Terminal ileitis induced by Henoch-Schonlein purpura that presented as acute appendicitis: a case report

Effective treatment with intravenous immunoglobulin for Henoch-Schönlein purpura with refractory gastrointestinal symptoms in an adolescent: A CARE-compliant case report

RATIONALE

This article presents a complex case of refractory Henoch-Schönlein purpura (HSP), initially manifesting with complex gastrointestinal (GI) symptoms, and discusses diagnostic and therapeutic challenges encountered. It aims to enhance understanding of the disease and provide evidence for the potential efficacy of intravenous immunoglobulin (IVIG) treatment in this condition.

PATIENT CONCERNS

A 16-year-old male patient presented with persistent abdominal pain, nausea, vomiting, and constipation for 8 days, leading to hospital admission.

DIAGNOSES

Establishing a definitive diagnosis was challenging initially due to the absence of typical petechiae. However, the appearance of characteristic petechiae subsequently confirmed the diagnosis of HSP.

INTERVENTIONS

Initial treatment with methylprednisolone sodium succinate for 3 days failed to elicit improvement. Subsequently, IVIG was introduced as a combination therapy.

OUTCOMES

Following the combined administration of IVIG, the patient experienced complete resolution of abdominal pain, petechiae, and arthralgia within 4 days.

LESSONS

This case highlights the importance of considering HSP in the differential diagnosis of patients with complex GI symptoms. Furthermore, it suggests that IVIG may be a valuable therapeutic option for HSP patients with refractory GI symptoms. High-quality comparative trials are needed to establish more definitive evidence for the effectiveness of IVIG and to develop specific treatment guidelines.

Terminal ileitis: a rare gastrointestinal manifestation of IgA vasculitis in a child

A girl in middle childhood was referred to the paediatric surgical team with acute colicky abdominal pain and bile-stained vomiting. This was preceded by a viral illness. Investigations revealed raised inflammatory markers, and imaging of the abdomen demonstrated ileal and jejunal thickening. Concerns were raised regarding whether she had inflammatory bowel disease. Endoscopy revealed gastritis and duodenitis, and colonoscopy was unremarkable. Video capsule endoscopy demonstrated ulcers in the jejunum and ileum.On day 8 of admission, she developed a symmetrical purpuric rash over both ankles leading to the diagnosis of Henoch-Schonlein-related ileitis. Multidisciplinary team working led to appropriate management of the patient and avoided surgery. Video capsule endoscopy enabled visualisation of the small bowel. She was managed with 5 days of methylprednisolone followed by oral steroids. She made a good recovery with no sequelae. This case highlighted that terminal ileitis is a rare complication of IgA vasculitis with a good prognosis.

Delayed diagnosis of abdominal Henoch-Schonlein purpura in children: A case report

BACKGROUND

For children with abdominal Henoch-Schonlein purpura presenting abdominal pain as an initial symptom and severe clinical manifestations, but without purpura appearance on the skin, the diagnosis and treatment are relatively difficult. This study summarized the characteristics of this group of patients by literature review and provided additional references for further refinement of glucocorticoid therapy in this vasculitis.

CASE SUMMARY

A 6-year-old girl presented mainly with repeated abdominal pain and had received short-term out-of-hospital treatment with hydrocortisone. On day 7 after onset, gastroscopy revealed chronic non-atrophic gastritis and erosive duodenitis without purpuric rash, and no obvious resolution of the abdominal pain was found after treatment against infection and for protection of gastric mucosa. On day 14 the inflammatory indices continued to rise and the pain was relieved after enhanced anti-infective therapy, but without complete resolution. On day 19, the patient presented with aggravated abdominal pain with purplish-red dots on the lower limbs, by which Henoch-Schonlein purpura was confirmed. After 5 d of sequential treatment with methylprednisolone and prednisone, abdominal pain disappeared and she was discharged.

CONCLUSION

Henoch-Schonlein purpura-related rash may appear after long-term abdominal pain, and should be distinguished from acute and chronic gastrointestinal diseases at the early stage without typical rash. For bacterial infection-induced Henoch-Schonlein purpura, glucocorticoid therapy alone without clearing the infection may not relieve symptoms.

Development and Validation of a Differential Diagnosis Model for Acute Appendicitis and Henoch-Schonlein Purpura in Children

