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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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Zhang Q, Guo Q, Gui M, Ren Z, Hu B, Lu L, Deng F. Henoch-Schönlein purpura with acute pancreatitis: analysis of 13 cases. BMC Pediatr 2018; 18:159. [PMID: 29751784 PMCID: PMC5948829 DOI: 10.1186/s12887-018-1142-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura is a common small vessel vasculitis in children. Acute pancreatitis rarely presents as a complication of Henoch-Schönlein purpura and has not been well characterized. METHODS We retrospectively reviewed 13 cases of Henoch-Schönlein purpura with acute pancreatitis among 3212 patients who attended our hospital between January 2003 and June 2016 and analyzed their clinical characteristics, laboratory findings, imaging findings, treatment and overall prognosis. RESULTS All patients had abdominal manifestations, including significant abdominal pain (13/13), vomiting (9/13), abdominal distension (3/13) and melena (6/13). Serum amylase level significantly increased in all patients, and urine amylase was increased in 7 cases (7/10). However, increased urine lapse was only noted in 2 cases (2/5), and diffuse swelling of the pancreas was seen in 2 cases (2/13) by abdominal ultrasonography. Although all patients had typical skin purpura (13/13), 5 patients (5/13) with acute pancreatitis initially experienced acute abdominal pain in clinical onset of Henoch-Schönlein purpura. Glucocorticoid therapy was effective in alleviating abdominal symptoms of Henoch-Schönlein purpura patients with acute pancreatitis. All patients were in good general condition without any abdominal complications 6-12 months after discharge. CONCLUSIONS Acute pancreatitis is rarely observed in Henoch-Schönlein purpura children and has no specific clinical features that differentiate it from abdominal manifestations of Henoch-Schönlein purpura. Therefore, in Henoch-Schönlein purpura patients with severe abdominal pain, serum amylase levels should be assessed to confirm the diagnosis of acute pancreatitis. Early diagnose of Henoch-Schönlein purpura with acute pancreatitis and treatment timely was very important for good clinical outcomes.
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Affiliation(s)
- Qin Zhang
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, 19th Floor of Medicine and Medical Tech Building, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Qi Guo
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, 19th Floor of Medicine and Medical Tech Building, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Ming Gui
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, 19th Floor of Medicine and Medical Tech Building, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Zhenhua Ren
- Department of Anatomy, School of Basic Medicine, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Bo Hu
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, 19th Floor of Medicine and Medical Tech Building, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Ling Lu
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, 19th Floor of Medicine and Medical Tech Building, 218 Jixi Road, Hefei, 230022, Anhui, China
| | - Fang Deng
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, 19th Floor of Medicine and Medical Tech Building, 218 Jixi Road, Hefei, 230022, Anhui, China.
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Nishiwada S, Nakamura S, Tanaka T, Kirihataya Y, Nezu D, Sawa N, Fujita N, Ikegami H, Yoshimura A. Ileo-ileal fistula with severe malnutrition caused by strangulated ileus surgery while preserving ischemic ileum: A case report. Int J Surg Case Rep 2018; 43:4-8. [PMID: 29414503 PMCID: PMC5908384 DOI: 10.1016/j.ijscr.2018.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/13/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Entero-enteric fistulas are rare complications that occur in patients with inflammatory bowel disease and other intestinal diseases. In this report, we present an ileo-ileal fistula accompanied by severe malnutrition caused by strangulated ileus surgery while preserving the ischemic ileum in a very elderly patient. CASE PRESENTATION A 90-year-old woman underwent emergency surgery without bowel resection for strangulated ileus in another hospital. Minor abdominal pain and slight fever persisted after surgery. She lost weight, losing approximately 10 kg within half a year. She gradually became difficult to move due to dyspnea upon exertion and generalized edema and visited at our hospital. Pleural effusions, ascites and severe malnutrition were observed. An elastic hard mass with mild tenderness was palpated in her abdomen. Computed tomography showed a loop-like ileum and ileo-ileal fistula with adjacent fat stranding. We performed a partial small bowel resection. The resected specimen demonstrated an ileo-ileal fistula and circumferential ulceration in the loop-like adhesion. After the operation, the nutrition status was resolved immediately without any medications. DISCUSSION In cases of strangulated ileus, there are no deterministic criteria for evaluating intestinal blood flow. This is the first report of ileo-ileal fistula onset after surgery for strangulated ileus without intestinal resection. Furthermore, this fistula caused severe malnutrition duo to chronic inflammation, ulcer formation, and the blind-loop syndrome. CONCLUSIONS When preserving the intestinal tract in the operation of strangulated ileus, the occurrence of entero-enteric fistulas should be considered. Since malnutrition in the elderly is a serious problem, it should be treated promptly.
