Dapsone in Allergic Vasculitis: Its Use in Henoch-Schönlein Disease following Vaccination

Dapsone for Refractory Gastrointestinal Symptoms in Children With Immunoglobulin A Vasculitis

Immunoglobulin A vasculitis (IgAV) is a systemic small-vessel vasculitis. Although corticosteroids (CS) are the primary treatment for gastrointestinal manifestations associated with IgAV, some patients develop refractory or recurrent symptoms such as vomiting and abdominal pain despite CS treatment. Dapsone, a synthetic sulfone antimicrobial, has been used to treat cutaneous purpura in IgAV, but few authors have reported its use for refractory gastrointestinal symptoms. In this retrospective observational study, we describe results in 7 children with IgAV who were treated with dapsone for abdominal pain resistant to CS. Dapsone rapidly relieved abdominal pain in all 7 patients, who then were tapered off CS without relapse. Side effects of mild methemoglobinemia and hemolysis appeared to be manageable with planned monitoring and dose adjustment; a single patient who discontinued dapsone had fatigue and hypoxia associated with methemoglobinemia. No side effects were life-threatening. Dapsone may be considered as a therapeutic option for gastrointestinal symptoms refractory to CS in children with IgAV.

Successful Treatment of IgA Vasculitis With Prolonged Cutaneous Manifestation With Colchicine in a 10-Year-Old Boy

We report a 10-year-old boy with IgA vasculitis (IgAV) with prolonged cutaneous manifestations who was successfully treated with colchicine. At the age of 9, he was diagnosed as having IgAV by typical purpura, abdominal pain, and hematochezia. Initially, his severe gastrointestinal manifestation subsided by prednisolone 60 mg/day and intravenous methylprednisolone pulse therapy. However, his gastrointestinal manifestation was glucocorticoid-dependent and refractory to factor XIII concentrate, intravenous immunoglobulin G, and mycophenolate mofetil. His abdominal pain and hematochezia responded to the combination therapy with dapsone and low dose of prednisolone 5 mg/day and did not relapse even after discontinuation of dapsone. On the other hands, the effect of dapsone on his cutaneous manifestation was dose-dependent. As well dapsone had no glucocorticoid-sparing effect. Approximately 12 months after onset, colchicine treatment was started, which resulted in remission of his chronic cutaneous manifestation. After prednisolone was tapered off, his cutaneous manifestation is currently well-controlled on colchicine 0.5 mg/day without adverse events. He had never complicated by kidney involvements. In conclusion, colchicine treatment exerts a beneficial effect in IgAV patients with prolonged cutaneous manifestation refractory to multiple drugs.

Treatment of refractory IgA vasculitis with dapsone: a systematic review

IgA vasculitis, formerly known as Henoch-Schönlein purpura, is a systemic IgA-mediated vasculitis of the small vessels commonly seen in children. The natural history of IgA vasculitis is generally self-limiting; however, one-third of patients experience symptom recurrence and a refractory course. This systematic review examined the use of dapsone in refractory IgA vasculitis cases. A literature search of PubMed databases retrieved 13 articles published until June 14, 2018. The most common clinical feature was a palpable rash (100% of patients), followed by joint pain (69.2%). Treatment response within 1-2 days was observed in 6 of 26 patients (23.1%) versus within 3-7 days in 17 patients (65.4%). Relapse after treatment discontinuation was reported in 17 patients (65.4%) but not in 3 patients (11.5 %). Four of the 26 patients (15.4%) reported adverse effects of dapsone including arthralgia (7.7%), rash (7.7%), and dapsone hypersensitivity syndrome (3.8%). Our findings suggest that dapsone may affect refractory IgA vasculitis. Multicenter randomized placebo-controlled trials are necessary to determine the standard dosage of dapsone at initial or tapering of treatment in IgA vasculitis patients and evaluate whether dapsone has a significant benefit versus steroids or other medications.

