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Sestan M, Kifer N, Sozeri B, Demir F, Ulu K, Silva CA, Campos RT, Batu ED, Koker O, Sapina M, Srsen S, Held M, Gagro A, Fonseca AR, Rodrigues M, Rigante D, Filocamo G, Baldo F, Heshin-Bekenstein M, Giani T, Kataja J, Frkovic M, Ruperto N, Ozen S, Jelusic M. Clinical features, treatment and outcome of pediatric patients with severe cutaneous manifestations in IgA vasculitis: Multicenter international study. Semin Arthritis Rheum 2023; 61:152209. [PMID: 37126983 DOI: 10.1016/j.semarthrit.2023.152209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE IgA vasculitis (IgAV) (formerly Henoch-Schönlein Purpura, HSP) rarely causes severe skin lesions in children. The purpose of the research was to determine whether severe skin manifestations were associated with a more severe disease course. METHODS Severe cutaneous manifestations were defined as presence of hemorrhagic vesicles, bullae, ulcerations and/or necroses. Data were collected retrospectively from 12 international tertiary university medical centers. RESULTS A total of 64 patients with the most severe skin changes in IgAV/HSP and median (Q1, Q3) age of 8.08 (5.08, 11.92) years at the disease onset were compared with 596 IgAV/HSP patients without these manfiestations and median (Q1, Q3) age of 6.33 (4.50, 8.92) years. The patients with severe cutaneous manifestations were older in comparison to other patients with IgAV/HSP (p<0.001), they developed nephritis more frequently (40.6% vs. 20.6%, p = 0.001) with worse outcome of renal disease (p = 0.001). This group of patients also had higher frequencies of severe gastrointestinal complications like hematochezia, massive bleeding and/or intussusception (29.3% vs. 14.8%, p<0.001). d-dimer concentrations were significantly higher in these patients (4.60 mg/L vs. 2.72 mg/L, p = 0.003) and they had more frequent need for treatment with systemic glucocorticoids (84.4% vs. 37.2%, p<0.001) in comparison with the control group. Further multivariate analysis showed that severe cutaneous changes were associated with higher risk of developing nephritis [OR=3.1 (95%CI 1.04-9.21), p = 0.042] and severe gastrointestinal complications [OR=3.65 (95%CI 1.08-12.37), p = 0.038]. CONCLUSION Patients with IgAV/HSP and severe skin manifestations had a more severe clinical course and more frequently required glucocorticoids compared to classic IgAV/HSP patients.
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Affiliation(s)
- Mario Sestan
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nastasia Kifer
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Betul Sozeri
- University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Ferhat Demir
- University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Kadir Ulu
- University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Clovis A Silva
- Pediatric Rheumatology Unit, ICr-HC-FMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Reinan T Campos
- Pediatric Rheumatology Unit, ICr-HC-FMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ezgi Deniz Batu
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Oya Koker
- Department of Pediatric Rheumatology, Marmara University-Pendik Training and Research Hospital, Istanbul, Turkey
| | - Matej Sapina
- Department of Paediatrics, Josip Juraj Strossmayer University of Osijek, Medical Faculty and Faculty of Dental Medicine and Health Osijek, University Hospital Centre Osijek, Osijek, Croatia
| | - Sasa Srsen
- Department of Paediatrics, University of Split School of Medicine, University Hospital Centre Split, Split, Croatia
| | - Martina Held
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Alenka Gagro
- Department of Paediatrics, Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia; Josip Juraj Strossmayer University of Osijek, Medical Faculty Osijek, Osijek, Croatia
| | - Adriana Rodrigues Fonseca
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, Brazil
| | - Marta Rodrigues
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, Brazil
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giovanni Filocamo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Baldo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Merav Heshin-Bekenstein
- Pediatric Rheumatology Service, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | | | - Janne Kataja
- Department of Paediatrics and Adolescents Medicine, Turku University Hospital, Turku, Finland
| | - Marijan Frkovic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, UOSID centro trial, Genoa, Italy
| | - Seza Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
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Popov H, Koleva T, Stoyanov GS. Bullous Henoch-Schönlein Purpura and Associated Nephritis: A Pathological Case Report. Cureus 2023; 15:e35051. [PMID: 36942172 PMCID: PMC10024341 DOI: 10.7759/cureus.35051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
Henoch-Schönlein purpura (HSP) is the most common vasculitis in childhood, presenting with purpura, predominantly of the lower extremities and occasionally with renal involvement as well. Although associated with childhood, HSP, although rarely, can also develop in adults as well. Here we present a patient in his sixties, presenting with a myriad of rash units on his lower extremities, including bullous ones, and a constellation of chronic kidney failure. Skin and renal biopsy specimens revealed morphological changes and immune depositions representative of HSP. Despite treatment, the patient's kidney failure slowly progressed, and he expired eight months after his presentation due to associated complications. Although rare, the bullous form of HSP can be viewed as a more aggressive form of the disease, as seen by the presentation constellation and rapid progression in our case.
