Incidence and risk factors for recurrent Henoch-Schönlein purpura in children from a 16-year nationwide database

Clinical characteristics and risk factors of cardiac involvement in pediatric immunoglobulin A vasculitis: A 7-year retrospective study from a single tertiary medical center

Immunoglobulin A vasculitis(IgAV) is the most common form of systemic vasculitis affecting children. To date, cardiac involvement in pediatric IgAV has not been fully investigated and its prevalence may be underestimated. This study aims to reveal the clinical and laboratory characteristics of cardiac involvement in pediatric IgAV and further determine its risk factors. A total of 1451 children with IgAV were recruited between January 2016 and December 2022. According to the severity of cardiac involvement, the patients were divided into the myocarditis/suspected myocarditis group, cardiac abnormalities group, and non-cardiac involvement group. Demographic, clinical, and laboratory characteristics were retrospectively extracted from the individual data collected in the medical records. Among the 1451 pediatric IgAV patients, 179 (12.3%) were identified with cardiac involvement, including 154 (10.6%) with cardiac abnormalities and 25 (1.7%) with myocarditis/suspected myocarditis. Cardiac involvement in pediatric IgAV mainly manifested as elevated cardiac biomarker levels (n = 162), electrocardiogram abnormalities (n = 46), and echocardiogram/chest X-ray abnormalities (n = 15); however, cardiac-related symptoms were only observed in 15.1% of patients with cardiac involvement. Multivariate analysis demonstrated that interval from disease onset to diagnosis > 7 days (OR, 2.157; 95% CI, 1.523-3.057; p < 0.001), IgAV with multi-organ involvement (OR, 1.806; 95% CI, 1.242-2.627; p = 0.002), and elevated D-dimer levels (OR, 1.939; 95% CI, 1.259-2.985; p < 0.001) were independent risk factors for cardiac involvement in pediatric IgAV. The length of hospital stay was significantly longer in the myocarditis/suspected myocarditis group compared with the other two groups (p < 0.05).     Conclusion: This study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV. What is Known: • Immunoglobulin A vasculitis (IgAV) is the most common form of systemic vasculitis affecting children and adolescents, which exhibits diverse clinical manifestations. Cases of severe IgAV complicated by cardiac involvement have been anecdotally reported. What is New: • The present study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV.

Modern diagnostic methods for early assessment of the abdominal involvement in Schönlein-Henoch disease

INTRODUCTION

Schönlein-Henoch disease is a small vessel vasculitis resulting from IgA-mediated inflammation. It is the most common acute systemic vasculitis in childhood, mainly affecting the skin, gastrointestinal tract, joints, and kidneys. Although the prognosis of Schönlein-Henoch is generally good, gastrointestinal tract involvement is a potential complication, presenting as massive gastrointestinal bleeding, bowel infarction, perforation, as well as intussusception and peritonitis.

A Review of IgA Vasculitis (Henoch-Schönlein Purpura) Past, Present, and Future

The clinical association of purpura, arthralgia, and arthritis was first described in 1837 in a publication by Johann Lukas Schönlein, a German physician. In 1874, Eduard Henoch, a student of Schönlein, reported cases of children with purpura, abdominal pain, bloody diarrhea, and joint pain. IgA vasculitis, or Henoch-Schönlein purpura, is a systemic hypersensitivity vasculitis caused by the deposition of immune complexes in small blood vessels, including the renal glomeruli and mesangium. In the skin, the presentation is with non-thrombocytopenic purpura or urticaria. Worldwide, IgA nephropathy is the most common cause of primary glomerulonephritis. Detection of IgA deposition in small blood vessels and the renal glomeruli is diagnostic in most cases. This article aims to review the history, current classification, epidemiology, presentation, and diagnosis of IgA vasculitis and nephropathy, disease associations or trigger factors, including infections, vaccines, and therapeutic agents, and highlights some future approaches to improve diagnosis and clinical management.

Does age at disease onset affect the clinical presentation and outcome in children with immunoglobulin A vasculitis?

Objectives

The study aimed to determine whether there is a relationship between the age at diagnosis and the clinical, laboratory, and prognostic features in pediatric immunoglobulin A vasculitis (IgAV) patients.

Patients and methods

In this study, 539 pediatric IgAV patients (298 males, 241 females; mean age: 7.74±3.36 years; range, 1 to 17.8 years) were retrospectively evaluated between January 2005 and July 2020. The relationship between clinical findings and age at diagnosis was analyzed by univariate logistic regression analysis. Factors associated with renal involvement, steroid-dependent or refractory disease, and recurrence were examined.

Results

The median age of diagnosis was 7.1 (1-17.8) years in all patients. At the time of admission, purpura, abdominal pain, and arthritis were the most common clinical findings. At the time of diagnosis, there was a positive association between age and purpura and an inverse association with the presence of arthritis. There were associations between renal involvement and age at diagnosis (odds ratio=1.22, 95% confidence interval 1.13-1.31, p<0.001), follow-up time (p<0.001), no history of previous infection (p<0.001), and presence of gastrointestinal (GI) involvement (p=0.003). Significant relationships were found between the age at diagnosis, follow-up time, GI involvement, renal involvement, scrotal involvement, the C-reactive protein value at the time of diagnosis, and the presence of steroid-dependent disease. An association was found between recurrence and GI involvement. All refractory patients had renal involvement. Age at diagnosis (p<0.001) and follow-up time (p<0.001) was found to be associated with refractory disease.

Conclusion

Age at diagnosis and follow-up time may be associated with renal involvement and refractory and steroid-dependent disease in IgAV. In addition, there may be a relationship between steroid-dependent disease and renal, GI, and scrotal involvement and between GI involvement and recurrence.

