure. The wounds resulting from severe purpura fulminans can be extensive and limb threatening. The simultaneous transfer of 2 free flaps can provide expeditious soft tissue repair while minimizing the risk of repeat anesthesia in these critically ill patients. We found that certain details concerning planning and performing the procedure fostered its successful outcome.
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203
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Briassoulis G, Kalabalikis P, Thanopoulos V, Hatzis T. Non-Q wave acute myocardial infarction in acute meningococcemia in a 10-year-old girl. Pediatr Emerg Care 2000; 16:33-8. [PMID: 10698142 DOI: 10.1097/00006565-200002000-00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Children with acute meningococcemia may have impaired myocardial function resulting in low cardiac output despite normal intravascular volume. Severe meningococcal infection has been associated with acute interstitial myocarditis, endocarditis, and pericarditis, but not with myocardial infarction. CASE We present the case of a 10-year-old girl with positive family history for premature myocardial infarction who sustained an acute myocardial infarction temporally related to meningococcemia. DISCUSSION This is the first pediatric case of non-Q wave acute myocardial infarction associated with purpura fulminans in meningococcemia. Similarly, the association of high troponin I levels and meningococcemia has not been described previously. Although, the patient's genetic predisposition for myocardial infarction might have been a potential contributing factor, there was no angiographic evidence of coronary artery disease in this patient. Thereby, other factors related to shock, endotoxin, microthrombi of meningococcemia, and their treatment might have been also contributing. We propose possible mechanisms for this rare but serious complication of meningococcemia and review the literature.
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Egan CA, O'Reilly MA, Meadows KP, Zone JJ. Relapsing Henoch-Schönlein purpura associated with Pseudomonas aeruginosa pyelonephritis. J Am Acad Dermatol 2000; 42:381-3. [PMID: 10640939 DOI: 10.1016/s0190-9622(00)90118-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Henoch-Schönlein purpura is a systemic vasculitis of unknown cause. It is frequently triggered by a streptococcal upper respiratory tract infection. Other bacteria have been implicated as triggering agents. We report a recurring case of Henoch-Schönlein purpura in a patient with Pseudomonas pyelonephritis. The Henoch-Schönlein purpura remitted only when the infection was eradicated. Pseudomonas infection should be added to the list of bacteria that can trigger Henoch-Schönlein purpura.
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205
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Murray S, Lung NP, Alvarado TP, Gamble KC, Miller MA, Paglia DE, Montali RJ. Idiopathic hemorrhagic vasculopathy syndrome in seven black rhinoceros. J Am Vet Med Assoc 2000; 216:230-3, 194. [PMID: 10649760 DOI: 10.2460/javma.2000.216.230] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Idiopathic hemorrhagic vasculopathy syndrome (IHVS) was diagnosed in 7 black rhinoceros; this newly described syndrome is characterized by severe body swelling in conjunction with a rapid and profound decrease in Hct. The disorder may be acute or chronic, may recur, and is potentially fatal. Five of the rhinoceros survived an initial episode of IHVS, and 2 of these 5 survived a recurrent episode of IHVS. Two rhinoceros died during treatment of IHVS. Treatment protocols varied, but all 7 rhinoceros received broad-spectrum antibiotics, because an infectious cause was suspected. All rhinoceros also received nonsteroidal antiinflammatory drugs and supportive care. Idiopathic hemorrhagic vasculopathy syndrome has many similarities to other vasculopathies of domestic animals, such as equine purpura hemorrhagica, but it also appears to have unique identifying features. It has been hypothesized that IHVS may be an immune response to an as yet unidentified infectious agent. Thorough and extensive testing has not identified the potential causative agent, nor the factors that predispose some black rhinoceros to developing IHVS. Further research into the rhinoceros immune system is ongoing and should help elucidate the mechanisms through which IHVS develops.