Indications and efficiency of dapsone in IgA vasculitis (Henoch-Schonlein purpura): case series and a review of the literature

Immunoglobulin A (IgA) vasculitis (Henoch-Schonlein purpura (HSP)) is the most common vasculitis in children. It is characterized by purpuric rash, arthritis, gastrointestinal, and/or renal involvement. Spontaneous resolution is the typical outcome. In chronic cutaneous manifestations of IgA vasculitis, dapsone seems to show a good effectiveness. Multiple case reports and case series about dapsone in chronic IgA vasculitis are available. However, no clear evaluation of its indications, its effectiveness, or its usage guidelines (optimal dosage or duration of treatment) is available. We reviewed the published cases of IgA vasculitis treated by dapsone and compared them with 2 similar cases that we encountered. Seventeen patients (ranging from 22 months old to 16 years old) with severe or persistent clinical signs of IgA vasculitis were included. Dapsone showed good results on the resolution of cutaneous lesions but not on renal manifestations. Complications (methemoglobinemia) were observed on 1 patient. Half of the patients relapsed after treatment discontinuation. The difference between the time lapse before initiation and the duration of the treatment was not significant.Conclusion: We suggest that dapsone can have a positive effect in chronic IgA vasculitis when cutaneous manifestations last more than 6 weeks at the dosage of 1-2 mg/kg once per day during 1 week. What is Known: • IgA vasculitis or Henoch-Schonlein purpura is the most common vasculitis in children and affects mostly small vessels of the skin, kidney, and gastrointestinal tract. It resolves spontaneously in most of the cases. Exceptionally, cutaneous lesions can last several weeks. • Dapsone is a bacteriostatic antibacterial sulfonamide drug found to be effective in the treatment of some inflammatory dermatological diseases like IgA vasculitis. What is New: • Dapsone is effective against chronic purpuric lesion (> 6 weeks) at the minimal dose of 1 mg/kg/day. • Relapse occurs frequently after discontinuation but responds after a second course of treatment. A longer duration of treatment or a delay in treatment by dapsone does not seem to influence the relapse rate.

Vaccination and Risk of Childhood IgA Vasculitis

BACKGROUND AND OBJECTIVES

Immunoglobulin A vasculitis (IgAV) might develop after vaccination. However, this potential relationship is essentially based on case reports, and robust pharmaco-epidemiologic data are scarce. We aimed to investigate the effect of vaccination on short-term risk of IgAV in children.

METHODS

We enrolled children <18 years old with IgAV seen in 5 pediatric departments from 2011 to 2016. Data on vaccinations administered during the year preceding IgAV onset were collected from immunization records. With a case-crossover method and by using conditional logistic-regression analyses, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by comparing vaccine exposure during the 3-month "index period" immediately preceding IgAV onset to that during 3 consecutive 3-month "control" periods immediately before the index period. Stratifications by season, year of onset, infection history, age, sex, type, or number of vaccines were performed. Sensitivity analyses used 1-, 1.5-, or 2-month index and control periods.

RESULTS

Among 167 children (mean age: 6.7 years) enrolled, 42 (25%) received ≥1 vaccine during the year before IgAV onset. Fifteen (9%) children were vaccinated during the 3-month index period as compared with 4% to 7% during the 3 control periods. The OR for IgAV occurring within the 3 months after vaccination was 1.6 (95% CI: 0.8-3.0). Analyses of IgAV risk within 1, 1.5, or 2 months of vaccination yielded ORs of 1.4 (95% CI: 0.5-3.5), 1.4 (95% CI: 0.6-3.2), and 1.3 (95% CI: 0.6-2.6), respectively. Stratifications revealed no significant association.

CONCLUSIONS

Vaccination may not be a major etiological factor of childhood IgAV.

Adult Henoch-Schönlein Purpura with Severe Abdominal Pain Treated with Dapsone and Factor XIII Concentrate

We describe an adult patient with Henoch-Schönlein purpura who had arthralgia, severe abdominal pain, and low plasma factor XIII activity. Corticosteroids were not used because of his history of multidrug-resistant pulmonary tuberculosis. Dapsone had no immediate effect on his abdominal pain, but appeared to have some effect on the purpura and arthralgia. Marked improvement of the abdominal pain was observed immediately after the administration of factor XIII concentrate. Factor XIII concentrate may be useful for alleviating abdominal pain in Henoch-Schönlein purpura patients when corticosteroids are contraindicated

Cutaneous manifestations of gastrointestinal disease: part II

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.

Management of haemorrhagic bullous lesions in Henoch-Schonlein purpura: is there any consensus?

Henoch-Schonlein purpura (HSP) is the most common form of vasculitis affecting children. The cutaneous manifestations classically present as urticarial wheals, erythematous maculopapules, petechiae, purpura or oedema, which characteristically involve the lower extremities and buttocks. Haemorrhagic bullous lesions are a recognized but rare occurrence with HSP in children. We report a 6-year-old boy with HSP who developed extensive haemorrhagic bullae requiring dermatological referral and treatment. Scrutiny of our management and available literature reveals a lack of consensus in the management of extensive cutaneous involvement in HSP.

