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Barbour SJ, Coppo R, Er L, Pillebout E, Russo ML, Alpers CE, Fogo AB, Ferrario F, Jennette JC, Roberts IS, Cook HT, Ding J, Su B, Zhong X, Fervenza FC, Zand L, Peruzzi L, Lucchetti L, Katafuchi R, Shima Y, Yoshikawa N, Ichikawa D, Suzuki Y, Murer L, Wyatt RJ, Park C, Nelson RD, Narus JH, Wenderfer S, Geetha D, Daugas E, Monteiro RC, Nakatani S, Mastrangelo A, Nuutinen M, Koskela M, Weber LT, Hackl A, Pohl M, Pecoraro C, Tsuboi N, Yokoo T, Takafumi I, Fujimoto S, Conti G, Santoro D, Materassi M, Zhang H, Shi S, Liu ZH, Tesar V, Maixnerova D, Avila-Casado C, Bajema I, Barreca A, Becker JU, Comstock JM, Cornea V, Eldin K, Hernandez LH, Hou J, Joh K, Lin M, Messias N, Muda AO, Pagni F, Diomedi-Camassei F, Tokola H, D'Armiento M, Seidl M, Rosenberg A, Sannier A, Soares MF, Wang S, Zeng C, Haas M. Histologic and Clinical Factors Associated with Kidney Outcomes in IgA Vasculitis Nephritis. Clin J Am Soc Nephrol 2024; 19:438-451. [PMID: 38261310 PMCID: PMC11020428 DOI: 10.2215/cjn.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/18/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Nephritis is a common manifestation of IgA vasculitis and is morphologically indistinguishable from IgA nephropathy. While MEST-C scores are predictive of kidney outcomes in IgA nephropathy, their value in IgA vasculitis nephritis has not been investigated in large multiethnic cohorts. METHODS Biopsies from 262 children and 99 adults with IgA vasculitis nephritis ( N =361) from 23 centers in North America, Europe, and Asia were independently scored by three pathologists. MEST-C scores were assessed for correlation with eGFR/proteinuria at biopsy. Because most patients ( N =309, 86%) received immunosuppression, risk factors for outcomes were evaluated in this group using latent class mixed models to identify classes of eGFR trajectories over a median follow-up of 2.7 years (interquartile range, 1.2-5.1). Clinical and histologic parameters associated with each class were determined using logistic regression. RESULTS M, E, T, and C scores were correlated with either eGFR or proteinuria at biopsy. Two classes were identified by latent class mixed model, one with initial improvement in eGFR followed by a late decline (class 1, N =91) and another with stable eGFR (class 2, N =218). Class 1 was associated with a higher risk of an established kidney outcome (time to ≥30% decline in eGFR or kidney failure; hazard ratio, 5.84; 95% confidence interval, 2.37 to 14.4). Among MEST-C scores, only E1 was associated with class 1 by multivariable analysis. Other factors associated with class 1 were age 18 years and younger, male sex, lower eGFR at biopsy, and extrarenal noncutaneous disease. Fibrous crescents without active changes were associated with class 2. CONCLUSIONS Kidney outcome in patients with biopsied IgA vasculitis nephritis treated with immunosuppression was determined by clinical risk factors and endocapillary hypercellularity (E1) and fibrous crescents, which are features that are not part of the International Study of Diseases of Children classification.
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Affiliation(s)
- Sean J. Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- BC Renal, Vancouver, British Columbia, Canada
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Lee Er
- BC Renal, Vancouver, British Columbia, Canada
| | | | - Maria Luisa Russo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Charles E. Alpers
- Department of Laboratory Medicine and Pathology, University of Washington Medical Center, Seattle, Washington
| | - Agnes B. Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Franco Ferrario
- Department of Medicine and Surgery, IRCCS San Gerardo, University Milan Bicocca, Monza, Italy
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ian S.D. Roberts
- Department of Cellular Pathology, Oxford University Hospitals NHS FT, Oxford, United Kingdom
| | | | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Baige Su
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xuhui Zhong
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | | | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, AOU Città della Salute della Scienza di Torino, Turin, Italy
| | - Laura Lucchetti
- Division of Nephrology, Bambino Gesù Children's Hospital–IRCCS, Rome, Italy
| | - Ritsuko Katafuchi
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, Wakayam Medical University, Takatsuki City, Japan
| | - Daisuke Ichikawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Luisa Murer
- Pediatric Nephrology Dialysis and Transplant Unit, Department of Women's and Child's Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Robert J. Wyatt
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Catherine Park
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Raoul D. Nelson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - JoAnn H. Narus
- Pediatrics Clinical Trials Office, University of Utah, Salt Lake City, Utah
| | - Scott Wenderfer
- Division of Pediatric Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Texas Children's Hospital, Houston, Texas
| | - Duvuru Geetha
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Daugas
- Nephrology, Bichat Hospital, AP-HP, Paris, France
- INSERM U1149 and Université Paris Cité, Paris, France
| | - Renato C. Monteiro
- Centre for Research on Inflammation, Bichat Hospital, Inserm and Université Paris Cité, Paris, France
| | - Shinya Nakatani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCC Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Mikael Koskela
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lutz T. Weber
- Pediatric Nephrology, Faculty of Medicine and University Hospital Cologne, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Agnes Hackl
- Pediatric Nephrology, Faculty of Medicine and University Hospital Cologne, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Martin Pohl
- Medical Center, Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carmine Pecoraro
- Comitato Tecnico Scientifico per la Ricerca e Innovaziione, A.O. Santobono-Pausilipon, Naples, Italy
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Department of Nephrology and Hypertension, Jikei University School of Medicine, Tokyo, Japan
| | - Ito Takafumi
- Kidney Center, Department of Internal Medicine, Nephrology, Teikyo University School of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Shouichi Fujimoto
- Division of Dialysis, Department of Nephrology, University of Miyazaki Hospital, Miyazaki, Japan
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU Policlinic G Martino, University of Messina, Messina, Italy
| | - Domenico Santoro
- Nephrology and Dialysis Unit AOU, G. Martino, University of Messina, Messina, Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China
| | - Sufang Shi
- Kidney Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Dita Maixnerova
- Department of Nephrology, 1st Faculty of Medicine, General University Hospital, Prague, Czech Republic
| | | | - Ingeborg Bajema
- Department of Pathology and Medical Biology, University of Groningen, Groningen, The Netherlands
| | - Antonella Barreca
- Pathology Unit, Città della Salute e della Scienza di Torino University Hospital, Turin, Italy
| | - Jan U. Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | | | - Virgilius Cornea
- Department of Pathology, University of Kentucky Medical Center, Lexington, Kentucky
| | - Karen Eldin
- Department of Pathology, Mass General Brigham, Salem Hospital, Salem, Massachusetts
| | | | - Jean Hou
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mercury Lin
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nidia Messias
- Department of Pathology, Washington University in Saint Louis, St. Louis, Missouri
| | | | - Fabio Pagni
- Department of Medicine and Surgery, IRCCS San Gerardo, University Milan Bicocca, Monza, Italy
| | | | - Heikki Tokola
- Pathology, University Oulu and Oulu University Hospital, Oulu, Finland
| | - Maria D'Armiento
- Pathology Section, Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maximilian Seidl
- Medical Center-University of Freiburg and Faculty of Medicine, Institute for Surgical Pathology, University of Freiburg, Freiburg, Germany
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aurélie Sannier
- Department of Pathology, AP-HP, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Maria Fernanda Soares
- Department of Cellular Pathology, Oxford University Hospitals NHS FT, Oxford, United Kingdom