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Affiliation(s)
- Satoshi Nishiwada
- Department of Surgery, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Shinji Nakamura
- Department of Surgery, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Tetsuya Tanaka
- Department of Surgery, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Yuki Kirihataya
- Department of Surgery, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan; Department of General Internal Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Daiki Nezu
- Department of Surgery, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Nobuhiro Sawa
- Department of General Internal Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Naoki Fujita
- Department of General Internal Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Haruka Ikegami
- Department of General Internal Medicine, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
| | - Atsushi Yoshimura
- Department of Surgery, Minami-Nara General Medical Center, 8-1 Fukugami, Oyodo-cho, Yoshino, 638-8551 Nara, Japan.
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Abstract
Henoch-Schönlein purpura (HSP) is the most common vasculitis in children. It is a disorder of the inflammatory cascade leading to immunoglobulin A deposition and leukocytoclastic vasculitis of small vessels of skin, kidneys, joints, and gastrointestinal (GI) tract. A wide variety of GI manifestations are seen in ∼50% to 75% of patients with HSP. Diffuse colicky abdominal pain is the most common GI symptom. The small bowel is the most frequently involved GI site. Intussusception is rare but is the most common surgical complication. We report the case of a 2-year-old girl with a 5-day history of abdominal pain followed by a palpable purpuric rash. Her urinalysis, complete blood cell count, and tests of renal function were normal. An acute abdominal series was unremarkable initially, and abdominal ultrasound imaging showed ascites and thickened small bowel loops. She was diagnosed with HSP. The abdominal pain worsened, and an abdominal computed tomography scan demonstrated distal small bowel wall thickening and pneumatosis intestinalis in the descending colon. She was started on total parenteral nutrition and antibiotics and placed on bowel rest. She was given 2 mg/kg of intravenous immunoglobulin. Her abdominal pain gradually improved over the next week, and a repeat computed tomography scan showed significant improvement of the small bowel wall thickening and pneumatosis. The purpuric rash improved, and her abdominal pain resolved. We report a case of HSP and pneumatosis intestinalis, an association that has not been reported previously.
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Affiliation(s)
- Ayesha Fatima
- Pediatric Gastroenterology, Department of Pediatrics, and
| | - Donald Paul Gibson
- Department of Diagnostic Radiology, Beaumont Children's Hospital and Oakland University William Beaumont School of Medicine, Rochester, Michigan
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Park SJ, Suh JS, Lee JH, Lee JW, Kim SH, Han KH, Shin JI. Advances in our understanding of the pathogenesis of Henoch-Schönlein purpura and the implications for improving its diagnosis. Expert Rev Clin Immunol 2014; 9:1223-38. [PMID: 24215411 DOI: 10.1586/1744666x.2013.850028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Henoch-Schönlein purpura (HSP) is a leukocytoclastic vasculitis classically characterized by palpable purpura, arthritis, abdominal pain and renal disease. In this article, we summarize our current understanding of the pathogenesis of HSP and the implications for improving its diagnosis. Although the pathogenesis of HSP is not fully understood yet, exciting new information has emerged in recent years, leading to a better understanding of its pathogenesis. Here, we discuss genetic predisposition, immunoglobulins with a particular emphasis on IgA1, activated complements, cytokines and chemokines, abnormal coagulation and autoantibodies in the underlying pathogenic mechanisms. Finally, diagnostic criteria for HSP developed by institutions such as the American College of Rheumatology and the European League against Rheumatism/Paediatric Rheumatology European Society were proposed to improve early detection and diagnosis.