Henoch-Schönlein purpura in the setting of COVID-19 infection: Two pediatrics cases and review of the literature

Henoch-Schönlein purpura (HSP) is the most common systemic vasculitis in children, often following a viral infection. Various types of rashes attributed to COVID-19 infection have been described in the literature; however, HSP has rarely been reported. We report two children with HSP associated with acute COVID-19 infection with a review of the available literature. We highlight the clinical presentation, medical management, outcome and age-related difference of reported patients. A limitation of this article is the retrospective nature, limiting full patient history and associated conditions. The findings of this review show that HSP in the setting of COVID-19 is more common in children than adults, with a male predominance, involving various body systems creating a constellation of presentations. Given that HSP can have long-term morbidity from renal disease if untreated, this review may help guide the practitioner's approach to HSP and recognition in the setting of COVID-19 infection.

Clinical features of paediatric immunoglobulin A vasculitis patients with scrotal involvement

OBJECTIVES

Immunoglobulin (Ig) A vasculitis (IgAV), is the most common vasculitis of childhood, is a leucocytoclastic vasculitis that affects small vessels of the skin, gastrointestinal (GI) tract, joints, and kidneys. Scrotal involvement is relatively rare. In this study, we aimed to reveal the clinical and laboratory characteristics of patients with scrotal involvement in IgAV and its relationship with other clinical features of the disease.

METHODS

A total number of 301 male patients with a diagnosis of IgAV between January 2005 and 2022 were retrospectively analysed. The patients were divided into two groups as with and without scrotal involvement. The clinical and laboratory characteristics of the groups were compared.

RESULTS

Scrotal involvement was detected in 16.3% (49) of male IgAV patients. Scrotal involvement was unilateral in 51% of patients. While single acute scrotal attack was present in 93.9% of patients, only three patients had recurrent acute scrotal involvement. In patients with scrotal involvement, the age at diagnosis was younger (p = .007), and disease recurrence was higher (p = .003). Glucocorticoid use was more common in patients with scrotal involvement (p < .001). In multivariable analysis, a statistically significant relation between scrotal involvement and age at diagnosis (odds ratio = 0.85, 95% confidence interval 0.76-0.96, p =  .006) was detected.

CONCLUSIONS

In IgAV patients with scrotal involvement, the age at diagnosis is lower, steroid use is more common, and recurrent disease is more frequent.

A case series on recurrent and persisting IgA vasculitis (Henoch Schonlein purpura) in children

BACKGROUND

IgA vasculitis (IgAV) is a small vessel vasculitis that is more common in childhood. Very limited evidence exists on patients who experience an atypical disease course. The aim of this study was to describe a cohort of children diagnosed with recurrent or persisting IgAV to identify any themes associated with their disease course and areas of unmet needs.

METHODS

A single centre retrospective study of children diagnosed with recurrent or persisting IgAV at Alder Hey Children's Hospital (Liverpool, UK). Clinical data, including features at presentation and during follow up, potential triggers, abnormal laboratory and histology results, treatment and outcome at last clinical review were retrospectively collected. Key themes were identified.

RESULTS

A total of 13 children met the inclusion criteria (recurrent disease, n = 4; persisting disease, n = 9). Median age at first presentation was 10.2 years [2.6-15.5], female:male ratio 1.2:1. Children in the atypical cohort were significantly older than a larger cohort of children who followed a non-complicated disease course (median age 5.5 years (range [0.6-16.7], p = 0.003)). All children re-presented with a purpuric rash (either recurring or persisting), accompanied by joint involvement in 92% of patients (12/13). Disease-modifying anti-rheumatic drugs (DMARDs) were used in 8/13 (62%) children. The median time from first presentation to diagnosis of atypical disease was 18.4 months [5.3-150.8] and the time from first presentation to treatment was 24.1 months [1.8-95.4]. Use of corticosteroids was significantly higher in children with renal involvement (p = 0.026). During follow up, 8/13 (62%) children were admitted at least once, whilst 10/13 (77%) had re-presented at least once to the emergency department. Five (38%) children were referred to psychology services and 7 (54%) children reported feelings of frustration.

CONCLUSIONS

This series describes some characteristics of a small cohort of children with atypical IgAV. It also identifies unmet needs in children with atypical IgAV, which includes delays in diagnosis and lengthy waits for treatment, lack of high-quality evidence regarding treatment choices and a high unrecognised disease burden. Further research is needed to study this subgroup of children as evidence is lacking.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

Risk factors associated with recurrence of Henoch-Schonlein purpura: a retrospective study

Background

Recurrence is considered a vital problem for assessing the prognosis of Henoch-Schonlein purpura (HSP). The objective of this study was to evaluate factors affecting the recurrence in children with HSP.

Methods

We retrospectively reviewed records of 368 patients under the age of 16 years diagnosed with HSP from October 2019 to December 2020 in Beijing Children's Hospital. Patients were divided into a non-recurrence group and a recurrence group according to whether there was a recurrence. Incidence of manifestation, possible cause, age, and treatment were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the risk factors of recurrence in HSP.

Results

Percentages of patients were 65.2% for the non-recurrence group and 34.8% for the recurrence group. The percentage of patients with renal involvement was significantly higher in the recurrence group (40.6%) than in the non-recurrence group (26.3%). Respiratory tract infection was the most frequent trigger: 67.5% in the non-recurrence group and 66.4% in the recurrence group. Recurrence was more likely to occur in patients aged >6 years (53.3% vs. 71.9%). Logistic regression analysis revealed that hematuria plus proteinuria was an independent risk factor for the recurrence of HSP. Conversely, animal protein, exercise restriction, and age ≤6 years were independent favorable factors for the non-recurrence of HSP.