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206
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Nakajima H, Ikeda M, Yamamoto Y, Kodama H. Large annular purpura and paraneoplastic purpura in a patient with Sjögren's syndrome and cervical cancer. J Dermatol 2000; 27:40-3. [PMID: 10692824 DOI: 10.1111/j.1346-8138.2000.tb02116.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report a 79-year-old female with anaphylactoid purpura on her legs and unusual large annular purpura on the trunk. Histopathological characteristics of leukocytoclastic vasculitis were observed in the upper and middle dermis of both types of skin lesions. She was complicated by Sjögren's syndrome and advanced cervical cancer. The annular purpura spontaneously resolved in a week and did not recur. However, the anaphylactoid purpura relapsed more frequently and spread more widely following the elevation of her serum SCC antigen levels from the onset of purpura until her death. We consider that the characteristic annular configuration was caused by the complication of Sjögren's syndrome and that the recurrent anaphylactoid purpura indicated paraneoplastic vasculitis primarily caused by the tumor specific protein immune complexes. Complication by Sjögren's syndrome many also play a role in the development of allergic vasculitis.
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207
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Ulukavak T, Sipit T, Oğuz D, Coban G, Apaydin Z. [Rheumatoid purpura in a patient with pulmonary tuberculosis]. Presse Med 1999; 28:2228. [PMID: 10636014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
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209
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Sedivá A, Smetana K, Stejskal J, Bartůnková J, Liu FT, Bovin NV, Gabius HJ. Binding sites for carrier-immobilized carbohydrates in the kidney: implication for the pathogenesis of Henoch-Schönlein purpura and/or IgA nephropathy. Nephrol Dial Transplant 1999; 14:2885-91. [PMID: 10570092 DOI: 10.1093/ndt/14.12.2885] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura is a common vasculitis of childhood affecting the skin, joints, gastrointestinal tract, and kidney. The mesangial deposition of IgA1 is the most critical factor for the prognosis of patients with this disease. The aberrant glycosylation of the IgA1 subclass with the absence of terminally located galactose and presence of only alpha-N-acetylgalactosamine in O-linked oligosaccharides in the hinge region of IgA1 represents a prominent difference from the normal IgA1. These alterations prompt the supposition that the sugar part may guide IgA deposition by recognition of endogenous lectins on the mesangium. METHODS Owing to the limited knowledge about the expression of carbohydrate-binding sites in the human kidney we initiated the study of this aspect with a class of tools which are suitable to map the lectinome of cells. Employing biotinylated neoglycoconjugates, glycosaminoglycans, and sulphated polysaccharides we monitored the presence of accessible carbohydrate-binding sites in control kidneys represented by tumour-free areas of kidneys with Grawitz tumour and in biopsies from patients with Henoch-Schönlein purpura-associated IgA nephropathy. RESULTS Using frozen sections, no expression of any tested carbohydrate-binding site(s) was observed in the endothelial and the mesangial cells in glomeruli of the control kidneys as well as in the biopsies from Henoch-Schönlein purpura IgA nephropathic kidneys, in contrast to the tubules. The N-acetylgalactosamine-binding sites were expressed only in the inner layer of Bowman's capsule of 20% of glomeruli of the control kidney from one patient with Grawitz tumour and one biopsy from a patient with Henoch-Schönlein purpura-associated IgA nephropathy. However, the macrophages in the glomeruli of patients with IgA nephropathy and interstitial macrophages from both studied groups, i.e. without and with IgA nephropathy, harbour capacity to recognize carrier-immobilized alpha-N-acetylgalactosamine. Access to this binding site for the neoligand conjugate can be blocked by the monoclonal antibody MEM-18 recognizing CD14 antigen. CONCLUSION The possibility for a participation of macrophage deposition of IgA1 in mesangium via a lectin mechanism involving this binding capacity warrants further studies.