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Affiliation(s)
- Se Jin Park
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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Chen O, Zhu XB, Ren H, Wang YB, Sun R. The imbalance of Th17/Treg in Chinese children with Henoch-Schonlein purpura. Int Immunopharmacol 2013; 16:67-71. [PMID: 23562836 DOI: 10.1016/j.intimp.2013.03.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/05/2013] [Accepted: 03/15/2013] [Indexed: 12/23/2022]
Abstract
Interleukin 17 (IL-17)-producing T helper (Th17) cells and CD4(+)CD25(+) regulatory T (Treg) cells are two new T-cell subsets that are thought to be critically involved in mediating and regulating autoimmune responses. The imbalance of Th17/Treg cells has been implicated in a wide range of autoimmune disorders. The aim of our study was to determine whether the Th17/Treg balance was abnormal in children with Henoch-Schonlein Purpura (HSP). We examined twenty-three new-onset HSP patients and eighteen healthy children. The frequency of Th17 cells and the IL-17 concentration were higher in HSP patients than in healthy controls. The frequency of Treg cells and the interleukin 10 (IL-10) concentration were lower in HSP patients than in healthy controls. Compared to healthy controls, HSP patients exhibited an increase in the ratio of Th17/Treg. The Th17/Treg ratio was positively correlated with the erythrocyte sedimentation rate (ESR), kidney lesions and the clinical symptom of the presence of more than two organ systems with lesions. However, the ratio had no correlation with anti-streptolysin O (ASO) or complement 3 (C3) levels. These results indicate that a Th17/Treg imbalance exists in HSP, and it appears to be closely related to the disease onset.
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Affiliation(s)
- Ou Chen
- Division of Nursing Management, Nursing School, Shandong University, Jinan 250012, China
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Chen O, Zhu XB, Ren P, Wang YB, Sun RP, Wei DE. Henoch Schonlein Purpura in children: clinical analysis of 120 cases. Afr Health Sci 2013; 13:94-9. [PMID: 23658574 DOI: 10.4314/ahs.v13i1.26] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Henoch Schonlein Purpura (HSP) is a systemic vasculitic disease which is common in children. It is very important to understand the clinical features of this disease for doctors and nurses. OBJECTIVES To study the clinical characteristics of HSP in children. METHODS Collect the clinical data of the HSP children, and analyze the clinical characteristics of these HSP patients. RESULTS The ratio of M:F was 1.9:1. The mean age was 6.6 ± 1.6 years. The typical onset seasons were spring, winter and autumn. Infection and food allergy were the main etiological factors. The first symptom was skin purpura and these purpura mainly concentrated the lower extremities and buttocks. The dominant digestive clinical features were abdominal pains and vomiting. The knee joint and ankle joint were most frequently affected. The typical kidney symptoms were microscopic hematuria and albuminuria. An increased ESR was reported in 68 patients (56.7%). Serum C3 decreased in 13 cases (10.8%). ASO titer was higher in 57 children (47.5%). CONCLUSION There were gender, season and area differences for the HSP patients. The etiological factors were diverse. HSP patients could have various clinical symptoms and rare complications.