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Affiliation(s)
- Hristo Popov
- General and Clinical Pathology, Forensic Medicine and Deontology, Medical University of Varna, Varna, BGR
| | | | - George S Stoyanov
- General and Clinical Pathology, St. Marina University Hospital, Varna, BGR
- General and Clinical Pathology, Forensic Medicine and Deontology, Medical University of Varna, Varna, BGR
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3
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Bailleux S, Collins P, Nikkels AF. The Relevance of Skin Biopsies in General Internal Medicine: Facts and Myths. Dermatol Ther (Heidelb) 2022; 12:1103-1119. [PMID: 35430724 PMCID: PMC9110592 DOI: 10.1007/s13555-022-00717-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Non-dermatology medical specialties may refer patients for skin biopsies, searching for a particular diagnosis. However, the diagnostic impact of the skin biopsy is not clearly established. This article aims to assess the indications for, and evaluate the clinical relevance of, skin biopsies in non-dermatology medical specialties. Methods A questionnaire was sent to 23 non-dermatology specialty departments in a university medical center, requesting a list of indications for skin biopsies, as well as to 10 staff dermatologists to collect the indications of skin biopsies requested by non-dermatology specialties. Once the indications were collected, a literature search was performed to evaluate their clinical value and relevance. Results Eleven non-dermatology specialties provided a list of skin biopsy indications, to which staff dermatologists added seven more indications. A literature search revealed evidence-based medicine data for six diseases, that is, amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, and chronic graft-versus-host disease. Results were questionable concerning infectious endocarditis, acute graft-versus-host-disease, and the lupus band test. Skin biopsy were not evidenced as useful for the diagnosis of calciphylaxis, systemic scleroderma, Behçet’s disease, or hypermobile Ehlers–Danlos syndrome. For the diagnosis of Alport’s syndrome, pseudoxanthoma elasticum, and vascular Ehlers–Danlos syndrome, skin biopsy is currently outperformed by genetic analyses. For diagnoses such as Henoch–Schönlein purpura and Sjögren’s syndrome, skin biopsy represents an additional item among other diagnostic criteria. Conclusion The usefulness of skin biopsy as requested by non-dermatology specialties is only evidenced for amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, chronic graft-versus-host-disease, Henoch–Schönlein purpura, and Sjögren’s syndrome.
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Affiliation(s)
- Sophie Bailleux
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium
| | - Patrick Collins
- Department of Dermatopathology, University Hospital Centre, CHU du Sart Tilman, Liège, Belgium
| | - Arjen F Nikkels
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium.