| | - Suxia Wang
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Harris BW, Maxfield L, Hunter A, Alhajj M, Ban B, Pulsipher KJ. Worldwide Distribution and Extracutaneous Manifestations of Henoch-Schönlein Purpura in Adults: Narrative Review. JMIR DERMATOLOGY 2024; 7:e49746. [PMID: 38271008 PMCID: PMC10853858 DOI: 10.2196/49746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/21/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP), a leukocytoclastic small vessel vasculitis, exhibits both cutaneous and systemic manifestations. While predominantly observed in childhood, it may manifest in adults with more pronounced systemic involvement. Furthermore, HSP is a global phenomenon showcasing epidemiological and systemic variances. OBJECTIVE This study aims to scrutinize extracutaneous manifestations in adults with HSP, discerning distinctions according to geographical regions on a worldwide scale. METHODS A comprehensive search encompassing PubMed, Embase, Cochrane Library, and Web of Science was executed, covering papers published from January 1, 1970, to December 1, 2019. Keywords used included "Henoch-Schönlein purpura," "henoch schonlein purpura+adult," "IgA vasculitis+adult," "HSP+adult," and "IgAV." A total of 995 publications were identified, from which 42 studies encompassing 4064 patients were selected, with a predominant focus on cases reported in Asia, Europe, and the Americas. RESULTS Among adults afflicted with HSP, European patients exhibited a higher propensity for male predominance (P<.001), gastrointestinal involvement (P<.001), and musculoskeletal complications (P<.001). Conversely, patients from the Americas were least likely to experience genitourinary involvement (P<.001). CONCLUSIONS HSP demonstrates a variance in distribution and extracutaneous manifestations within distinct geographical boundaries. In the adult population, European patients exhibited a higher prevalence of male gender and gastrointestinal and musculoskeletal involvement. Asian patients were more predisposed to genitourinary involvement when compared to their American counterparts. The establishment of prospective studies using standardized reporting measures is imperative to validate the relationships unveiled in this investigation.
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Affiliation(s)
- Blair W Harris
- Department of Dermatology, Sampson Regional Medical Center, Campbell University, Clinton, NC, United States
| | - Luke Maxfield
- Department of Dermatology, Sampson Regional Medical Center, Campbell University, Clinton, NC, United States
| | - Abigail Hunter
- Department of Dermatology, Sampson Regional Medical Center, Campbell University, Clinton, NC, United States
| | - Mandy Alhajj
- Department of Dermatology, Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Byung Ban
- Department of Rheumatology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Kayd J Pulsipher
- Department of Dermatology, Sampson Regional Medical Center, Campbell University, Clinton, NC, United States
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Lei W, Yun-Yun S, Ai-E X. Neutrophil-to-lymphocyte Ratio: A Biomarker for Predicting Systemic Involvement in Henoch-Schonlein Purpura. Indian J Dermatol Venereol Leprol 2021; 88:132. [PMID: 34623056 DOI: 10.25259/ijdvl_760_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Henoch-Schonlein purpura (HSP) is one of the commonest entities included within the category of cutaneous vasculitis (CV). Our work is purposed to explore the predictive value of neutrophil-to-lymphocyte ratio (NLR) for systemic involvement in Henoch- Schonlein purpura patients. This ratio is known as an inflammatory marker, and is used to assess the systemic inflammation associated with various diseases. Our objective is to establish whether it can be applied for the prediction of renal and gastrointestinal (GI) or purely renal involvement in Henoch-Schonlein purpura. AIM To determine the relationship between neutrophil-to-lymphocyte ratio and systemic involvement in Henoch-Schonlein purpura Methods: This is a retrospective review of the patients who were diagnosed with Henoch-Schonlein purpura in our hospital between 2012 and 2018. RESULTS A total of 57 patients met our inclusion criteria. Pre-treatment neutrophil-to-lymphocyte ratio was significantly associated with renal and/or GI manifestations of the disease (p<0.001). The optimal cut-off value of this ratio for predicting systemic involvement was 2.48, with a 95% specificity and a 94% sensitivity. In addition, pretreatment ratio was also found to be significantly correlated with the severity of relevant systemic manifestations of Henoch-Schonlein purpura (r=0.831; p<0.01). LIMITATIONS The small number of patients recruited for our research, its retrospective design, and the inclusion of patients attending the same hospital. CONCLUSION This study suggests that neutrophil-to-lymphocyte ratio is suitable as a potential indicator for predicting the systemic involvement in Henoch-Schonlein purpura.
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Affiliation(s)
- Wang Lei
- Department of Dermatology, Third People's Hospital of Hangzhou, Hangzhou, China
| | - Shan Yun-Yun
- Department of Dermatology, Third People's Hospital of Hangzhou, Hangzhou, China
| | - Xu Ai-E
- Department of Dermatology, Third People's Hospital of Hangzhou, Hangzhou, China
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4
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Mohamed M, Shariff M, Al Hillan A, Haj RA, Kaunzinger C, Hossain M, Asif A, Pyrsopoulos NT. A Rare Case of Helicobacter pylori Infection Complicated by Henoch-Schonlein Purpura in an Adult Patient. J Med Cases 2020; 11:160-165. [PMID: 34434390 PMCID: PMC8383653 DOI: 10.14740/jmc3480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/07/2020] [Indexed: 01/08/2023] Open
Abstract
Henoch-Schonlein purpura (HSP) is known as a leukocytoclastic vasculitis of small vessels, resulting in skin, joint, gastrointestinal (GI) and renal involvement. It is the most common acute vasculitis in children but is relatively uncommon in adults. The pathogenesis of HSP remains unclear, but a wide variety of conditions such as bacterial or viral infections, vaccinations, drugs and other environmental exposures may be responsible for the onset. A few previous case reports have described an association between gastric Helicobacter pylori (HP) infection and HSP. A 30-year-old Indian man who migrated to the USA from India 3 years prior to this presentation with a past medical history of psoriasis on remission, not on any medications presented to the emergency department with sudden onset constant abdominal pain for 5 days. The pain was in the right upper quadrant, spasmodic in nature. The abdominal examination was normal. The patient was evaluated with complete blood count, comprehensive metabolic panel, urinalysis, computed tomography scan of abdomen and pelvis, and right upper quadrant ultrasound, all of which were negative except for leukocytosis. He was discharged on pantoprazole and tramadol. Pain continued despite treatment. Patient was readmitted 2 days later, when he noticed a new maculopapular rash on both legs. Upper GI endoscopy was done showing non-bleeding small gastric ulcer with multiple duodenal erosions. Gastric biopsy came back positive for HP and he was started on clarithromycin, amoxicillin and lansoprazole. Pain persisted after finishing antibiotic course. Rash continued to spread to involve the thighs, flanks, around the umbilicus and extensor surfaces of arms. Immunological workup was negative. A skin biopsy of the skin rash came back positive for leukocytoclastic vasculitis. HSP diagnosis was made by exclusion. Patient was started on prednisone 40 mg daily and improved drastically on the following day. He was continued steroids taper for 8 weeks. Rash as well as abdominal pain resolved completely. In conclusion, HSP involves the skin, GI tract, joints and kidneys. It is a pediatric disease and rarely occurs in adults. It can be associated with underlying malignancy in adults. HP infection can trigger HSP in pediatric and adult patients. Detection of the carrier state is crucial in HSP patients in areas where HP is endemic. Eradication of HP infection is usually associated with the resolution of HSP. In resistant cases with GI and renal involvement, corticosteroids use results in resolution of symptoms and reduction of the duration of mild nephritis.