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Affiliation(s)
- O Chen
- Department of Pediatrics, Qilu Hospital, Shandong University, #107 West Wenhua Road, Jinan 250012, China
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Lemerman HB, Khaitan A, Lemmon M, Serwint JR, Hourigan SK. A case of Henoch-Schönlein purpura presenting with a gastrocutaneous fistula. Clin Pediatr (Phila) 2011; 50:978-80. [PMID: 21098533 DOI: 10.1177/0009922810384727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gastrointestinal manifestations of Henoch-Schonlein Purpura. Dig Dis Sci 2008; 53:2011-9. [PMID: 18351468 DOI: 10.1007/s10620-007-0147-0] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 11/24/2007] [Indexed: 12/11/2022]
Abstract
Henoch-Schonlein Purpura (HSP) is the most common systemic vasculitis in childhood. The diagnostic criteria include palpable purpura with at least one other manifestation -- abdominal pain, IgA deposition, arthritis or arthralgia, or renal involvement. Immune complex deposits result in necrosis of the wall of small- and medium-sized arteries with infiltration of tissue by neutrophils and deposition of nuclear fragments, a process called leukocytoclastic vasculitis (LCV). It is often associated with infections, medications, or tumors. It may coexist with or mimic Crohn's disease. Periumbilical and epigastric pain worsens with meals, from bowel angina. Bleeding is usually occult or, less commonly, associated with melena. Intussusception, the most common surgical complication, is usually ileo-ileo or ileo-colic. Perforations, usually ileal, may occur spontaneously or be associated with intussusception. Ultrasound, recommended as the first diagnostic test, and CT scans may show intussusception and asymmetric bowel wall thickening mainly involving the jejunum and ileum. There are a range of endoscopic findings including gastritis, duodenitis, ulceration, and purpura, with the second portion of the duodenum characteristically being involved more than the bulb. Intestinal biopsies show IgA deposition and LCV in the submucosal vessels. Superficial biopsies may show inflammation, ulceration, edema, hemorrhage, and vascular congestion, presumably due to vasculitis-induced mucosal ischemia. The efficacy of corticosteroids in preventing severe complications or relapses is controversial. The majority of patients, however, improve spontaneously.
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Abstract
Schönlein-Henoch syndrome is a form of systemic small-vessel vasculitis, characterised by vascular and/or mesangial immunoglobulin A1 deposits. The main clinical manifestations are vascular purpura, predominating on the lower limbs, and articular, gastrointestinal and renal symptoms. Pulmonary, cardiac, genital and neurological symptoms have also be observed. The syndrome usually affects children, whereas it is rare in adults. The frequency of renal involvement varies between individual studies (from 20 to 100%). Renal manifestations are usually mild and transient, although chronic nephropathies may occur. Overall, an estimated 2% of children with Schönlein-Henoch purpura progress to renal failure and up to 20% of children with nephritis treated in specialised centres require haemodialysis. The renal prognosis appears to be worse in adults. Aetiological investigations are required, as a triggering factor is found in approximately half the patients (e.g. viral, bacterial and parasitic infections, drugs, toxins, systemic diseases and cancer). Dapsone has beneficial effects on cutaneous, gastrointestinal and articular manifestations in adults, especially those with chronic forms. Corticosteroids may be useful for refractory abdominal pain. Methylprednisolone pulse therapy, immunosuppressive drugs (e.g. cyclophosphamide and azathioprine), plasma exchange and polyclonal immunoglobulin therapy are beneficial in very rare life-threatening forms of the disease and in rare instances where renal function is compromised.
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Affiliation(s)
- G Rostoker
- Service de Néphrologie et de Dialyse, Centre Hospitalier Privé Claude Galien, Quincy Sous Senart, France
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Abstract
Gastrointestinal involvement occurs in approximately two thirds of children with Henoch-Schönlein Purpura (HSP) and usually is manifested by abdominal pain. Abdominal symptoms precede the typical purpuric rash of HSP in 14-36%; the symptoms may mimic an acute surgical abdomen and result in unnecessary laparotomy. Major complications of abdominal involvement develop in 4.6% (range 1.3-13.6%), of which intussusception is by far the most common. The intussusceptum is confined to the small bowel in 58%; its frequent inaccessibility to demonstration by contrast enema means that ultrasonography is the investigation of choice. Ultrasonography complements serial clinical assessment, clarifies the nature of the gastrointestinal involvement and reduces the likelihood of unnecessary surgery. Bowel ischaemia and infarction, intestinal perforation, fistula formation, late ileal stricture, acute appendicitis, massive upper gastrointestinal haemorrhage, pancreatitis, hydrops of the gallbladder and pseudomembranous colitis are seen infrequently. Earlier diagnosis and prompt treatment of intra-abdominal complications has reduced the mortality from 40% to almost zero.
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Affiliation(s)
- C K Choong
- Department of Paediatric Surgery, Christchurch Hospital, Christchurch, New Zealand
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