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4
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Jelusic M, Sestan M, Giani T, Cimaz R. New Insights and Challenges Associated With IgA Vasculitis and IgA Vasculitis With Nephritis-Is It Time to Change the Paradigm of the Most Common Systemic Vasculitis in Childhood? Front Pediatr 2022; 10:853724. [PMID: 35372148 PMCID: PMC8965283 DOI: 10.3389/fped.2022.853724] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
What are the challenges ahead and how have we responded so far when it comes to the non-granulomatous systemic vasculitis, characterized mainly by deposits of IgA immune complexes in the endothelium of small blood vessels-IgA vasculitis (IgAV)? That is the question to which we tried to answer. We summarized existing knowledge about epidemiology, pathogenesis, genetics, diagnostic tests and therapy in this somewhat neglected entity in pediatric rheumatology. Since etiopathogenesis of IgA vasculitis is complex, with factors other than galactose-deficient IgA1-containing immune complexes also being important, and may involve numerous interactions between environmental and genetic factors, genomics alone cannot explain the entirety of the risk for the disease. The incidence of IgAV and nephritis varies worldwide and may be a consequence of overlapping genetic and environmental factors. In addition to the role of the HLA class II genes, some studies have pointed to the importance of non-HLA genes, and modern geostatistical research has also indicated a geospatial risk distribution, which may suggest the strong influence of different environmental factors such as climate, pathogen load, and dietary factors. The application of modern geostatistical methods until recently was completely unknown in the study of this disease, but thanks to the latest results it has been shown that they can help us a lot in understanding epidemiology and serve as a guide in generating new hypotheses considering possible environmental risk factors and identification of potential genetic or epigenetic diversity. There is increasing evidence that an integrative approach should be included in the understanding of IgA vasculitis, in terms of the integration of genomics, proteomics, transcriptomics, and epigenetics. This approach could result in the discovery of new pathways important for finding biomarkers that could stratify patients according to the risk of complications, without an invasive kidney biopsy which is still the gold standard to confirm a diagnosis of nephritis, even if biopsy findings interpretation is not uniform in clinical practice. Ultimately, this will allow the development of new therapeutic approaches, especially important in the treatment of nephritis, for which there is still no standardized treatment.
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Affiliation(s)
- Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mario Sestan
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Teresa Giani
- Department of Clincial Sciences and Community Health, University of Milan, Milan, Italy
| | - Rolando Cimaz
- Department of Clincial Sciences and Community Health, University of Milan, Milan, Italy.,ASST Pini-CTO, Milan, Italy
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5
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Guo Q, Hu X, Song C, Ren X, Zhai W, Ding Y, Zhang X, Yang M, Zhang J, Jiang M. Clinical characteristics and associating risk factors of gastrointestinal perforation in children with IgA vasculitis. Ann Med 2021; 53:2315-2320. [PMID: 34878346 PMCID: PMC8667883 DOI: 10.1080/07853890.2021.2009554] [Citation(s) in RCA: 4] [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] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) is a common small vessel vasculitis in children. Gastrointestinal perforation (GP) rarely presents as a complication of IgAV and is not well characterized. This study is aimed to investigate the clinical features, diagnosis, and risk factors of GP in children with IgAV. METHODS We retrospectively reviewed the clinical data of children with IgAV who attended our hospital between January 2014 and June 2018. The clinical risk factors and the corresponding treatments were analyzed for the children with IgAV complication with GP. RESULTS In total, 10,791 children with IgAV were reviewed in this study. GP was observed in 11 children with IgAV, accounted for 0.10% of the total cases. Among those GP patients, 1 case was gastric perforation, 10 cases were intestinal perforation. Five GP cases were identified by abdominal CT. Ultrasonography was failed to detect the occurrence of GP in five cases. The average duration of abdominal pain in the GP cases was 9.3 days, and 9 cases (81.8%) presented with abdominal pain for over 7 days. Gastric/intestinal perforation repair were performed for 3 IgAV GP cases under open surgery. The other eight cases were treated through enterectomy. In comparison with the patients without GP, the GP patients had significant higher rates in the aspect of the abdominal or mixed type of IgAV, abdominal pain duration more than 7 days, hematochezia, renal damage, and methylprednisolone treatment with the daily dosage more than 2 mg/kg. CONCLUSION GP children accounted for 0.10% of the total IgAV cases. The risk of GP is elevated in IgAV patients who has gastrointestinal symptoms and/or other symptoms such as hematochezia, renal damage, a prolonged abdominal pain (>7 days), administration of methylprednisolone (>2 mg/kg). Abdominal CT is highly recommended for the early detection of GP in IgAV patients.Key messagesGastrointestinal perforation (GP) rarely presents as a complication of IgAV and is not well characterized.11 out of 10,791 children with IgAV developed GP, accounting for 0.10% of the total number of cases.Abdominal CT is highly recommended for the early detection of GP in IgAV patients.