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Affiliation(s)
- Mujtaba Mohamed
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohammed Shariff
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Alsadiq Al Hillan
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Rani Al Haj
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Christian Kaunzinger
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohammad Hossain
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-532, Newark, NJ 07103, USA
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Su HW, Chen CY, Chiou YH. Hemorrhagic bullous lesions in Henoch-Schönlein purpura: a case report and review of the literature. BMC Pediatr 2018; 18:157. [PMID: 29747613 PMCID: PMC5944150 DOI: 10.1186/s12887-018-1117-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 04/18/2018] [Indexed: 11/10/2022] Open
Abstract
Background Henoch-Schönlein purpura (HSP) is a common vasculitis in childhood characterized by purpura, arthritis, abdominal pain and renal involvement. However, bullous HSP is a rare cutaneous manifestation, and a few cases have been reported. Case presentation Herein, we report a 15-year-old male with bullous HSP who presented with severe abdominal pain and hemorrhagic bullous lesions over his lower extremities. He was treated with corticosteroid, after which the symptoms improved dramatically. No recurrence was noted after follow-up, though scarring was present. We also reviewed the literature related to bullous HSP and identified 39 cases, most of whom were treated with corticosteroids. Conclusion Clinicians should be aware of the atypical types of HSP, including bullous HSP. Most patients with bullous HSP have a good prognosis.
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Affiliation(s)
- Hung-Wen Su
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Road, Zuoying District, Kaohsiung City, 813, Taiwan
| | - Chiu-Yu Chen
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Road, Zuoying District, Kaohsiung City, 813, Taiwan
| | - Yee-Hsuan Chiou
- Division of Pediatric Allergy, Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Road, Zuoying District, Kaohsiung City, 813, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Peeters V, De Raeve L. Blistering eruptions in Henoch-Schönlein syndrome: more common than assumed. Eur J Pediatr 2018; 177:475-476. [PMID: 28812140 DOI: 10.1007/s00431-017-2990-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 07/31/2017] [Accepted: 08/04/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Valérie Peeters
- Department of Dermatology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Linda De Raeve
- Department of Dermatology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090, Brussels, Belgium
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7
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Nothhaft M, Klepper J, Kneitz H, Meyer T, Hamm H, Morbach H. Hemorrhagic Bullous Henoch-Schönlein Purpura: Case Report and Review of the Literature. Front Pediatr 2018; 6:413. [PMID: 30723709 PMCID: PMC6349767 DOI: 10.3389/fped.2018.00413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 12/11/2018] [Indexed: 12/27/2022] Open
Abstract
Henoch-Schönlein Purpura (HSP) or IgA vasculitis is the most common systemic vasculitis of childhood and may affect skin, joints, gastrointestinal tract, and kidneys. Skin manifestations of HSP are characteristic and include a non-thrombocytopenic palpable purpura of the lower extremities and buttocks. Rarely, HSP may initially present as or evolve into hemorrhagic vesicles and bullae. We present an otherwise healthy 5-year-old boy with an acute papulovesicular rash of both legs and intermittent abdominal pain. After a few days the skin lesions rapidly evolved into palpable purpura and hemorrhagic bullous lesions of variable size and severe hemorrhagic HSP was suspected. A histological examination of a skin biopsy showed signs of a small vessel leukocytoclastic vasculitis limited to the upper dermis and direct immunofluorescence analysis revealed IgA deposits in vessel walls, compatible with HSP. To further characterize the clinical picture and treatment options of bullous HSP we performed an extensive literature research and identified 41 additional pediatric patients with bullous HSP. Two thirds of the reported patients were treated with systemic corticosteroids, however, up to 25% of the reported patients developed skin sequelae such as hyperpigmentation and/or scarring. The early use of systemic corticosteroids has been discussed controversially and suggested in some case series to be beneficial by reducing the extent of lesions and minimizing sequelae of disease. Our patient was treated with systemic corticosteroids tapered over 5 weeks. Fading of inflammation resulted in healing of most erosions, however, a deep necrosis developing from a large blister at the dorsum of the right foot persisted so that autologous skin transplantation was performed. Re-examination 11 months after disease onset showed complete clinical remission with re-epithelialization but also scarring of some affected areas.
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Affiliation(s)
- Matthias Nothhaft
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Joerg Klepper
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Hermann Kneitz
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Meyer
- Department of Pediatric Surgery, Pediatric Traumatology and Pediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - Henning Hamm
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Henner Morbach
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
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Ilyas M, Sharma A. Leukocytoclastic vasculitis in transplant recipients: A case series of 7 patients. JAAD Case Rep 2017; 3:291-293. [PMID: 28702498 PMCID: PMC5484977 DOI: 10.1016/j.jdcr.2017.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Muneeb Ilyas
- Department of Dermatology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Amit Sharma
- Department of Dermatology, Mayo Clinic Arizona, Scottsdale, Arizona
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Calvo-Río V, Hernández JL, Ortiz-Sanjuán F, Loricera J, Palmou-Fontana N, González-Vela MC, González-Lamuño D, González-López MA, Armesto S, Blanco R, González-Gay MA. Relapses in patients with Henoch-Schönlein purpura: Analysis of 417 patients from a single center. Medicine (Baltimore) 2016; 95:e4217. [PMID: 27428226 PMCID: PMC4956820 DOI: 10.1097/md.0000000000004217] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To further investigate into the relapses of Henoch-Schönlein purpura (HSP), we analyzed the frequency, clinical features, and predictors of relapses in series of 417 unselected patients from a single center. After a median follow-up of 12 (interquartile range [IQR]: 2-38) years, almost one-third of the 417 patients (n = 133; 32%; 85 men/48 women) had experienced at least 1 relapse. At the time of disease diagnosis, patients who later experienced relapses had less commonly infections than those who never suffered flares (30.8% vs 41.9%; P = 0.03). In contrast, patients who experienced relapses had a longer duration of the first episode of palpable purpura than those without relapses (palpable purpura lasting >7 days; 80.0% vs 68.1%; P = 0.04). Abdominal pain (72.3% vs 62.3%; P = 0.03) and joint manifestations (27.8% vs 15.5%; P = 0.005) were also more common in patients who later developed relapses. In contrast, patients who never suffered relapses had a slightly higher frequency of fever at the time of disease diagnosis (9.3% vs 3.8%; P = 0.06). At the time of disease diagnosis, corticosteroids were more frequently given to patients who later had relapses of the disease (44% vs 32% in nonrelapsing patients; P = 0.03). Relapses generally occurred soon after the first episode of vasculitis. The median time from the diagnosis of HSP to the first relapse was 1 (IQR: 1-2) month. The median number of relapses was 1 (IQR 1-3). The main clinical features at the time of the relapse were cutaneous (88.7%), gastrointestinal (27.1%), renal (24.8%), and joint (16.5%) manifestations. After a mean ± standard deviation follow-up of 18.9 ± 9.8 years, complete recovery was observed in 110 (82.7%) of the 133 patients who had relapses. Renal sequelae (persistent renal involvement) was found in 11 (8.3%) of the patients with relapses. The best predictive factors for relapse were joint and gastrointestinal manifestations at HSP diagnosis (odds ratio [OR]: 2.22; 95% confidence interval [CI]: 1.34-3.69, and OR: 1.60; 95% CI: 1.01-2.53, respectively). In contrast, a history of previous infection was a protective factor for relapses (OR: 0.60; 95% CI: 0.38-0.94). In conclusion, joint and gastrointestinal manifestations at the time of diagnosis of HSP are predictors of relapses.