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al-Ismail S, Collins P, Najib R, James-Ellison M, O'Hagan M. Postinfection purpura fulminans in a patient heterozygous for prothrombin G20210A and acquired protein S resistance. Pediatr Hematol Oncol 1999; 16:561-4. [PMID: 10599098 DOI: 10.1080/088800199276877] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Purpura fulminans usually consists of large, often symmetrical, spreading ecchymosis, which may later develop into extensive areas of skin necrosis and peripheral gangrene. Postinfectious purpura fulminans associated with an autoantibody directed against protein S has been described. The interaction and the contribution of recently described mutations such as factor V Leiden and prothrombin G20210A to the development and progression of postinfectious purpura fulminans and venous thrombosis is not known. The authors describe a patient heterozygous for prothrombin G20210A who developed purpura fulminans and extensive venous thrombosis secondary to acquired protein S deficiency.
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211
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Kondaveeti S, Hibberd ML, Booy R, Nadel S, Levin M. Effect of the Factor V Leiden mutation on the severity of meningococcal disease. Pediatr Infect Dis J 1999; 18:893-6. [PMID: 10530586 DOI: 10.1097/00006454-199910000-00011] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND One of the most serious complications of meningococcal disease is the syndrome of purpura fulminans, which is characterized by intravascular thrombosis and hemorrhagic infarction of skin, limbs and digits. The reasons why some patients with meningococcal disease develop purpura fulminans while others have minimal thrombotic and skin involvement despite having profound septic shock are not yet understood. The Factor V Leiden mutation (FV(L)) is associated with thrombotic events, and we hypothesized that children carrying FV(L) who develop meningococcal disease may be at increased risk of purpura fulminans. METHODS We determined the FV(L) genotype by PCR and restriction enzyme digestion (Mnl1) in 259 children with meningococcal disease and 80 healthy controls. In addition 79 parents of children with fatal meningococcal disease were studied. RESULTS There was no significant increase in the frequency of FV(L) in patients with meningococcal disease (10%) as compared with healthy controls (9%) or with the parents of children who died of meningococcal disease (12%). Although the mortality was not increased in patients heterozygous for FV(L), they had increased complications of purpura fulminans, as assessed by requirement for skin grafting, referral to plastic surgeon and/or amputation. Among survivors 5 of 24 (21%) of those heterozygous for FV(L) had complications, compared with 14 of 233 (7%) who were wild type [P < 0.03; relative risk, 3.1 (95% confidence intervals, 1.2 to 7.9)]. CONCLUSIONS FV(L) exacerbates purpura fulminans in meningococcal disease but does not have a significant effect on mortality.
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al-Sheyyab M, Batieha A, el-Shanti H, Daoud A. Henoch-Schonlein purpura and streptococcal infection: a prospective case-control study. ANNALS OF TROPICAL PAEDIATRICS 1999; 19:253-5. [PMID: 10715710 DOI: 10.1080/02724939992329] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
A prospective, matched, case-control study conducted over a period of 3 years was designed to examine the association of group A beta-haemolytic streptococcal infections and Henoch-Schonlein purpura. Demographic and clinical data were collected as well as measurement of antistreptolysin O titres and throat swab culture on all children admitted with Henoch-Schonlein purpura, as well as their matched controls. Antistreptolysin O titre positivity was associated with a 10-fold increase in the risk of Henoch-Schonlein purpura. Renal involvement was common among cases with positive antistreptolysin O titres (27%) compared with cases with a negative titre (8%) but this difference has no statistical significance.
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Abstract
BACKGROUND Neisseria meningitidis is the most frequent isolate associated with purpura fulminans in children. Although Streptococcus pneumoniae infection has been associated with purpura fulminans, with the exception of one adult, it has only been reported in immunocompromised hosts. PURPOSE We report an apparently previously healthy child who presented with purpura fulminans associated with pneumococcal meningitis. METHODS Case report and review of the medical literature from September 1966 to June 1997, using a MEDLINE search. CONCLUSION While systemic pneumococcal infection is common in childhood, progression to purpura fulminans does not typically occur in overtly healthy children. Our patient illustrates that invasive pneumococcal infection should be considered and empirically treated in a child who presents with purpura fulminans, even in the absence of preexisting functional or anatomic asplenia.