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Affiliation(s)
- Qingyin Guo
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Xiaolei Hu
- Henan University of Chinese Medicine, Zhengzhou, China
| | - Chundong Song
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Xianqing Ren
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Wensheng Zhai
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Ying Ding
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China.,Henan University of Chinese Medicine, Zhengzhou, China
| | - Xia Zhang
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Meng Yang
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Jian Zhang
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
| | - Miao Jiang
- First Affiliated Hospital of Henan University of Chinese Medicine, Henan Children's Hospital of Integrated Traditional Chinese and Western Medicine, Zhengzhou, China
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6
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic bullous IgA vasculitis (Schönlein-Henoch purpura), does it have a worse prognosis? REUMATOLOGIA CLINICA 2021; 17:549-551. [PMID: 34756318 DOI: 10.1016/j.reumae.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/08/2020] [Indexed: 06/13/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, Spain
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7
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AlKhater SA, Al Moaigel HM. Clinical spectrum and outcome of immunoglobulin A vasculitis in children: A 10-year clinical study. Int J Clin Pract 2021; 75:e13930. [PMID: 33319433 DOI: 10.1111/ijcp.13930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Immunoglobulin A (IgA) vasculitis is the most common vasculitides of childhood. The aim of this study was to characterise the disease and identify clinical and laboratory factors associated with renal involvement. METHODS Medical records of children aged ≤18 years with the diagnosis of IgA vasculitis according to the EULAR/PRES criteria were retrospectively reviewed for demographic data, clinical manifestations and laboratory tests. Factors associated with renal involvement were determined using multivariable logistic regression analysis. RESULTS A total of 113 patients were involved in the study. There were 57.5% of males (male: female ratio of 1.4:1). The mean (SD) age was 7.1 (3.0) years. Most of the patients presented during the fall (37.2%) and winter (29.2%). The most common presenting complaints were skin rash (83.2%) and arthralgia (9.7%). The most frequent presentation of the skin was palpable purpuric rash, except for two patients (1.8%) presenting with blistering eruptions in the form of hemorrhagic bullae and ecchymoses of both extremities. We have encountered one patient with pulmonary-renal syndrome. Renal involvement was found in 27.4% of the patients. In the multivariate analysis, the strongest factors associated with renal involvement were older age and elevated creatinine level. Factors that improved model fit were higher platelet and lower white blood cell counts, elevated anti-streptolysin O and a history of preceding infection. CONCLUSION The clinical profile of the disease in our cohort was similar to other reports. However, we have encountered a few severe and rare atypical presentations. Over a quarter of children in our setting had renal involvement. Children presenting with these risk factors need to be closely monitored and long-term follow-up is recommended.