Conclusion

These results suggest that organ involvement, exercise, and diet management during the initial episode of HSP should be strictly monitored for children with HSP. Adequate clinical intervention for these risk factors may limit or prevent HSP recurrence. Moreover, renal involvement is associated with the long-term prognosis of HSP.

Prediction of renal damage in children with IgA vasculitis based on machine learning

This article is objected to explore the value of machine learning algorithm in predicting the risk of renal damage in children with IgA vasculitis by constructing a predictive model and analyzing the related risk factors of IgA vasculitis Nephritis in children. Case data of 288 hospitalized children with IgA vasculitis from November 2018 to October 2021 were collected. The data included 42 indicators such as demographic characteristics, clinical symptoms and laboratory tests, etc. Univariate feature selection was used for feature extraction, and logistic regression, support vector machine (SVM), decision tree and random forest (RF) algorithms were used separately for classification prediction. Lastly, the performance of four algorithms is compared using accuracy rate, recall rate and AUC. The accuracy rate, recall rate and AUC of the established RF model were 0.83, 0.86 and 0.91 respectively, which were higher than 0.74, 0.80 and 0.89 of the logistic regression model; higher than 0.70, 0.80 and 0.89 of SVM model; higher than 0.74, 0.80 and 0.81 of the decision tree model. The top 10 important features provided by RF model are: Persistent purpura ≥4 weeks, Cr, Clinic time, ALB, WBC, TC, Relapse, TG, Recurrent purpura and EB-DNA. The model based on RF algorithm has better performance in the prediction of children with IgA vasculitis renal damage, indicated by better classification accuracy, better classification effect and better generalization performance.

Association between common laboratory indices and IgAV recurrence in children

Background

IgA vasculitis (IgAV) is a common type of vasculitis seen in children. IgAV recurrence can result in chronic kidney disease. We aimed to explore the association between common laboratory indices and IgAV recurrence in children, and to establish a prediction model.

Methods

This retrospective study included children with diagnosed with IgAV hospitalized in Bazhong Central Hospital, Sichuan, from January 2014 to December 2019. Children were assigned to two groups based on IgAV recurrence, and baseline clinical data were collected for comparison. A logistic regression model to predict IgAV recurrence was established. The receiver operating characteristic curve was plotted. The area under the curve (AUC) was used to detect performance of the predictive model.

Results

This study included 193 children (39 [20.2%], recurrence group; 154 [79.8%], non-recurrence group). Based on multivariate regression analysis, the duration of illness and joint involvement were independent predictors of IgAV recurrence in children (P < 0.05). No significant differences were observed in common laboratory indices (P > 0.05). The AUC of the prediction model was 0.766 (P < 0.001) with sensitivity of 74.4% and specificity of 68.8%.

Conclusion

Common laboratory indices were not associated with recurrence of IgAV in children.

Development and validation of nomogram prediction model for severe kidney disease in children with Henoch–Schönlein purpura: A prospective analysis of two independent cohorts—forecast severe kidney disease outcome in 2,480 hospitalized Henoch–Schönlein purpura children

This study aimed to develop and validate a nomogram to forecast severe kidney disease (SKD) outcomes for hospitalized Henoch–Schönlein purpura (HSP) children. The predictive model was built based on a primary cohort that included 2,019 patients with HSP who were diagnosed between January 2009 and December 2013. Another cohort consisting of 461 patients between January 2014 and December 2016 was recruited for independent validation. Patients were followed up for 24 months in development/training and validation cohorts. The data were gathered at multiple time points after HSP (at 3, 6, 12, and 24 months) covering severe kidney disease as the severe outcome after HSP. The least absolute shrinkage and selection operator (LASSO) regression model was utilized to decrease data dimension and choose potentially relevant features, which included socioeconomic factors, clinical features, and treatments. Multivariate Cox proportional hazards analysis was employed to establish a novel nomogram. The performance of the nomogram was assessed on the aspects of its calibration, discrimination, and clinical usefulness. The nomogram comprised serious skin rash or digestive tract purpura, severe gastrointestinal (GI) manifestations, recurrent symptoms, and renal involvement as predictors of SKD, providing favorable calibration and discrimination in the training dataset with a C-index of 0.751 (95% CI, 0.734–0.769). Furthermore, it demonstrated receivable discrimination in the validation cohort, with a C-index of 0.714 (95% CI, 0.678–0.750). With the use of decision curve analysis, the nomogram was proven to be clinically useful. The nomogram independently predicted SKD in HSP and displayed favorable discrimination and calibration values. It could be convenient to promote the individualized prediction of SKD in patients with HSP.

Serum immunoglobulin profiles in Chinese children with Henoch-Schönlein purpura

OBJECTIVE

The present study focuses on the associations of serum immunoglobulin with disease activity, relapse/recurrence and renal involvement in Henoch-Schönlein purpura (HSP) children.

METHODS

1683 Chinese children with HSP were recruited from January 2015 to January 2021. Laboratory data of blood samples and urine tests were collected. Renal biopsy was performed by the percutaneous technique. Patients' histories associated with HSP onset were obtained by interviews and questionnaires.

RESULTS

(1) IgA and IgE were dramatically elevated in HSP patients as compared with their normal values, and subject to a 1.75-3.09 fold and a 1.97-2.61 fold increase, respectively. (2) No significant correlation of the disease activity with IgA and IgE was determined, respectively. (3) The serum IgA levels were significantly lower in patients with relapse/recurrence than that in patients without relapse/recurrence, which may be attributed to the transmission of IgA-mediated immune complexes from blood to vessel walls. (4) No significant correlation was found between serum IgA, IgE levels and the pathological classification.