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Affiliation(s)
- Vanesa Calvo-Río
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - José Luis Hernández
- Division of Internal Medicine, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - Francisco Ortiz-Sanjuán
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - Javier Loricera
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - Natalia Palmou-Fontana
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - Maria C. González-Vela
- Division of Pathology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - Domingo González-Lamuño
- Division of Pediatrics, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
| | - Marcos A. González-López
- Division of Dermatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Santander, Spain
| | - Susana Armesto
- Division of Dermatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Santander, Spain
| | - Ricardo Blanco
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
- Correspondence: Miguel A. González-Gay, Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avda, Valdecilla s/n, ES-39008 Santander, Spain (e-mail: ); Ricardo Blanco, Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avda, Valdecilla s/n, ES-39008 Santander, Spain (e-mail: )
| | - Miguel A. González-Gay
- Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria
- Correspondence: Miguel A. González-Gay, Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avda, Valdecilla s/n, ES-39008 Santander, Spain (e-mail: ); Ricardo Blanco, Division of Rheumatology, Hospital Universitario Marqués de Valdecilla, IDIVAL, University of Cantabria, Avda, Valdecilla s/n, ES-39008 Santander, Spain (e-mail: )
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Park CH, Han DS, Jeong JY, Eun CS, Yoo KS, Jeon YC, Sohn JH. The Optimal Cut-Off Value of Neutrophil-to-Lymphocyte Ratio for Predicting Prognosis in Adult Patients with Henoch-Schönlein Purpura. PLoS One 2016; 11:e0153238. [PMID: 27073884 PMCID: PMC4830542 DOI: 10.1371/journal.pone.0153238] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/27/2016] [Indexed: 12/03/2022] Open
Abstract
Background The development of gastrointestinal (GI) bleeding and end-stage renal disease (ESRD) can be a concern in the management of Henoch–Schönlein purpura (HSP). We aimed to evaluate whether the neutrophil-to-lymphocyte ratio (NLR) is associated with the prognosis of adult patients with HSP. Methods Clinical data including the NLR of adult patients with HSP were retrospectively analyzed. Patients were classified into three groups as follows: (a) simple recovery, (b) wax & wane without GI bleeding, and (c) development of GI bleeding. The optimal cut-off value was determined using a receiver operating characteristics curve and the Youden index. Results A total of 66 adult patients were enrolled. The NLR was higher in the GI bleeding group than in the simple recovery or wax & wane group (simple recovery vs. wax & wane vs. GI bleeding; median [IQR], 2.32 [1.61–3.11] vs. 3.18 [2.16–3.71] vs. 7.52 [4.91–10.23], P<0.001). For the purpose of predicting simple recovery, the optimal cut-off value of NLR was 3.18, and the sensitivity and specificity were 74.1% and 75.0%, respectively. For predicting development of GI bleeding, the optimal cut-off value was 3.90 and the sensitivity and specificity were 87.5% and 88.6%, respectively. Conclusions The NLR is useful for predicting development of GI bleeding as well as simple recovery without symptom relapse. Two different cut-off values of NLR, 3.18 for predicting an easy recovery without symptom relapse and 3.90 for predicting GI bleeding can be used in adult patients with HSP.
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Affiliation(s)
- Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Dong Soo Han
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
- * E-mail:
| | - Jae Yoon Jeong
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Chang Soo Eun
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Kyo-Sang Yoo
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yong Cheol Jeon
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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11
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Gulati G, Siv J, Ware AE. Bullous skin lesions in an adult male: a diagnostic dilemma. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:215-9. [PMID: 25858335 PMCID: PMC4399480 DOI: 10.12659/ajcr.893218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Patient: Male, 42 Final Diagnosis: Henoch-Schönlein Purpura (HSP) Symptoms: Bullous hemorrhagic lesions • elevated liver enzymes Medication: — Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Gaurav Gulati
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jenny Siv
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Avis E Ware
- Division of Immunology, Allergy and Rheumatology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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12
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Validation of the absolute renal risk of dialysis/death in adults with IgA nephropathy secondary to Henoch-Schönlein purpura: a monocentric cohort study. BMC Nephrol 2013; 14:169. [PMID: 23915019 PMCID: PMC3733957 DOI: 10.1186/1471-2369-14-169] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 07/30/2013] [Indexed: 11/25/2022] Open
Abstract
Background We established earlier the absolute renal risk (ARR) of dialysis/death (D/D) in primary IgA nephropathy (IgAN) which permitted accurate prospective prediction of final prognosis. This ARR was based on the potential presence at initial diagnosis of three major, independent, and equipotent risk factors such as hypertension, quantitative proteinuria ≥ 1 g per day, and severe pathological lesions appreciated by our local classification scoring ≥ 8 (range 0–20). We studied the validity of this ARR concept in secondary IgAN to predict future outcome and focused on Henoch-Schönlein purpura (HSP) nephritis. Methods Our cohort of adults IgAN concerned 1064 patients with 101 secondary IgAN and was focused on 74 HSP (59 men) with a mean age of 38.6 at initial diagnosis and a mean follow-up of 11.8 years. Three major risk factors: hypertension, proteinuria ≥1 g/d, and severe pathological lesions appreciated by our global optical score ≥8 (GOS integrated all elementary histological lesions), were studied at biopsy-proven diagnosis and their presence defined the ARR scoring: 0 for none present, 3 for all present, 1 or 2 for the presence of any 1 or 2 risk factors. The primary end-point was composite with occurrence of dialysis or death before (D/D). We used classical statistics and both time-dependent Cox regression and Kaplan-Meier survival curve methods. Results The cumulative rate of D/D at 10 and 20 years post-onset was respectively 0 and 14% for ARR = 0 (23 patients); 10 and 23% for ARR = 1 (N = 19); 27 and 33% for ARR = 2 (N = 24); and 81 and 100% (before 20 y) in the 8 patients with ARR = 3 (P = 0.0007). Prediction at time of diagnosis (time zero) of 10y cumulative rate of D/D event was 0% for ARR = 0, 10% for ARR = 1, 33% for ARR = 2, and 100% by 8.5y for ARR = 3 (P = 0.0003) in this adequately treated cohort. Conclusion This study clearly validates the Absolute Renal Risk of Dialysis/Death concept in a new cohort of HSP-IgAN with utility to individual management and in future clinical trials.