Schönlein-Henoch purpura during pregnancy with successful outcome for mother and newborn

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.

Atraumatic acute upper limb ischemia: a series of 64 patients in a Middle East tertiary vascular center and literature review

This paper documents the various causes of upper limb ischemia in a series of 64 Egyptian patients presenting to a tertiary referral center over a 4-year period and offers a diagnostic dissertation and review of the pertinent literature. Atraumatic upper limb ischemia is an uncommon entity. It has a broad etiology with diverse management pathways. Nineteen patients presented with severe and immediate limb-threatening ischemia. These patients underwent immediate surgical exploration: an embolus was diagnosed in 15 and thrombosis in 4. Twenty-eight patients presented with ischemia of lesser severity, allowing preoperative angiography. Of these 28 patients, 6 had an embolus, 14 had thrombosis, 4 had thoracic outlet syndrome, the remainder had miscellaneous causes. Fifteen patients had upper limb ischemia secondary to arteritis, and 2 patients with dissection of the ascending thoracic aorta presented with upper limb ischemia. Forty-seven patients underwent a surgical procedure, with a morbidity rate of 21% and mortality rate of 19%. Patients presenting with upper limb ischemia tend to have significant co-existing disease. Management of upper limb ischemia requires preoperative and/or peroperative angiography with careful application of vascular surgical expertise.

Can immunization precipitate connective tissue disease? Report of five cases of systemic lupus erythematosus and review of the literature

OBJECTIVES

To report a series of five patients who developed systemic lupus erythematosus (SLE) after immunization and review the literature on vaccine-associated connective tissue diseases and the theoretical mechanisms that could explain such an association.

METHODS

Uncontrolled retrospective analysis of cases identified sporadically over 7 years at three centers.

RESULTS

In our series of 5 patients, symptoms of SLE developed within 2 to 3 weeks after secondary immunization. All patients met American College of Rheumatology (ACR) criteria for the diagnosis of SLE. In most patients, symptoms have been persistent.

CONCLUSION

Although a coincidental association between vaccination and the onset of SLE cannot be excluded, the temporal relationship with the development of symptoms makes it immunologically plausible that vaccination triggered systemic autoimmunity in these rare cases. We propose that epidemiological studies be performed to examine this potential association in more detail to quantitate the risk and identify possible genetic risk factors.

Henoch-Schönlein purpura in children. Report of 100 patients and review of the literature

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.

Purpura in infants and children

Hemorrhage into the skin (purpura) may result from abnormalities in any of the three components of hemostasis: platelets, plasma coagulation factors, and blood vessels. The morphology, size, and distribution of the hemorrhagic lesions are helpful diagnostic features. The main causes of purpura in the newborn and the more common hemorrhagic disorders in children are reviewed.

Dapsone in rheumatoid arthritis

Dapsone, a synthetic sulfone with chemical similarities to sulfapyridine, has been used for a number of years to treat leprosy and dermatitis herpetiformis. Recently, a number of prospective, randomized, double-blind trials have shown their success in the management of rheumatoid arthritis, with dapsone being superior to placebo and comparable to chloroquine and hydroxychloroquine. Its mode of anti-inflammatory actions in rheumatoid arthritis is not clearly understood, but modulation of neutrophil activity or inhibition of neutrophil inflammatory product formation or release appear to play a role. The major limiting side effect is hemolytic anemia, which may be mitigated through careful patient selection, conservative drug dosing, close monitoring, and possibly, concurrent administration of antioxidants or cytochrome P450 inhibitors. Methemoglobinemia is another common finding among patients receiving dapsone therapy, but rarely does it result in prominent symptoms other than transient pallor. Less common adverse events to dapsone include the idiosyncratic reactions of leukopenia and agranulocytosis, cutaneous eruptions, peripheral neuropathy, psychosis, toxic hepatitis, cholestatic jaundice, nephrotic syndrome, renal papillary necrosis, severe hypoalbuminemia without proteinuria, an infectious mononucleosis-like syndrome, and minor neurological and gastrointestinal complaints. In this report, two patients with advanced rheumatoid arthritis, who were safely and effectively treated with dapsone after failure with other second-line agents, are described and the literature is reviewed. We suggest that dapsone is an effective second-line agent in the treatment of rheumatoid arthritis.