CONCLUSIONS

HSP children have marked disorders of serum immunoglobulin profiles, characterized by significant increases in IgA and IgE. The detection of serum IgA may be applicable to predict relapse/recurrence of HSP, whereas not associated with disease activity and renal involvement.

[Analysis of clinical characteristics of Henoch-Schonlein purpura patients from different altitudes in plateau areas]

OBJECTIVE

To investigate the clinical characteristics of Henoch-Schonlein purpura (HSP) patients from different altitudes in Tibet plateau areas of China.

METHODS

A retrospective study was used to analyze the 190 HSP patients admitted to Tibet Autonomous Region People ' s Hospital form April 2014 to May 2021. The subjects were divided into 3 groups according to the altitude of long-term residence before onset and the clinical data at different altitudes were compared and analyzed.

RESULTS

There were no significant differences in the age of onset and gender in HSP patients at different altitudes (P>0.05). The HSP patients in high altitude areas were more likely to have digestive symptoms (P < 0.01). The patients were more likely to have kidney or joint involvement at higher altitudes. The platelets [(512.1±55.0)×10⁹ /L] and C reactive protein [11.2 (5.7, 19.4) g/L] in high altitude areas were significantly higher than at medium altitudes [(498.3±76.9)×10⁹ /L and 9.5 (4.6, 13.5) g/L] and lower altitudes [(456.4±81.2)×10⁹/L and 3.7 (0.2, 8.9) g/L] respectively. The effective rate of treatment was 98.9%, while there was no significant difference of outcome from different altitudes (P>0.05). The patients who were repeatedly hospitalized all had kidney involvement and no immunosuppressive agents were added in the initial treatment.

CONCLUSION

HSP is common in high altitude areas. There was little difference in age of onset and gender at different altitudes. Abdominal pain was the most common clinical manifestation. Patients in high altitude areas were more likely to have severe abdominal problems. Kidney involvement may be poor prognostic factor. Early application of glucocorticoid combined with immunosuppressive agents can effectively control the disease and reduce the recurrence of HSP.

Metagenomic profiling reveals dominance of gram-positive bacteria in the gut microbiome shifts associated with immunoglobulin A vasculitis (Henoch-Schönlein Purpura)

Objectives

Immunoglobulin A vasculitis (IgAV), previously known as Henoch-Schönlein purpura, is the most common vasculitis that has a classical skin manifestation of palpable purpuric rash. Factors pertinent to IgAV remain inadequately understood. Here, we aimed to examine the gut microbiome shifts associated with IgAV and its recovery.

Methods

Stool samples were collected from 10 children with IgAV (6-14 years old) before and after a multi-drug therapy, along with 9 age-matched healthy children. The samples were subjected to metagenomic analyses to investigate the taxonomic and functional shifts of the gut microbiome.

Results

The analyses revealed that compared with healthy controls, treatment-naïve patients exhibited substantial taxonomic and functional alterations of gut microbiota, including 104 IgAV-depleted species and 7 IgAV-elevated species (FDR < 0.05). After treatment, the IgAV patients displayed a partial restoration of the microbiota shifts, as the relative abundances of some biomarkers (e.g. 9 genera and 22 species) became comparable (FDR > 0.1) between the patients and healthy controls. The treatment-responsive features included Weissella, Faecalibacterium prausnitzii and Bifidobacterium pseudocatenulatum and three components of a putative glutamine transport system. Importantly, gram-positive bacteria accounted for over 85% of the numbers and total relative abundance of the species that were associated with IgAV and responsive to the treatment. In addition, of the 122 IgAV-depleted bacterial genes, 82 were mainly contributed by gram-positive bacteria and 12 by gram-negative bacteria.

Conclusions

Gram-positive bacteria are the main drivers underlying the gut microbiome shifts of IgAV, which may assist rational management of the disease.

Effect of animal protein diet on the prognosis of children with Henoch-Schönlein purpura

OBJECTIVES

To study the association of animal protein diet with the recurrence of Henoch-Schönlein purpura (HSP)/skin rash and the risk factors for recurrence of HSP.

METHODS

A prospective analysis was performed for 121 children with HSP who were admitted to the Beijing Children's Hospital from October to December 2020. The children were given the doctor's advice of the same diet (animal protein diet could be added after 1 week without new-onset skin rash). Follow-up was performed at the outpatient service for half a year. According to the presence or absence of animal protein intake, the children were divided into an observation group with 65 children and a control group with 56 children. The times of skin rash recurrence, the incidence of HSP recurrence, and the incidence of kidney injury were compared between the two groups. According to the presence or absence of recurrence, the children were divided into a recurrence group with 32 children and a non-recurrence group with 89 children. A questionnaire on food frequency was used to record the daily intake of animal protein in the two groups. A multivariate logistic regression analysis was used to identify the risk factors for recurrence of HSP in children.

RESULTS

There was no significant difference between the observation and control groups in the times of skin rash recurrence, the incidence rate of HSP recurrence, and the incidence rate of kidney injury (P>0.05). There was no significant difference in the daily intake of animal protein between the recurrence and non-recurrence groups (P>0.05). The multivariate logistic regression analysis showed that presence of kidney injury at initial onset, respiratory infection after cure for the first time, and lack of exercise control after cure for the first time were independent risk factors for the recurrence of HSP in children (P<0.05).

CONCLUSIONS

There is no significant association between animal protein diet and the recurrence of HSP or skin rash. Timely treatment of kidney injury, avoidance of infection after cure, and limitation of strenuous exercise may help to reduce the recurrence rate of HSP in children. Citation.

Deficiency in the frequency and function of Tr1 cells in IgAV and the possible role of IL-27

Objective

Type 1 regulatory T (Tr1) cells are involved in the pathogenesis of numerous immune-mediated diseases. However, little is known about whether and how Tr1 cells affect the development of IgA vasculitis (IgAV). We aimed to investigate this question in IgAV patients.