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13
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Cutaneous manifestations of gastrointestinal disease: part II. J Am Acad Dermatol 2013; 68:211.e1-33; quiz 244-6. [PMID: 23317981 DOI: 10.1016/j.jaad.2012.10.036] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 02/07/2023]
Abstract
The gastrointestinal (GI) and cutaneous organ systems are closely linked. In part I of this continuing medical education article, the intricacies of this relationship were explored as they pertained to hereditary polyposis disorders, hamartomatous disorders, and paraneoplastic disease. Part II focuses on the cutaneous system's links to inflammatory bowel disease and vascular disorders. An in-depth analysis of inflammatory bowel disease skin findings is provided to aid dermatologists in recognizing and facilitating early consultation and intervention by gastroenterologists. Cutaneous signs of inflammatory bowel disease include fissures and fistulae, erythema nodosum, pyoderma gangrenosum, pyostomatitis vegetans, oral aphthous ulcers, cutaneous polyarteritis nodosa, necrotizing vasculitis, and epidermolysis bullosa acquisita. Additional immune-mediated conditions, such as diverticulitis, bowel-associated dermatosis-arthritis syndrome, Henoch-Schönlein purpura, dermatitis herpetiformis, and Degos disease, in which the skin and GI system are mutually involved, will also be discussed. Genodermatoses common to both the GI tract and the skin include Hermansky-Pudlak syndrome, pseudoxanthoma elasticum, Ehlers-Danlos syndrome, hereditary hemorrhagic telangiectasia, and blue rubber bleb nevus syndrome. Kaposi sarcoma is a neoplastic disease with lesions involving both the skin and the gastrointestinal tract. Acrodermatitis enteropathica, a condition of zinc deficiency, likewise affects both the GI and dermatologic systems. These conditions are reviewed with updates on the genetic basis, diagnostic and screening modalities, and therapeutic options. Finally, GI complications associated with vascular disorders will also be discussed.
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14
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Cheungpasitporn W, Jirajariyavej T, Howarth CB, Rosen RM. Henoch-Schönlein purpura in an older man presenting as rectal bleeding and IgA mesangioproliferative glomerulonephritis: a case report. J Med Case Rep 2011; 5:364. [PMID: 21831272 PMCID: PMC3163221 DOI: 10.1186/1752-1947-5-364] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 08/10/2011] [Indexed: 11/28/2022] Open
Abstract
Introduction Henoch-Schönlein purpura is the most common systemic vasculitis in children. Typical presentations are palpable purpura, abdominal pain, arthritis, and hematuria. This vasculitic syndrome can present as an uncommon cause of rectal bleeding in older patients. We report a case of an older man with Henoch-Schönlein purpura. He presented with rectal bleeding and acute kidney injury secondary to IgA mesangioproliferative glomerulonephritis. Case presentation A 75-year-old Polish man with a history of diverticulosis presented with a five-day history of rectal bleeding. He had first noticed colicky left lower abdominal pain two months previously. At that time he was treated with a 10-day course of ciprofloxacin and metronidazole for possible diverticulitis. He subsequently presented with rectal bleeding to our emergency department. Physical examination revealed generalized palpable purpuric rash and tenderness on his left lower abdomen. Laboratory testing showed a mildly elevated serum creatinine of 1.3. Computed tomography of his abdomen revealed a diffusely edematous and thickened sigmoid colon. Flexible sigmoidoscopy showed severe petechiae throughout the colon. Colonic biopsy showed small vessel acute inflammation. Skin biopsy resulted in a diagnosis of leukocytoclastic vasculitis. Due to worsening kidney function, microscopic hematuria and new onset proteinuria, he underwent a kidney biopsy which demonstrated IgA mesangioproliferative glomerulonephritis. A diagnosis of Henoch-Schönlein purpura was made. Intravenous methylprednisolone was initially started and transitioned to prednisone tapering orally to complete six months of therapy. There was marked improvement of abdominal pain. Skin lesions gradually faded and gastrointestinal bleeding stopped. Acute kidney injury also improved. Conclusion Henoch-Schönlein purpura, an uncommon vasculitic syndrome in older patients, can present with lower gastrointestinal bleeding, extensive skin lesions and renal involvement which responds well to systemic steroid therapy. A history of diverticulosis can mislead physicians to the diagnosis of diverticular bleeding which is more common in this age group. The clinical manifestations of the disease, including characteristic skin rash, abdominal pain, joint inflammation and renal involvement raised the suspicious of Henoch-Schönlein purpura.
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Affiliation(s)
- Wisit Cheungpasitporn
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY 13326, USA.
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15
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Khasnis A, Langford CA. Update on vasculitis. J Allergy Clin Immunol 2009; 123:1226-36. [PMID: 19501230 DOI: 10.1016/j.jaci.2009.04.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 04/13/2009] [Accepted: 04/20/2009] [Indexed: 01/15/2023]
Abstract
The primary systemic vasculitides comprise a broad group of diseases identified by their clinical, histopathologic, and therapeutic characteristics. These unique entities have a broad spectrum of organ involvement and severity, which influences the approach to diagnosis and treatment. Immunosuppressive and cytotoxic agents are used to manage most vasculitic diseases. Long-term outcome is influenced by chronic sequelae from organ damage, disease relapses, and medication side effects. Further research is needed to understand these diseases and discover more efficacious yet less toxic therapeutic options. This review will focus on vasculitic syndromes more likely to be presented to an allergist/immunologist in an outpatient setting.
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Affiliation(s)
- Atul Khasnis
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH 44195, USA
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16
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Abstract
Vasculitis is characterized by an inflammatory reaction of vessel walls with damage to the dependent tissues. Forms of vasculitis which frequently have skin changes include leukocytoclastic angiitis (LcV), Henoch-Schönlein purpura (HSP), cutaneous polyarteriitis nodosum (cPAN), erythema elevatum et diutinum (EED) and urticarial vasculitis (UV). In other forms of vasculitis, systemic manifestations predominate but there are a variety of skin changes. Kawasaki disease (MK), cryoglobulinemic vasculitis (kV), Wegener granulomatosis (WG), Churg-Strauss syndrome (CSS) and microscopic polyangitis (MPA) belong to this group. The causes of vasculitis are heterogeneous. Triggers include infections, drugs, collagen vascular diseases, autoimmune diseases and lymphoproliferative disorders. Idiopathic vasculitis, particularly LcV and EED, occur only once and have a self-limited course. The diagnostic work up depends on the clinical picture and includes inflammatory markers, circulating immune complexes, different types of cryoglobulins and anti-neutrophilic cytoplasmic antibodies, collagen vascular disease specific autoantibodies and additional hematological studies. Vasculitis can manifest in many organs and requires a thorough work up specifically in cases where WG, MPA, CSS and PAN are under consideration.