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Lohse A, Michel F, Auge B, Toussirot E, Wendling D. Vascular purpura and cryoglobulinemia after influenza vaccination. Case-report and literature review. REVUE DU RHUMATISME (ENGLISH ED.) 1999; 66:359-60. [PMID: 10418068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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215
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Magro CM, Crowson AN. A clinical and histologic study of 37 cases of immunoglobulin A-associated vasculitis. Am J Dermatopathol 1999; 21:234-40. [PMID: 10380044 DOI: 10.1097/00000372-199906000-00005] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunoglobulin (Ig) A-associated vasculitis is commonly equated with the multiorgan systemic vasculitic syndrome Henoch-Schonlein purpura (HSP), which occurs predominantly in the pediatric age group. By natural language search of the databases of two outpatient dermatopathology practices, the authors selected for review 37 cases of IgA-associated vasculitis, 23 of which were associated with antecedent infection, most commonly of the upper respiratory tract. Criteria for a diagnosis of HSP were met in 15 cases, 13 of which were in the setting of prior infection. Lower extremity skin involvement was ubiquitous. A more widespread form of vasculitis was also seen, particularly in the setting of previous infection. Several of the patients with previous infection had underlying medical illnesses including rheumatoid arthritis, atopy, renal failure, lupus erythematosus, insulin dependent diabetes mellitus, autoimmune thyroid disease, and Wegener's granulomatosis. In those patients lacking an apparent microbial trigger, Sjogren's disease with anti-Ro antibodies and hypergammaglobulinemia, lupus erythematosus, inflammatory bowel disease, IgA paraproteinemia, bronchogenic and prostatic carcinoma, cryoglobulinemia, and lymphoma were uncovered. Regardless of whether an infectious stimulus was implicated, certain cofactors with the potential to enhance vascular injury were uncovered; these included anti-Ro antibodies, antineutrophil cytoplasmic antibody, diabetic microangiopathy, and a hyperviscosity state. In the infective group, a pustular vasculitis, defined as a neutrophilic vascular reaction in concert with epithelial pustulation, was seen in 81% of cases versus 33% in the noninfectious group (p = 0.02). The prototypic histomorphology in the noninfective group was one of a mild cell poor leukocytoclastic vasculitis; Vasculitis was of greater severity in patients with antecedent infection (p = 0.026). An infectious trigger, typically of mucosal origin, can frequently be identified in patients with cutaneous IgA-associated vasculitis, especially those with the symptom complex of HSP. The light microscopy appears to distinguish patients who have an infectious trigger from those who do not. IgA-associated vasculitis may be a clue to the presence of certain underlying disorders where there is immune dysregulation or enhanced susceptibility to immune complex entrapment.
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Esposito C, Fasoli G, Cornacchia F, Foschi A, Mazzullo T, Morando G, Plati AR, Dal Canton A. Henoch-Schönlein purpura in a chronic hemodialysis patient. J Nephrol 1999; 12:197-200. [PMID: 10440519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
We describe a patient on maintenance hemodialysis who developed purpura, abdominal pain with bloody stool, and gross hematuria. A skin biopsy revealed leukocytoclastic vasculitis with IgA deposits. This is the first report of Henoch-Schönlein purpura in a hemodialysis patient.