Methods

. Tr1 cells in peripheral blood and kidney tissue of IgAV patients were analysed by multi-parametric flow cytometry and immunofluorescence techniques. An in vitro assay of suppression of T cell proliferation and cytokine release was performed to evaluate the function of Tr1 cells. Real-time PCR and cell stimulation in vitro were used to explore the roles of IL-27 and early growth response gene 2 (EGR2).

Results

The frequency of Tr1 cells was decreased in peripheral blood but increased in kidney tissue from IgAV patients. A defective suppressive function of Tr1 cells in IgAV was observed. The frequency of Tr1 cells and the cytokines secreted by them were up-regulated in the presence of recombinant IL-27 in vitro. Moreover, IL-27 also increased the expression of EGR2. Furthermore, lower frequency of Tr1 cells during remission had a higher recurrence rate.

Conclusion

Tr1 cells are involved in the pathogenesis of IgAV. The low IL-27 in IgAV is responsible for impaired frequency and function of Tr1 cells, and EGR2 may be the specific transcription factor involved in the progression. Tr1 may be a risk factor for IgAV recurrence.

Streptococcal infection in childhood Henoch-Schönlein purpura: a 5-year retrospective study from a single tertiary medical center in China, 2015-2019

BACKGROUND

The present study focuses on the associations of streptococcal infection with the clinical phenotypes, relapse/recurrence and renal involvement in Henoch-Schönlein purpura (HSP) children.

METHODS

Two thousand seventy-four Chinese children with HSP were recruited from January 2015 to December 2019. Patients' histories associated with HSP onset were obtained by interviews and questionnaires. Laboratory data of urine tests, blood sample and infectious agents were collected. Renal biopsy was performed by the percutaneous technique.

RESULTS

(1) Streptococcal infection was identified in 393 (18.9%) HSP patients, and served as the most frequent infectious trigger. (2) Among the 393 cases with streptococcal infection, 43.0% of them had arthritis/arthralgia, 32.1% had abdominal pain and 29.3% had renal involvement. (3) 26.1% of HSP patients relapsed or recurred more than 1 time within a 5-year observational period, and the relapse/recurrence rate in streptococcal infectious group was subjected to a 0.4-fold decrease as compared with the non-infectious group. (4) No significant differences in renal pathological damage were identified among the streptococcal infectious group, the other infectious group and the non-infectious group.

CONCLUSIONS

Streptococcal infection is the most frequent trigger for childhood HSP and does not aggravate renal pathological damage; the possible elimination of streptococcal infection helps relieve the relapse/recurrence of HSP.

A Rare and Severe Presentation of Henoch-Schönlein Purpura in an Adolescent With Crescentic Glomerulonephritis, Arrhythmia, Acute Gastrointestinal Bleed, and Neurological Complications

Henoch-Schönlein purpura (HSP) is a childhood vasculitis disorder that involves the skin, joints, gastrointestinal (GI) tract, and kidneys. It is related to immunoglobulin A (IgA) antibody deposition in small blood vessels. HSP is a self-limiting disorder, but its morbidity is primarily associated with renal involvement. GI pathologies like intussusception, gastritis, duodenitis, ileitis, or ulcer have been reported to be associated with this disease. However, cardiac and neurological complications are rarely reported.

We present the case of a 16-year-old, previously healthy male who was diagnosed with HSP after presenting with a non-blanching purpuric rash in the lower extremities. The patient also had joint and abdominal pain, and swelling in the extremities. There was renal dysfunction at presentation with blood urea nitrogen (BUN) of 67 mg/dL and serum creatinine of 1.9 mg/dL. The serum albumin was low at 2 g/dL, and the patient had nephrotic range proteinuria. Urine microscopy showed red blood cell casts. A renal biopsy was performed, which showed IgA deposition in glomeruli. He was started on intravenous (IV) pulse methylprednisolone and was later prescribed oral steroids. Four weeks after the treatment initiation, he presented with syncope and acute anemia (hemoglobin of 3.5 g/dL). The fecal occult blood was positive. Esophagogastroduodenoscopy (EGD) was not suggestive of gastritis, duodenitis, or ulcer. The pill-cam capsule endoscopy revealed GI bleeding from the terminal ileum near Meckel’s diverticulum. He subsequently required blood transfusions, and the bleeding eventually improved with symptomatic management. Six weeks after treatment initiation, he presented with dizziness and palpitations. The EKG showed the presence of atrial fibrillation, and he had an episode of non-sustained ventricular tachycardia on telemetry. Arrhythmia was diagnosed secondary to HSP cardiac vasculitis, and we initiated treatment with metoprolol and amiodarone. Seven weeks after the initial treatment, he had neurological clinical findings of proximal muscle weakness, tremors, and upper and lower extremity clonus. A second renal biopsy was then performed due to the presence of persistently elevated serum creatinine, which showed 75% of glomeruli with cellular crescents. He was treated with IV cyclophosphamide. Subsequently, the renal function improved. There were no other GI, cardiac, or neurological complications after six months of follow-up.

The presentation of HSP can be more severe in adolescents, and they need to be closely monitored for GI, cardiac, renal, and neurological complications after the disease occurrence. Bleeding from Meckel’s diverticulum or an episode of non-sustained ventricular tachycardia with HSP has not been previously reported to our knowledge. Arrhythmia is an exceptionally unusual occurrence in HSP, and it is usually treated with anti-arrhythmic drugs and intensification of the immunosuppressive regimen.