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Affiliation(s)
- K Schäkel
- Klinik und Poliklinik für Dermatologie am Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden
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17
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Xu LY, Esparza EM, Anadkat MJ, Crone KG, Brasington RD. Cutaneous manifestations of vasculitis. Semin Arthritis Rheum 2008; 38:348-60. [PMID: 18355896 DOI: 10.1016/j.semarthrit.2008.01.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 12/11/2007] [Accepted: 01/05/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To discuss the clinical features, diagnostic evaluation, and treatment options for cutaneous vasculitis. METHODS The literature in the PubMed database was reviewed regarding the presentation, pathophysiology, clinical workup, and treatment of cutaneous vasculitis. RESULTS Available classification criteria of vasculitis are based on histopathologic criteria or clinicohistologic features. These have been designed more for research purposes than for clinical application. Skin findings such as palpable purpura, nodules, urticaria, ulcers, and infarction are clues to the presence of vasculitis. Pathologic findings of fibrinoid necrosis, infiltration by neutrophils or lymphocytes, and deposition of complement and immunoglobulin may be helpful in reaching a specific diagnosis. However, there is considerable overlap across different conditions. CONCLUSIONS The correct diagnosis of cutaneous manifestations of vasculitis requires an understanding of vasculitis classification, recognition of specific clinical patterns, and the ability to interpret histopathologic data.
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Affiliation(s)
- Lisa Y Xu
- Rheumatology and Dermatology, Department of Internal Medicine and Lauren V. Ackerman Laboratory of Surgical Pathology, Washington University School of Medicine, St. Louis, MO, USA
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18
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Abstract
Henoch-Schönlein purpura (HSP) is a small-vessel vasculitis characterized by purpura, arthritis, abdominal pain, and hematuria. It is the most common form of vasculitis affecting children. The skin manifestations typically present as palpable purpura over the buttock and the lower extremities, but bullous lesions are particularly rare in children. We report a case of HSP presented as painful bullae on both lower limbs.
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Affiliation(s)
- Kingsley Han Ngai Chan
- Social Hygiene Service, Centre for Health Protection, Department of Health, Hong Kong, China.
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19
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Kellerman PS. Henoch-Schönlein Purpura in Adults. Am J Kidney Dis 2006; 48:1009-16. [PMID: 17162160 DOI: 10.1053/j.ajkd.2006.08.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 08/15/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Paul S Kellerman
- Division of Nephrology, University of Wisconsin School of Medicine, Madison, WI, USA.
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20
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Abstract
Vasculitis is histologically defined as inflammatory cell infiltration and destruction of blood vessels. Vasculitis is classified as primary (idiopathic, eg, cutaneous leukocytoclastic angiitis, Wegener's granulomatosis) or secondary, a manifestation of connective tissue diseases, infections, adverse drug eruptions, or a paraneoplastic phenomenon. Cutaneous vasculitis, manifested as urticaria, purpura, hemorrhagic vesicles, ulcers, nodules, livedo, infarcts, or digital gangrene, is a frequent and often significant component of many systemic vasculitic syndromes such as lupus or rheumatoid vasculitis and antineutrophil cytoplasmic antibody-associated primary vasculitic syndromes such as Churg-Strauss syndrome. In most instances, cutaneous vasculitis represents a self-limited, single-episode phenomenon, the treatment of which consists of general measures such as leg elevation, warming, avoidance of standing, cold temperatures and tight fitting clothing, and therapy with antihistamines, aspirin, or nonsteroidal anti-inflammatory drugs. More extensive therapy is indicated for symptomatic, recurrent, extensive, and persistent skin disease or coexistence of systemic disease. For mild recurrent or persistent disease, colchicine and dapsone are first-choice agents. Severe cutaneous and systemic disease requires more potent immunosuppression (prednisone plus azathioprine, methotrexate, cyclophosphamide, cyclosporine, or mycophenolate mofetil). In cases of refractory vasculitis, plasmapheresis and intravenous immunoglobulin are viable considerations. The new biologic therapies that work via cytokine blockade or lymphocyte depletion such as tumor alpha inhibitor infliximab and the anti-B-cell antibody rituximab, respectively, are showing benefit in certain settings such as Wegener's granulomatosis, antineutrophil cytoplasmic antibody-associated vasculitis, Behçet's disease, and cryoglobulinemic vasculitis.
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Affiliation(s)
- J Andrew Carlson
- Division of Dermatology, Albany Medical College, MC-81, NY 12208, USA.
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21
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Barquero-Romero J, Chaves-Alvarez AJ, Catalina-Fernández I, López-Cortezón C. Púrpura de Schönlein-Henoch en una paciente gestante. Med Clin (Barc) 2006; 127:276-7. [PMID: 16942733 DOI: 10.1157/13091271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
An 8-year-old boy with Henoch-Schönlein purpura who developed hemorrhagic bullae is described. The occurrence of hemorrhagic bullae in children with Henoch-Schönlein purpura is rare. A perusal of the literature revealed but seven occurrences to which we add another one.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada.
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23
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Ishii Y, Takizawa T, Arakawa H, Saga R, Mochizuki H, Tokuyama K, Morikawa A. Hemorrhagic bullous lesions in Henoch-Schönlein purpura. Pediatr Int 2005; 47:694-7. [PMID: 16354228 DOI: 10.1111/j.1442-200x.2005.02133.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yoichiro Ishii
- Department of Pediatrics and Developmental Medicine, Gunma University Graduate School, Gunma, Japan
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24
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Koizumi M, Hagino D, Fukuyama C, Abe K, Inoue K, Arai Y, Takechi K. Schonlein-Henoch purpura during pregnancy: Case report and review of the literature. J Obstet Gynaecol Res 2004; 30:37-41. [PMID: 14718019 DOI: 10.1111/j.1341-8076.2004.00153.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The clinical features of Schönlein-Henoch Purpura (SHP) consist of non-thrombocytopenic purpura in association with joint, gastrointestinal and renal involvements. Because it is uncommon in adults, there is little information on the effects of SHP on pregnancy in the literature. This report documents the clinical findings and outcome of an uncommon case of SHP affecting a woman who was 25 weeks pregnant. Prompt steroid-therapy induced a rapidly favorable course and successful vaginal delivery at 40 weeks gestation. If SHP develops during pregnancy, it is not always easy to distinguish from obstetrical complications such as pre-eclampsia. An early diagnosis is important especially if renal involvement exists, because the prognosis for this disease can include nephropathy and it therefore needs close monitoring.