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Affiliation(s)
- Suzan A AlKhater
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
| | - Hala M Al Moaigel
- Department of Pediatrics, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
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8
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Severe Disfiguring Scalp and Facial Oedema due to Henoch–Schönlein Purpura in a Child. Case Rep Pediatr 2020; 2020:8823611. [PMID: 33005469 PMCID: PMC7509540 DOI: 10.1155/2020/8823611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/05/2020] [Accepted: 08/29/2020] [Indexed: 11/23/2022] Open
Abstract
Henoch–Schönlein purpura is a small vessel vasculitis that usually presents with palpable purpura, arthritis, abdominal pain, and nephritis. Subcutaneous oedema of dependent areas is common; however, oedema in the scalp is extremely rare especially in children older than two years. Here, we report a child with massive disfiguring scalp and facial oedema due to Henoch–Schönlein purpura. An eight-year-old boy presented with characteristic palpable purpuric rash and extensive disfiguring scalp and facial swelling for five days. He complained of blurred vision, vomiting, and severe headache on the day of admission. Examination revealed an ill child with extensive oedema of the face and scalp that was tender on palpation. His blood pressure was above the 99th percentile, and he had exaggerated deep tendon reflexes and extensor plantar responses. All biochemical investigations including renal function tests were normal. Noncontrast CT head showed normal brain, with marked soft tissue swelling of the scalp. Ultrasonography showed soft tissue oedema within and surrounding facial muscles without evidence of neck vessel compression. Urine analysis revealed microscopic haematuria on day 14 of the illness, and immunohistochemical staining of renal biopsy confirmed Henoch–Schönlein purpura nephritis. In conclusion, this case report presents a child with severe, disfiguring scalp and facial oedema due to Henoch–Schönlein purpura. It highlights that severe subcutaneous oedema of Henoch–Schönlein purpura can involve any part of the body not limiting to dependent areas.
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9
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic Bullous IgA Vasculitis (Schönlein-Henoch purpura), Does it Have a Worse Prognosis? REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30195-9. [PMID: 32893147 DOI: 10.1016/j.reuma.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/17/2020] [Accepted: 07/08/2020] [Indexed: 06/11/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, España
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10
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Zhang LH, Lan T, He D, Wen SL, Tong H. A challenging case on diagnosing Henoch–Schönlein purpura. EUR J INFLAMM 2020. [DOI: 10.1177/2058739220929580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Henoch–Schönlein purpura (HSP) could involve multiple organs, including gastrointestinal tract. It is commonly observed in children, but occasionally also in the elderly. It is challenging to diagnose HSP with delayed purpura. Herein, we report an elderly with HSP, whose non-thrombocytopenic purpura erupted more than 1 month after the first onset of abdominal pain.
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Affiliation(s)
- Lin-Hao Zhang
- Lab of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Division of Peptides Related with Human Diseases, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Tian Lan
- Lab of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Division of Peptides Related with Human Diseases, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Du He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, China
| | - Shi-Lei Wen
- Department of Human Anatomy, West China School of Basic Medical Sciences and Forensic Medicine, Sichuan University, Chengdu, China
| | - Huan Tong
- Lab of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
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11
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Du L, Wang P, Liu C, Li S, Yue S, Yang Y. Multisystemic manifestations of IgA vasculitis. Clin Rheumatol 2020; 40:43-52. [PMID: 32557258 DOI: 10.1007/s10067-020-05166-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 01/27/2023]
Abstract
Immunoglobulin A vasculitis (IgAV), also known as Henoch-Schönlein Purpura, is one of the most common kind of systemic vasculitis in children, and due to the involvement of small blood vessels throughout the body, this disease can cause a variety of symptoms in different organs. Our aim was to review the data on various systemic manifestations of IgAV. A research of the literature was performed in PubMed database, utilizing the MeSH terms "IgA vasculitis" and "Henoch Schönlein Purpura". According to the predetermined structure of the manuscript, we extracted and sorted out the relevant data. Clinically, almost all the patients will present with palpable skin purpura, together with arthritis, gastrointestinal tract involvement, or kidney damage. Other rare systemic manifestations include neurological symptoms, scrotal involvement, and cardiopulmonary disease. When uncommon complications occur, patients may be misdiagnosed as other diseases, thus delaying treatment. Although the course of IgAV is mostly self-limited, misdiagnosis can also lead to a poor prognosis. A comprehensive awareness to the clinical manifestations of IgAV is the necessary prerequisite for its timely diagnosis. Prompt diagnosis and adequate treatment are essential for optimal results.
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Affiliation(s)
- Lina Du
- Department of Chinese Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Panpan Wang
- Department of Chinese Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Chang Liu
- Department of Chinese Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Shaojing Li
- Department of Chinese Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Shuang Yue
- Department of Chinese Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Yan Yang
- Department of Chinese Medicine, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, No. 56 Nanlishi Road, Beijing, 100045, China.