Henoch-Schonlein Purpura Presenting as Upper Gastrointestinal Bleed in an Adult Patient

Henoch-Schonlein purpura (HSP) is a multi-system autoimmune disease that is relatively common in pediatric patients. HSP usually manifests as palpable purpura, arthralgia, abdominal pain, and acute kidney injury. Here, we present a case of an adult male with hematemesis as the initial presenting symptom of HSP. A previously healthy, 18-year-old Caucasian male presented with a one-day history of hematemesis associated with abdominal pain and non-bloody diarrhea. He also reported bilateral knee and ankle arthralgias with a painless skin rash on both lower extremities. Physical exam was positive for palpable, purpuric, non-blanchable skin rash involving bilateral lower extremities. Notable labs on admission included a white cell count of 10.8 x 10⁹/L and C-reactive protein of 4.8 mg/L. Upper endoscopy showed non-bleeding erosive gastropathy and duodenal erosions. Skin biopsy of the left leg showed immunoglobulin A (IgA) deposition within the walls of the superficial dermal vessels. The patient was started on intravenous methylprednisolone 500 mg daily followed by a steroid taper. Due to incomplete clinical response to steroids, mycophenolate mofetil 1000 mg twice daily was added and maintained for three months. His symptoms improved significantly, and he no longer complained of abdominal pain or diarrhea. Gastrointestinal manifestations are common in HSP patients. However, the diagnosis will be challenging when these symptoms precede other classical manifestations of HSP. History and physical exam are key components in accurately diagnosing HSP; nevertheless, skin biopsy remains the gold standard to confirm the diagnosis.

Gastrointestinal Henoch-Schönlein purpura successfully treated with Mycophenolate Mofetil: Description of 2 case reports

RATIONALE

Henoch-Schönlein Purpura (HSP) is an acute small vessel vasculitis. It is the most common vasculitis in children. In majority of the cases, the disease is self-limited. Relapses can occur, in particular during the first year of the disease. There is no consensus on a specific treatment. The efficacy and safety of steroidal treatment in treating HSP is still controversial. Immunosuppressive treatment of HSP nephritis is used in patients with severe renal involvement (nephrotic range proteinuria and/or progressive renal impairment). The literature on immunosuppressive treatment of severe HSP without kidney involvement is scanty.

PATIENTS CONCERNS

We report 2 case reports of 2 adolescents affected from Henoch-Schönlein Purpura and severe gastrointestinal involvement. Both patients presented a poor response to steroids treatment.

DIAGNOSES

The diagnosis of HSP was made according to the diagnostic criteria published by European League against Rheumatism and Pediatric Rheumatology European Society in 2006.

INTERVENTIONS

In consideration of the recurrence of the Henoch Schönlein Purpura and the gastrointestinal involvement, we decided to start Mycophenolate Mofetil treatment.

OUTCOMES

In both patients all clinical manifestations resolved in few days.

LESSONS

In our cases of HSP with gastrointestinal involvement Mycophenolate Mofetil treatment has been very effective. This experience teaches us that immunosuppressive agents may be very useful to induce and maintain remission not only in renal involvement, but in all cases of persistent, recurrent, or complicated Henoch Schönlein Purpura in children.

Onset age is a risk factor for refractory pediatric IgA vasculitis: a retrospective cohort study

BACKGROUND

Though outcome differences between children and adults with immunoglobulin A vasculitis (IgAV) has been well documented, it remains unclear if disease features in pediatric IgAV patients vary with onset age. We aimed to explore clinical features and prognosis of pediatric IgAV stratified by onset age.

METHODS

We retrospectively reviewed records of patients under 18 years old diagnosed with IgAV from January 1999 to December 2018 in one tertiary medical center in Taiwan. Patients were grouped by onset age: ≤ 6 years old, 6-12 years old (> 6, ≤ 12), and 12-18 years old (> 12, < 18). Demographics, laboratory data, incidence of gastrointestinal, renal, and joint involvement, corticosteroid dependence, recurrence, and refractory disease were analyzed. Recurrence was defined as disease flare-up after complete remission and discontinuation of all medications for at least 3 months. Corticosteroid dependence was defined by more than 6 weeks of daily oral corticosteroid intake. Refractory disease was defined as not achieving complete remission 6 months after disease onset. Statistical analysis was performed using R software (v3.6.0).

RESULTS

There were 484 IgAV patients, with an onset age of 6.10 (4.72-8.58) (median (IQR)) years old. There were 234 (48.3%) patients ≤6 years old, 210 (43.4%) 6-12 years old, and 40 (8.3%) 12-18 years old. One hundred and thirty (26.9%) patients had renal involvement, which was more frequent in older children (≤ 6 years old, 18.4%; 6-12 years old, 31.0%; 12-18 years old, 55.0%; p <  0.001). There were 361 patients (74.6%) with joint involvement; younger children were affected more frequently (≤ 6 years old, 82.1%; 6-12 years old, 71.9%; 12-18 years old, 45.0%; p <  0.001). Gastrointestinal involvement was present in 311 (64.3%) patients, showing no difference among age groups. There were 46 patients (9.5%) with recurrent IgA vasculitis, 136 (28.1%) with corticosteroid dependent and 76 (15.7%) with refractory disease. Corticosteroid dependence and refractory disease occurred more frequently as onset age increased (p <  0.001).

CONCLUSION

Pediatric IgAV with different onset ages are associated with distinct clinical manifestations and outcomes. The risk of developing corticosteroid dependence, refractory disease and renal involvement increased with onset age.

Life-threatening complications of Henoch-Schönlein purpura: diffuse alveolar haemorrhage, venous thrombosis and bowel ischaemia

Henoch-Schönlein purpura (HSP) is a common systemic vasculitis occurring in children. Making a diagnosis of HSP is often straightforward, managing its complications can be difficult. Diffuse alveolar haemorrhage (DAH), bowel ischaemia and venous thrombosis are rare complications of this disorder. We present a case of a 15-year-old teenage girl presenting with typical purpuric rash of HSP, developed DAH, bowel ischaemia and venous thrombosis. She was successfully treated with pulse methylprednisolone, intravenous Ig and intravenous cyclophosphamide.