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25
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Barnadas MA, Pérez E, Gich I, Llobet JM, Ballarín J, Calero F, Facundo C, Alomar A. Diagnostic, prognostic and pathogenic value of the direct immunofluorescence test in cutaneous leukocytoclastic vasculitis. Int J Dermatol 2004; 43:19-26. [PMID: 14693016 DOI: 10.1111/j.1365-4632.2004.01714.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND No precise studies have been performed on cutaneous leukocytoclastic vasculitis (LV) to establish whether it is better to obtain a skin biopsy from lesional or from perilesional skin for direct immunofluorescence (DIF). There is no agreement on the immunoglobulins most frequently detected and the value of DIF for the classification of cutaneous vasculitis. METHODS A prospective study of DIF in lesional and perilesional skin was performed in 50 leukocytoclastic vasculitis patients and 15 nonvasculitis patients. RESULTS We detected a higher level of positivity in involved skin than in uninvolved skin for IgG, IgA, IgM, C3 and fibrinogen but not for C1q. In vasculitic patients, IgA was the immunoglobulin most frequently detected in lesional (82%) and perilesional skin (68%), followed by IgM (56 and 34%, respectively) and IgG (20 and 8%, respectively). Only IgA deposits were associated with the diagnosis of vasculitis, with a sensitivity of 82% in lesional and 68% in perilesional skin, and with a specificity of 73 and 66.7%, respectively. The presence of IgA in lesional skin was associated with renal involvement but there was no association with severity. The presence of IgG or IgM, or the absence of IgA in perilesional skin was related to the presence of cryoglobulins. The absence of IgA in lesional and perilesional skin was also related to hepatitis C virus infection. CONCLUSIONS DIF findings in involved skin are more closely related to the diagnosis of vasculitis and can give more information about overall renal involvement than findings in uninvolved skin. However, findings in uninvolved skin are more closely related to the pathogenic factors that trigger the development of vasculitis.
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Affiliation(s)
- María A Barnadas
- Department of Dermatology, Hospital de la Sta. Creu i St. Pau, Barcelona, Spain.
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Abstract
Henoch-Schönlein purpura (HSP) is an IgA-mediated small vessel vasculitis which commonly involves the skin, gastrointestinal system and kidneys. Numerous HSP triggers have been identified, and pregnancy has been reported as an exacerbating factor. After a pregnant woman had been diagnosed as having new-onset HSP, we reviewed all cases of immunofluorescence-proven HSP evaluated by the Department of Dermatology at the Johns Hopkins Hospital between 1990 and 2002, and report three cases of HSP occurring during pregnancy. Two patients developed new-onset HSP, one at 16 weeks gestation and one at 22 weeks, while the third developed a recurrence of HSP at 12 weeks gestation after 19 years of remission. We conclude that pregnancy may be a trigger for HSP onset or recurrence in susceptible individuals.
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Affiliation(s)
- D L Cummins
- Johns Hopkins Hospital, Baltimore, MD, U.S.A
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Feldmann R, Rieger W, Sator PG, Gschnait F, Breier F. Schönlein-Henoch purpura during pregnancy with successful outcome for mother and newborn. BMC DERMATOLOGY 2002; 2:1. [PMID: 11866865 PMCID: PMC65680 DOI: 10.1186/1471-5945-2-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2001] [Accepted: 01/30/2002] [Indexed: 01/08/2023]
Abstract
BACKGROUND Schönlein-Henoch purpura is a systemic vasculitis that affects vessels of a small caliber and rarely reported in the literature. CASE PRESENTATION We report on a 35-year-old woman who developed palpable purpura with necrotizing cutaneous lesions on the lower limbs at 27 weeks of gestation. She also complained of epigastric pain and arthralgias. Histologic examination of a skin biopsy showed leukocytoclastic vasculitis with intravascular fibrin thrombi. The direct immunofluorescence analysis evidenced vascular deposits of IgA and C3 in the upper and mid-dermis. These findings were consistent with Schönlein-Henoch purpura. There was no evidence of renal involvement or placental dysfunction. The patient was treated with low-dose oral corticosteroids and a healthy infant was delivered by cesarean section. Examination of the placenta and the navel string disclosed no signs of vasculitis or infarction. CONCLUSION Schönlein-Henoch purpura is rarely reported in pregnancy. Treatment with orally administered corticosteroids may lead to a beneficial outcome for mother and newborn.
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Affiliation(s)
- Robert Feldmann
- Department of Dermatology, Lainz Municipal Hospital, Wolkersbergenstraβe 1, A-1130 Vienna, Austria
| | - Walter Rieger
- Department of Gynaecology and Obstetrics, Lainz Municipal Hospital, Wolkersbergenstraβ e 1, A-1130 Vienna, Austria
| | - Paul G Sator
- Department of Dermatology, Lainz Municipal Hospital, Wolkersbergenstraβe 1, A-1130 Vienna, Austria
| | - Friedrich Gschnait
- Department of Dermatology, Lainz Municipal Hospital, Wolkersbergenstraβe 1, A-1130 Vienna, Austria
| | - Friedrich Breier
- Department of Dermatology, Lainz Municipal Hospital, Wolkersbergenstraβe 1, A-1130 Vienna, Austria
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Piette WW. Therapy of leukocytoclastic (necrotizing) cutaneous vasculitis. Dermatol Ther 2001. [DOI: 10.1046/j.1529-8019.2001.014002095.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mahamedi H, André M, Privat C, Delèvaux I, D'Incan M, Piette JC, Francès C, Aumaître O. [Value of abdominal-pelvic computed tomography in adult rheumatoid purpura]. Rev Med Interne 2001; 22:132-40. [PMID: 11234671 DOI: 10.1016/s0248-8663(00)00303-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Henoch-Schonlein purpura is a rare eventuality in adulthood. Abdominal involvement can worsen the short-term prognosis and justify medical treatment to avoid surgery. METHODS Abdominopelvic computed tomography (CT) was performed in six adult patients (four men and two women; age range, 19-74 years) with Henoch-Schonlein purpura before any treatment. Abdominal symptoms were concomitant with the purpuric rash in two cases and followed it in the other cases. RESULTS The small bowel was always involved with a parietal thickening, and the target sign was observed in three patients. The lesions were located in the duodenum in two patients, the jejunum in two and the ileum in five. Two segments were involved in one patient and three segments in another patient. A peritoneal effusion was always present. No colonic lesion was discovered on CT. Once the results were known, all patients received steroids with initially intravenous methylprednisolone in five patients at doses ranging from 80 to 1,000 mg/day. On follow-up, none of the patients underwent surgery. CONCLUSION Abdominopelvic CT scan demonstrated signs suggestive of intestinal vasculitis. An underlying neoplasia or an eventual other cause of abdominal pain were explored and a steroid therapy was then began with a good outcome. Abdominal CT can be helpful in the diagnosis of abdominal involvement in Henoch-Schonlein purpura.