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12
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Ramelli V, Rinoldi PO, Bianchetti MG, Lava SAG, Ramelli GP, Milani GP. Dapsone in immunoglobulin A-associated vasculitis. Eur J Pediatr 2019; 178:1913-1914. [PMID: 31630232 DOI: 10.1007/s00431-019-03472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 07/24/2019] [Accepted: 09/11/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Vera Ramelli
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Pietro O Rinoldi
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Mario G Bianchetti
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois and University of Lausanne, 1010, Lausanne, Switzerland.
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Gian Paolo Ramelli
- Pediatric Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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13
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Watanabe T, Tsukano S. Blistering eruptions with tissue eosinophilia in a child with IgA vasculitis. Clin Case Rep 2018; 6:1422-1425. [PMID: 30147875 PMCID: PMC6099028 DOI: 10.1002/ccr3.1631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 11/09/2022] Open
Abstract
We present a child with bullous IgA vasculitis. Because skin biopsy showed epidermal vesicles with neutrophil infiltration and leukocytoclastic vasculitis in all layers of the dermis, with IgA deposits and tissue eosinophilia, extensive dermal infiltration of neutrophils may have led to both blistering eruptions and tissue eosinophilia in our patient.
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Affiliation(s)
- Toru Watanabe
- Department of PediatricsNiigata City General HospitalNiigata CityJapan
| | - Shinya Tsukano
- Department of PediatricsNiigata City General HospitalNiigata CityJapan
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14
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Lava SAG, Milani GP, Fossali EF, Simonetti GD, Agostoni C, Bianchetti MG. Cutaneous Manifestations of Small-Vessel Leukocytoclastic Vasculitides in Childhood. Clin Rev Allergy Immunol 2018; 53:439-451. [PMID: 28836099 DOI: 10.1007/s12016-017-8626-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In childhood, cutaneous small-vessel vasculitides include Henoch-Schönlein syndrome, a systemic vasculitis, and Finkelstein-Seidlmayer syndrome, a skin-limited vasculitis. Both Henoch-Schönlein and Finkelstein-Seidlmayer syndromes are seen more frequently in white or Asian compared with black children and occur especially in winter and spring with a male-to-female ratio of approximately 2:1. In everyday clinical practice, both conditions are diagnosed on clinical grounds without histological confirmation. The characteristic cutaneous hallmarks of Henoch-Schönlein syndrome include a purpuric rash in all and a subcutaneous edema in approximately every second case, which are often preceded by non-specific red or pink macular elements that mimic a non-itching urticarial rash. Recent data point out that Henoch-Schönlein children often present further cutaneous findings such as Köbnerization, Rumpel-Leede capillary fragility phenomenon, and blistering eruptions. Children with Finkelstein-Seidlmayer syndrome are usually ≤24 months of age and not ill-appearing. They present with (a) large, round, red to purpuric plaques (often with a targetoid appearance) predominantly over the cheeks, ears, and extremities and (b) often tender non-pitting edema of the distal extremities, ears, and face (without pruritus). Both in Henoch-Schönlein syndrome and Finkelstein-Seidlmayer syndrome, there is often scrotal involvement. The cutaneous findings remit without sequelae within 2 months in Henoch-Schönlein and 3 weeks in Finkelstein-Seidlmayer syndrome.
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Affiliation(s)
- Sebastiano A G Lava
- Department of Pediatrics, University Children's Hospital of Bern, Inselspital, Bern, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Emilio F Fossali
- Pediatric Emergency Department, Università degli Studi di Milano, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo D Simonetti
- Pediatric Department of Southern Switzerland, San Giovanni Hospital, 6500, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Carlo Agostoni
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Mario G Bianchetti
- Pediatric Department of Southern Switzerland, San Giovanni Hospital, 6500, Bellinzona, Switzerland.
- Università della Svizzera Italiana, Lugano, Switzerland.