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217
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Rutishauser M. [Purpura with cystic fibrosis]. SCHWEIZERISCHE MEDIZINISCHE WOCHENSCHRIFT 1999; 129:420. [PMID: 10212977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Realdi G, Dore MP, Fastame L. Extradigestive manifestations of Helicobacter pylori infection: fact and fiction. Dig Dis Sci 1999; 44:229-36. [PMID: 10063905 DOI: 10.1023/a:1026677728175] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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219
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Galanakis E, Apokotou M, Alfadaki S, Gesouli E, Lapatsanis P. Purpura fulminans complicating pneumococcal sepsis. Eur J Pediatr 1999; 158:171. [PMID: 10048620 DOI: 10.1007/s004310051044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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220
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Tekin M, Yalçinkaya F, Tümer N, Cakar N, Koçak H, Ozkaya N, Gençgönül H. Familial Mediterranean fever--renal involvement by diseases other than amyloid. Nephrol Dial Transplant 1999; 14:475-9. [PMID: 10069219 DOI: 10.1093/ndt/14.2.475] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In patients with familial Mediterranean fever (FMF) renal involvement is usually in the form of AA amyloidosis. There is increasing evidence that renal involvement may be due to diseases other than amyloid as well. METHODS Amongst 302 children with FMF we observed and followed 28 with typical clinical and laboratory features of vasculitis. The diagnosis of FMF was established according to the Tel Hashomer criteria. RESULTS Polyarteritis nodosa, protracted febrile attacks and Henoch-Schönlein purpura were diagnosed in 4, 13, and 11 patients, respectively. The presentation was often difficult to distinguish from FMF attacks, but protracted febrile attacks lasting several weeks, hypertension, thrombocytosis, and dramatic responses to corticosteroid therapy that were observed in many cases were different from what is observed in classical FMF. CONCLUSIONS We suggest that FMF, perhaps as a consequence of impaired control of inflammatory responses, predisposes to vasculitis with renal involvement.
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Blanco P, Denisi R, Rispal P, Deminière C, Pellegrin JL, Leng B, Aparicio M. Henoch-Schönlein purpura associated with segmental and focal proliferative glomerulonephritis in a patient with Hodgkin's disease. Nephrol Dial Transplant 1999; 14:179-80. [PMID: 10052501 DOI: 10.1093/ndt/14.1.179] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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222
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Kikuta A, Suzuki H. [Henoch-Schönlein purpura]. RYOIKIBETSU SHOKOGUN SHIRIZU 1998:408-11. [PMID: 9833528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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223
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Abstract
The development of progressive, severe skin changes (purpura fulminans) is a serious complication of septicaemia, particularly meningococcal septicaemia. Purpura fulminans almost invariably leads to some full thickness skin loss and may lead to limb amputation. The pathophysiology may involve microemboli, endotoxins and direct bacterial damage to the vessels. We describe a case of purpura fulminans, probably as a result of meningococcal septicaemia, localising to a recent, healed burn with complete resolution. We can find no other record of the skin manifestations of meningococcal septicaemia localising to a previous injury.
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224
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Woods CR, Johnson CA. Varicella purpura fulminans associated with heterozygosity for factor V leiden and transient protein S deficiency. Pediatrics 1998; 102:1208-10. [PMID: 9794956 DOI: 10.1542/peds.102.5.1208] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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225
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Demircin G, Oner A, Erdoğan O, Bülbül M, Memiş L. Henoch Schönlein purpura and amebiasis. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1998; 40:489-91. [PMID: 9821714 DOI: 10.1111/j.1442-200x.1998.tb01976.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The pathogenesis of Henoch Schönlein purpura (HSP) is unknown but is believed to result from an immune complex reaction to various antigenic stimuli, such as infectious agents. However, its association with Entamoeba histolytica has not been reported before. We present an 11-year-old boy with HSP, confirmed by the demonstration of leukocytoclastic vasculitis from skin and diffuse endocapillary proliferative glomerulonephritis, together with immunoglobulin A and complement component C3 deposition from renal biopsies. Cysts and trophozoites of Entamoeba histolytica were detected from the stool of the patient at the same time and disappeared after the treatment with metranidasole. The temporal association of these two disorders is either coincidental or due to a causal relationship between them.
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