Objective: To study and develop a predictive model for the differential diagnosis of acute appendicitis (AA) and Henoch-Schonlein purpura (HSP) in children and to validate the model internally and externally. Methods: The complete data of AA and HSP cases were retrospectively analyzed and divided into internal and external verification groups. SPSS software was used for single-factor analysis and screening of independent variables, and R software was used for the development and verification of the diagnostic model. Lasso regression analysis was used to screen predictors and Lasso-logistic regression model was constructed, and K-fold cross-validation was used for the internal verification. In addition, nonfever patients were selected for model development and validation in the same way. Receiver operating characteristic (ROC) curves and calibration curves were drawn, respectively, to evaluate the 2 models. Results: Internal development and validation of the model showed that fever, neutrophil ratio (NEUT%), albumin (ALB), direct bilirubin (DBIL), C-reactive protein (CRP), and K were predictive factors for the diagnosis of HSP. The model was presented in the form of a nomogram, and the area under ROC curve of the development group and verification group was 0.9462 (95% confidence interval [CI] = 0.9402-0.9522) and 0.8931 (95% CI = 0.8724-0.9139), respectively. In the model of patients without fever, NEUT%, platelets (PLT), ALB, DBIL, alkaline phosphatase (ALP), CRP, and K were predictive factors for the diagnosis of HSP, and the area under ROC curve of the development group and verification group was 0.9186 (95% CI = 0.908-0.9293) and 0.8591 (95% CI = 0.8284-0.8897), respectively. Conclusion: In this study, 2 diagnostic models were constructed for fever or not, both of which had good discrimination and calibration, and were helpful to distinguish AA and HSP in children.

Terminal Ileitis as the Presenting Feature of Henoch-Schönlein Purpura in a 22-Year-Old Male

Henoch-Schönlein purpura (HSP) is a self-limited vasculitis that affects children and the preadolescent population. It is characterized by the deposition of immunoglobulin A immune complexes in tissues leading to palpable purpura, abdominal pain, arthritis, and nephropathy. When it occurs in adults, the clinical manifestations are the same; however, adults present with more significant renal involvement. While abdominal pain is the most common gastrointestinal (GI) manifestation, it can also present with GI bleeding, intussusception, bowel ischemia, and bowel perforation. Here, we report the case of a 22-year-old gentleman who presented with nonspecific GI complaints such as nausea, vomiting, and loose stools. He was later found to have terminal ileitis preceding the onset of rash, the biopsy of which confirmed HSP. Terminal ileitis is a rare GI manifestation of HSP and is not very commonly reported in the literature.

Adult-Onset Immunoglobulin A Vasculitis

Immunoglobulin A vasculitis (IgAV), formerly Henoch–Schönlein purpura vasculitis, is a vasculitis commonly seen in children and only rarely described in adult patients. IgAV can present as arthralgia, rash, discolored urine, acute kidney injury, and gastrointestinal symptoms. We present a case of a 56-year-old man who presented with 1 month of worsening abdominal pain followed by a bilateral lower extremity rash. Laboratory evaluation indicated an acute kidney injury. Computed tomography and colonoscopy revealed terminal ileitis while kidney biopsy confirmed a diagnosis of IgAV.

Acute Terminal Ileitis in Children: A Retrospective Study in a Pediatric Emergency Department

OBJECTIVES

This study aims to describe the clinical presentation and outcome of patients diagnosed with acute ileitis in our pediatric emergency department.

METHODS

We performed a retrospective study of all patients diagnosed with terminal ileitis by abdominal ultrasonography findings in our pediatric emergency department, over the years 2013 and 2014. Patients with previous diagnosis of inflammatory bowel disease (IBD) were excluded. Data collected were clinical, radiological, and laboratory data at diagnosis; outcome including hospitalization care; and outpatient follow-up in pediatric gastroenterology and/or primary care.

RESULTS

A total of 20 cases were retrieved and studied. All of them presented with abdominal pain, 65% located in the right lower quadrant. Leukocyte count, C-reactive protein, and fibrinogen levels (means, 12,889; 4/μL; 50.1 mg/L; and 575 mg/dL, respectively) were above normal range. Hemoglobin and platelet count were normal. A microbial cause of ileitis was found in 3 cases (Yersinia enterocolitica, Campylobacter jejuni, and Adenovirus). Nine patients were referred to a pediatric gastroenterology unit. No cases of IBD were found.

CONCLUSIONS

Acute ileitis is a rare and benign cause of abdominal pain in the pediatric emergency department. The main intervention on initial assessment is to rule out potentially severe causes of abdominal pain that could benefit of an emergency surgical procedure. In contrast with adults and adolescents, acute ileitis in children does not have a clear association with development of IBD.

Pathogenesis and gastrointestinal manifestations of IgA vasculitis

Immunoglobulin A (IgA) vasculitis is a form of leukocytoclastic vasculitis of small vessels, clinically characterized by purpuric skin lesions unrelated to any underlying coagulopathy, gastrointestinal manifestations, arthritis and/or arthralgia and renal involvement. The etiology remains unknown, but various triggers including infections, vaccination, drugs and malignancy have been hypothesized to be associated with the development of IgA vasculitis. Although the pathogenesis has not been completely figured out, genetic predisposition, aberrant glycosylation of the hinge region of IgA1, activated complements, cytokines and chemokines were put out to play important roles in the immunopathogenesis of IgA vasculitis. Histologically, the infiltration of small blood vessels with polymorphonuclear leukocytes and the presence of leukocytoclasia are typical pathologic findings in IgA vasculitis. The treatment is usually supportive, and advanced treatments include immunosuppressive drugs (glucocorticoids and immunosuppressive agents), hemopurification and surgery. The prognosis depends on the age at the disease onset and the renal involvement or not.