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15
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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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16
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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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17
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Milani GP, Lava SAG, Ramelli V, Bianchetti MG. Prevalence and Characteristics of Nonblanching, Palpable Skin Lesions With a Linear Pattern in Children With Henoch-Schönlein Syndrome. JAMA Dermatol 2017; 153:1170-1173. [PMID: 28678983 DOI: 10.1001/jamadermatol.2017.2105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Linear nonblanching skin lesions are thought to occur very rarely in patients with Henoch-Schönlein syndrome. Objective To examine the prevalence and characteristics of linear nonblanching skin lesions in children with Henoch-Schönlein syndrome. Design, Setting, and Participants A prospective case series was conducted at the ambulatory practice of a hospitalist between January 1, 2010, and December 31, 2015, among 31 consecutive children with Henoch-Schönlein syndrome. Participants Thirty-one consecutive children affected with Henoch-Schönlein syndrome who were from 3.0 to 12.0 years of age (median age, 6.2 years). Main Outcome and Measures Children with Henoch-Schönlein syndrome underwent a careful, structured skin examination established in advance with emphasis on the presence of palpable lesions with a linear pattern. Results Among the 31 children in the study (12 girls and 19 boys; median age, 6.2 years [range, 3.0-12.0 years]), 8 (26%) had linear lesions on the legs, groin, waistline, wrists, or forearms. Patients with or without linear lesions did not differ significantly with respect to sex, age, and cutaneous, abdominal, articular, or renal involvement. Conclusions and Relevance This study illustrates the prevalence and characteristics of linear skin lesions in patients with Henoch-Schönlein syndrome. Patients with symptoms suggestive of this vasculitis should be evaluated for the presence of nonblanching, palpable lesions with a linear pattern.
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Affiliation(s)
- Gregorio P Milani
- Pediatric Unit, Fondazione Ca' Granda Ospedale Maggiore Policlinico and Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Sebastiano A G Lava
- Department of Pediatrics, University Children's Hospital of Bern, Inselspital, Bern, Switzerland
| | - Vera Ramelli
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
| | - Mario G Bianchetti
- Pediatric Department of Southern Switzerland, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
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18
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Rosti G, Milani GP, Laicini EA, Fossali EF, Bianchetti MG. Liver chemistry in new-onset Henoch-Schönlein syndrome. Ital J Pediatr 2017; 43:85. [PMID: 28934973 PMCID: PMC5609076 DOI: 10.1186/s13052-017-0405-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 09/13/2017] [Indexed: 11/23/2022] Open
Abstract
Background Henoch-Schönlein syndrome is a systemic small-vessel leukocytoclastic vasculitis that usually present with cutaneous, gastrointestinal, articular and renal manifestations. Little is known on liver involvement in this syndrome. This study investigated liver chemistry and creatine kinase in Henoch-Schönlein children. Case presentation Alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, lactate dehydrogenase, total bilirubin, prothrombin time and creatine kinase were assessed in 75 consecutive pediatric patients (41 boys and 34 girls aged from 2.9 to 17 years) with new-onset Henoch-Schönlein syndrome. Mildly altered values were found in 7 (9%) patients (5 boys and 2 girls aged from 3.3 to 17 years). In the mentioned cases, all tests returned to normal at a 2–4-week follow-up. Conclusions This preliminary study points out that altered and self-remitting liver parameters occur in approximately 10% of children with Henoch-Schönlein syndrome.
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Affiliation(s)
- Giulia Rosti
- Pediatric Emergency Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gregorio P Milani
- Pediatric unit, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via della Commenda 9, 20121, Milan, Italy.
| | - Emanuela A Laicini
- Pediatric Emergency Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emilio F Fossali
- Pediatric Emergency Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario G Bianchetti
- Pediatric Emergency Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Pediatric Department of Southern Switzerland, Bellinzona, Switzerland
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19
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Cattalini M, Soliani M, Caparello MC, Cimaz R. Sex Differences in Pediatric Rheumatology. Clin Rev Allergy Immunol 2017; 56:293-307. [DOI: 10.1007/s12016-017-8642-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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