The relevance of practical laboratory markers in predicting gastrointestinal and renal involvement in children with Henoch-Schönlein Purpura

OBJECTIVES

Henoch-Schönlein Purpura (HSP) is the most common self-limiting vasculitis of childhood. Both serious gastrointestinal and renal complications may be observed during the disease course. The aim of this study was to evaluate the role of hematological markers in predicting the likely complications of the disease.

METHODS

The demographic findings, clinical features, organ involvements and laboratory findings including white blood cell count (WBC), neutrophil, lymphocyte and platelet counts, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), mean platelet volumes (MPV), MPV/platelet count ratio (MPR) were evaluated retrospectively from the charts of the patients with HSP and all these parameters were compared with the same parameters of healthy children.

RESULTS

A total of 376 patients with HSP and age- and sex-matched 233 healthy children were evaluated. Mean age at the diagnosis was 7.5 ± 3.5. All patients had palpable purpura, 46% had arthritis, 56.1% GIS involvement and 21.3% had renal involvement. While platelet counts, neutrophil counts, NLR, and PLR were higher, lymphocyte counts, MPV, and MPR were lower in patients with GIS involvement. NLR was the sole biomarker that was higher in patients with renal involvement.

CONCLUSIONS

This study had shown that platelet counts, neutrophil counts, NLR, and PLR were increasing and lymphocyte counts, MPV, and MPR were decreasing when the patients had GIS involvement. However, these parameters were not relevant in distinguishing severe and mild GIS involvement. When patients had renal involvement NLR was the unique elevated parameter.

Functional Immunoregulation by Heme Oxygenase 1 in Juvenile Autoimmune Diseases

An autoimmune disease is an inflammatory condition in which the human body's immune system attacks normal cells, resulting in decreased and abnormal immune function, which eventually leads to tissue damage or organ dysfunction. In the field of medicine, especially in pediatrics, knowledge about autoimmune diseases is still inadequate. Some common juvenile autoimmune diseases such as Henoch-Schonlein purpura, systemic juvenile idiopathic arthritis, mucocutaneous lymph node syndrome, and autoimmune encephalitis cause considerable public concern. Recent studies revealed that heme oxygenase 1 (HO-1), an enzyme that participates in heme degradation, plays a critical role in the pathogenesis and may regulate autoimmunity. Firstly, it may promote the differentiation of T lymphocytes into CD4+CD25+ regulatory T cells and may be associated with changes in the ratios of cytokines (Th1/Th2 and Th17/Treg) as well. Secondly, HO-1 can regulate the immune system through the secretion of proteins such as transforming growth factors and interleukins. Moreover, increasing the expression of HO-1 can improve vascular function by increasing antioxidant levels. Thus, HO-1 may provide a theoretical basis and guidance for therapeutic management of juvenile autoimmune diseases.

Recurrent Henoch-Schönlein Purpura with bullous rash and pulmonary nodules

BACKGROUND

Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. It has a characteristic rash described as palpable purpura that most frequently affects the distal lower extremities and buttocks. HSP rarely presents with bullous rash nor pulmonary nodules.

CASE PRESENTATION

We present a novel case of a 12-years-old female with recurrent pediatric HSP with a combination of the rare manifestations of bullous rash and pulmonary nodules. She initially presented with the bullous rash, chest pain, cough, and abdominal pain. Patient was successfully treated with intravenous pulse corticosteroids followed by a high dose oral corticosteroid taper, with resolution of the bullous rash and pulmonary nodules.

CONCLUSION

The rare manifestations of scarring bullous rash and pulmonary nodules can be presenting features of pediatric HSP, the combination of which has not been previously reported. The treatment of intravenous corticosteroid resolved patient's abdominal symptoms, rash and pulmonary nodules.

Rheumatic diseases in Syrian refugee children: a retrospective multicentric study in Turkey

Since the Syrian civil war in 2011, an estimated number of 3.6 million Syrian refugees crossed into Turkey, and almost half of them were children. The distribution of rheumatic diseases in Syrian refugee children is not known. The aim of this study was to describe the profile of rheumatic diseases in Syrian refugee children living in Turkey. The demographic data, clinical and laboratory findings, medications, complications and outcome results of Syrian refugee children who had visited Pediatric Rheumatology Departments of University of Health Science Kanuni Sultan Süleyman Research and Training Hospital, Ümraniye Research and Training Hospital, Şanlıurfa Research and Training Hospital, and Cengiz Gökçek Maternity and Gynecology Hospital between April 1, 2011, and September 1, 2019, were evaluated retrospectively. A total of 151 patients were included in the study. Among them, 51 patients had juvenile idiopathic arthritis (JIA), 49 had familial Mediterranean fever (FMF), 43 had vasculitis, and 8 had connective tissue diseases. Homozygous M694V mutation was the most common mutation among FMF patients. Oligoarticular JIA (41.2%) was the most frequent type of JIA, and enthesitis-related arthritis (ERA) (27.5%) was the second one. The frequency of systemic JIA was 11.8%. One patient with SLE died due to complicated meningitis. This is the first study evaluating the distribution of rheumatic diseases in Syrian refugee children. Clinical follow-up of rheumatologic diseases is difficult in Syrian refugees due to language barriers, social and cultural differences. Health care systems should be well organized to provide appropriate care to asylum seekers.