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Affiliation(s)
- H Mahamedi
- Service de médecine interne, hôpital Gabriel-Montpied, BP 69, 63003 Clermont-Ferrand, France
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Stegeman CA, Kallenberg CG. Clinical aspects of primary vasculitis. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 2001; 23:231-51. [PMID: 11591100 DOI: 10.1007/s002810100079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- C A Stegeman
- Department of Internal Medicine/Division of Nephrology, University Hospital Groningen, Faculty of Medical Sciences, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
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Pertuiset E, Lioté F, Launay-Russ E, Kemiche F, Cerf-Payrastre I, Chesneau AM. Adult Henoch-Schönlein purpura associated with malignancy. Semin Arthritis Rheum 2000; 29:360-7. [PMID: 10924021 DOI: 10.1053/sarh.2000.6988] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Malignancies are among the well-established causes of vasculitis. We studied the association between adult Henoch-Schonlein purpura (HSP) and malignant neoplasms. METHODS We retrospectively reviewed 14 cases of adult HSP diagnosed during a 6-year period and found a malignant neoplasm in four. Fifteen reports of adult HSP with malignant disease were identified in the literature. These 19 cases were compared with 158 adults who had HSP but no malignancy and who where reported in the literature. RESULTS Most (63%) of the malignant neoplasms associated with adult HSP were solid tumors: lung, n = 6; prostate, n = 2; breast, n = 1; renal, n = 1; stomach, n = 1; and small bowel, n = 1. Hematologic malignancies (37%) included non-Hodgkin lymphoma, n = 2; Hodgkin disease, n = 2; IgA multiple myeloma, n = 1; myeloproliferative disease, n = 1; and myelodysplastic syndrome, n = 1. Patients with malignancy were older (median age, 59 years), were more likely to be male (M/F = 8.5), had joint involvement more frequently (95%), and had a lower frequency of prior acute infection than those without malignancy. A typical paraneoplastic course was documented in only two cases. CONCLUSIONS Epidemiological studies are needed to determine the association between adult HSP and malignancy. In practice, it may be wise to suspect a malignancy in men older than 40 years of age who develop HSP in the absence of a precipitating factor. Pathogenic hypotheses involve tumor antigens or abnormal IgA production leading to immune complex formation.
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Affiliation(s)
- E Pertuiset
- Department of Rheumatology, René Dubos Hospital, Pontoise, France
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Cribier B, Couilliet D, Meyer P, Grosshans E. The severity of histopathological changes of leukocytoclastic vasculitis is not predictive of extracutaneous involvement. Am J Dermatopathol 1999; 21:532-6. [PMID: 10608245 DOI: 10.1097/00000372-199912000-00005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Leukocytoclastic vasculitis is defined by histologic features and can be observed in a wide range of entities. Independent of the causative disease, extracutaneous complications are frequent, mainly in the kidneys and gastrointestinal tract. It has been suggested that the severity of histological changes could correlate with the clinical course of the disease. We have therefore compared the severity of histological changes of leukocytoclastic vasculitis to clinical and laboratory findings indicative of extracutaneous involvement in a large group of patients. Among 289 patients followed for cutaneous vasculitis, we included 184 patients with purpuric papules and proven leukocytoclastic vasculitis who all had standardized investigations. A cutaneous biopsy was performed early and standardized laboratory investigations were carried out. The slides were retrospectively randomized and the depth of vasculitis and severity of vascular necrosis were determined according to a semiquantitative scale. These data were compared to the renal, gastrointestinal and articular symptoms using Fischer's exact test, Chi-square test and variance analysis. The intensity of vascular necrosis and the depth of vasculitis were no more severe in patients having renal changes, gastrointestinal involvement or articular symptoms. Both variance analysis and Chi-square tests failed to show a significant increase in the severity score in patients having extracutaneous complications. In this study, the severity of histopathological changes was not predictive of extracutaneous involvement. Thus it appears that the degree of involvement of the cutaneous vessels probably does not correlate with that of vessels in visceral organs.
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Affiliation(s)
- B Cribier
- Laboratoire d'Histopathologie Cutanée Clinique Dermatologique, Hôpitaux Universitaires, Faculté de Médecine, Strasbourg, France
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Abstract
Henoch-Schönlein purpura (HSP) is an acute leukocytoclastic vasculitis that primarily affects children. In the current report, the author presents the clinical features of 100 children with HSP and reviews the literature, placing particular emphasis on new information concerning the etiology, immunopathogenesis, and treatment of HSP. The dominant clinical features of HSP are cutaneous purpura (100%), arthritis (82%), abdominal pain (63%), gastrointestinal bleeding (33%), and nephritis (40%). The etiology of HSP remains unknown, but it is clear that IgA plays a critical role in the immunopathogenesis of HSP, as evidenced by increased serum IgA concentrations, IgA-containing circulating immune complexes, and IgA deposition in vessel walls and renal mesangium. There are 2 subclasses of IgA, but HSP is associated with abnormalities involving IgA1 exclusively, and not IgA2. This finding may be a consequence of abnormal glycosylation of O-linked oligosaccharides unique to the hinge region of IgA1 molecules. Although several lines of evidence suggest a genetic susceptibility to HSP, the fundamental basis for the abnormalities involving IgA remain unclear. In general, HSP is an acute, self-limited illness, but one-third of patients will have 1 or more recurrences of symptoms. Corticosteroid therapy may hasten the resolution of arthritis and abdominal pain, but does not prevent recurrences. To date, no form of therapy has been shown to shorten appreciably the duration of HSP. The long-term prognosis of HSP is directly dependent on the severity of renal involvement. Corticosteroids in usual doses have no effect on established nephritis. Evidence is emerging that treatment with high-dose intravenous pulse methylprednisolone coupled with azathioprine or cyclophosphamide may be beneficial in patients with severe nephritis.
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Affiliation(s)
- F T Saulsbury
- Department of Pediatrics, University of Virginia Health Sciences Center, Charlottesville 22908, USA.
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García-Porrúa C, González-Gay MA. Comparative clinical and epidemiological study of hypersensitivity vasculitis versus Henoch-Schönlein purpura in adults. Semin Arthritis Rheum 1999; 28:404-12. [PMID: 10406408 DOI: 10.1016/s0049-0172(99)80006-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the incidence and clinical features of adults with hypersensitivity vasculitis (HV) and Henoch-SchOnlein purpura (HSP) in a well-defined population. METHODS Retrospective study of an unselected population of adult patients (>20 years) with biopsy-proven cutaneous vasculitis diagnosed as having HV or HSP who presented at a primary hospital between 1988 and 1997. Patients with cutaneous vasculitis secondary to collagen vascular diseases, neoplasia, severe infections, and those with other well-defined clinical entities were excluded. Patients were classified as having either HV or HSP according to the criteria proposed by Michel et al (J Rheumatol 1992;19:721-28). RESULTS Fifty-six adults (35 men/21 women), were classified as having HV and 27 adults as having HSP (19 men/8 women). The annual incidence rate for HV was 29.7/million and 14.3/million for HSP. At the onset of the disease, adults with HSP were younger than those with HV (46+/-18 years versus 59+/-18 years in HV; P = .005). Precipitating events were found in 50% of HV and in 30% of HSP patients. A history of drug therapy before the onset of vasculitis was found in 46% of HV and in 26% of HSP (P = .074). At disease onset, skin lesions were the most common manifestation in both groups. During the disease course, adults with HSP had joint manifestations more commonly (59% in HSP v25% in HV; P < .003) and more gastrointestinal (82% v 5% in HV; P < .001) and renal complications (48% v 5% in HV; P < .001). HSP subjects required more aggressive therapy consisting of steroids (P < .001) or cytotoxic agents (P < .001). After 37+/-28 (median, 31) months, complete recovery was observed in 98% of adults with HV. After 40+/-27 (median, 36) months, complete recovery was observed in only 67% of adults with HSP (P < .001). Renal insufficiency was observed in 8% of adults with HSP. CONCLUSIONS In adults, HV and HSP as defined by these criteria, behave as two well-differentiated diseases. HV has a milder course and lack of severe complications, and HSP a higher risk of gastrointestinal and renal complications.
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