[Rheumatoid purpura in adults. Apropos of 40 cases]

Fourty cases of Henoch-Schönlein purpura in adults (21 females, 19 males--age 39 years) are reviewed [departments of nephrology (28 cases) and internal medicine (12 cases)]. Dermatological manifestations occur in 39 cases and are similar to those seen in children. Gastrointestinal involvement (23 cases) usually takes the form of abdominal pains or diarrhea; gastrointestinal haemorrhages are rare. These symptoms are less severe than in children in this review as in the literature. Joint manifestations (22 cases) disappear without sequelae. The outcome of the disease depends on the nephropathy, present in 33 patients (82.5%) (all of those of the department of nephrology (100%) and 42% of those of the department of internal medicine). In one third of cases, renal manifestation appears after the onset of the disease (until 24 months). As in the children, haematuria and proteinuria are quasi constant. The renal histopathology is a focal and segmental proliferative glomerulonephritis in 58%, with IgA deposition in the mesangium (16/21 cases). Treatment regimen includes steroïds (10 cases), combination of steroïds with immunosuppressive agents (8 cases), steroïds-immunosuppressive drugs-plasma exchange (2 cases), dapsone (1 case). Of the 26 patients followed for 27 months, 11 are in clinical remission, 7 have persistent proteinuria or hematuria, and 8 have chronic renal failure after 3 months to 13 years. In this review, renal insufficiency, hypertension and young age predict a poor outcome. This severe outcome is probably explained by the fact that most of our patients referred to renal units. Unlike in the children, in which the affection is usually an acute illness, Henoch-Schönlein purpura in the adults seems to be a chronic disease, with prognosis depending on the nephropathy.

Cutaneous vasculitis and cutaneous vasculopathies

Cutaneous involvement may occur with virtually all syndromes of vasculitis. This can occur primarily as a dermatologic disorder or as a manifestation of a potentially life threatening systemic vasculitis. In this review article, classification, clinical manifestations, pathogenesis and therapy of cutaneous vasculitis will be discussed. Disorders which are primarily vascular in origin but lack a well defined inflammatory phase, referred to as 'vasculopathies' will also be discussed.

Cutaneous vasculitis presenting on the penis

Cutaneous vasculitis is frequently located on the lower limbs. We describe a patient who developed palpable purpura affecting the penis as the presenting sign of more widespread lesions of Henoch-Schönlein purpura.

Sulfapyridine and sulfones decrease glycosaminoglycans viscosity in dermatitis herpetiformis, ulcerative colitis, and pyoderma gangrenosum

Shortly after the introduction of sulfa drugs, sulfapyridine was found to have unique therapeutic properties, unrelated to antibacterial activity. Later, sulfones were found to share the same properties. The disorders initially improved were dermatitis herpetiformis, pyoderma gangrenosum, subcorneal pustular dermatosis, acrodermatitis continua, impetigo herpetiformis and ulcerative colitis. They were also sometimes helpful in many other disorders. They are effective in select disorders characterized by edema followed by granulocytic inflammation or edema followed by vesicle or bullae formation. The sulfones work in low doses in leprosy and their mode of action is not fully understood. Several pieces of experimental information are available. It is proposed that these drugs are entering or influencing the protein moiety of glycosaminoglycans and decreasing tissue viscosity. This decreased tissue viscosity prevents edema and dilution of tissue fluid and decreases acute inflammation and vesicle and bullae formation.

Henoch-Schönlein purpura after measles immunization

A three-year-old boy developed Henoch-Schönlein purpura after measles immunization. To our knowledge Henoch-Schönlein purpura in this setting has not been previously reported. This case illustrates that measles vaccine can act as an inducing factor Henoch-Schönlein purpura.

Hypocomplementemic urticarial vasculitis syndrome responsive to dapsone

A 45-year-old woman with cutaneous urticaria-like lesions subsequently developed polyarthritis, glomerulonephritis, and chronic obstructive pulmonary disease. Biopsy of skin showed leukocytoclastic vasculitis of superficial capillaries. Biopsy of the kidney revealed mesangioproliferative glomerulonephritis, and lung biopsy revealed severe emphysema and thick-walled blood vessels with immunoglobulin deposition. Therapy with dapsone produced dramatic improvement of the patient's cutaneous vasculitis and arthritis. This case uniquely demonstrates the efficacy of dapsone for both the urticarial vasculitic and the arthritic components of this syndrome and reemphasizes the potentially severe pulmonary and renal complications.