Predictive role of laboratory markers and clinical features for recurrent Henoch-Schönlein Purpura in childhood: A study from Turkey

Objectives: Henoch Schönlein Purpura is the most common systemic vasculitis of the childhood. The objective of this study was to evaluate whether there is a clinical significance of laboratory parameters and clinical features on the prediction of the recurrent Henoch Schönlein Purpura in children.Methods: For recurrent Henoch Schönlein Purpura, several laboratory results and clinical features were examined to identify the predictor factors via the logistic regression model in 99 children with Henoch Schönlein Purpura. A p-value of <.05 was considered significant. The patients were divided into two groups as the first attack and the recurrent.Results: The demographic features and laboratory results were not found statistically significant between the two groups (p > .05). The multiple logistic regression model showed that the risk of recurrent Henoch Schönlein Purpura increased 17.2-fold in children with Henoch Schönlein Purpura affected by the four systems including skin, joint, kidney and gastrointestinal system [Odds Ratio (OR) 17.2, 95% CI 1.4-12; p < .001].Conclusion: In our inpatient population, the laboratory characteristics were detected not to be a factor for the prediction of recurrence. However, the four systems including skin, joint, kidney and gastrointestinal involvement may be used as a predictive factor for recurrent HSP.

MEST-C pathological score and long-term outcomes of child and adult patients with Henoch-Schönlein purpura nephritis

BACKGROUND

Henoch-Schönlein purpura nephritis (HSPN), a small-vessel vasculitis, shares renal pathological features with immunoglobulin A nephropathy. Oxford classification of immunoglobulin A nephropathy pathology has been updated to the MEST-C score, but its application in HSPN remains unresolved.

METHODS

Two hundred and thirteen patients with biopsy-proven HSPN were retrieved from the Seoul National University Hospital between 2000 and 2017. Renal outcome risks (i.e., end-stage renal disease or doubling of serum creatinine) were evaluated according to MEST-C scores after stratification by age: 113 children aged < 18 years (9.2 ± 3.6 years) and 100 adults aged ≥18 years (38.6 ± 18.3 years). We pooled our data with four previous cohort studies in which MEST or MEST-C scores were described in detail.

RESULTS

Twenty-one child (19%) and 16 adult (16%) patients reached the renal outcome during the median follow-up periods of 12 years and 13 years, respectively (maximum 19 years). In children, M1 and T1/T2 scores revealed worse renal outcomes than did M0 and T0 scores, respectively, whereas the T score was the only factor related to worse outcomes in adult patients after adjusting for multiple clinical and laboratory variables. The pooled data showed that M1, S1, and T1/T2 in children and E1 and T1/T2 in adults were correlated with poorer renal outcomes than those of their counterpart scores.

CONCLUSIONS

The Oxford classification MEST-C scores can predict long-term renal outcomes in patients with HSPN.

Clinical manifestations and outcomes of 420 children with Henoch Schönlein Purpura from a single referral center from Turkey: A three-year experience

Objectives: Henoch Schönlein Purpura (HSP) is the most common systemic vasculitis in childhood. We aimed to evaluate the clinical features, seasonal variation, treatment outcomes and the possible predicting factors related to outcome among a large cohort of pediatric HSP patients.Methods: We conducted a medical record review study between July 2016 and January 2019 and evaluated the clinical manifestations and potential risk factors for severe gastrointestinal (GI) involvement, biopsy-proven nephritis and relapses.Results: The study included 420 HSP patients, of which the mean age at diagnosis was 7.68 ± 3.15 years. Clinical manifestations were arthralgia and/or arthritis (n = 244, 58.1%), abdominal pain (n = 235, 56%), subcutaneous edema (n = 163, 38.8%), and renal involvement (n = 125, 29.8%). Disease recurred for at least once, in 69 (16.4%) patients and colchicine treatment yielded a favorable response in 11 of 12 relapsing patients, who did not respond to ibuprofen or steroids. Frequencies of renal involvement and biopsy-proven nephritis were higher in patients with severe GI involvement. Besides, patients with biopsy-proven nephritis had higher rates of abdominal pain, intussusception, severe GI involvement, and systemic steroid administration.Conclusion: We speculate that renal involvement, biopsy-proven nephritis and severe GI involvement can be related to each other. Colchicine may be effective in patients with relapsing disease.

[Expression of gamma-delta T cells in immune microenvironment in children with Henoch-Schönlein purpura]

OBJECTIVE

To study the role of gamma-delta T (γδ T) cells and its subsets in the immunopathogenesis of Henoch-Schönlein purpura (HSP) in children, and to provide new ideas for the treatment of HSP in children from the aspect of γδ T cell regulation.

METHODS

A total of 33 children with HSP were enrolled as the HSP group, and 21 healthy children were enrolled as the healthy control group. The percentages of γδ T cells and its subsets Vδ1⁺ T and Vδ2⁺ T cells among peripheral blood mononuclear cells (PBMCs) were measured, as well as the apoptosis rate of γδ T cell and plasma level of interleukin-17 (IL-17).

RESULTS

Compared with the healthy control group, the HSP group had significantly lower percentages of lymphocytes in PBMCs and Vδ2⁺ T cells in γδ T cells (P<0.05). The HSP group had significantly higher percentage of Vδ1⁺ T cells in γδ T cells and plasma level of IL-17 than the healthy control group. The HSP group had a significantly higher overall apoptosis rate of γδ T cells than the healthy control group (P<0.05), especially early apoptosis. The percentage of Vδ2⁺ T cells was positively correlated with overall apoptosis rate (r_s=0.615, P<0.05) and was negatively correlated with IL-17 level (r_s=-0.398, P<0.05).

CONCLUSIONS

Vδ1⁺/Vδ2⁺ T cell immune imbalance mediated by γδ T cells and over-activation of IL-17 may be involved in the development of HSP, among which the disturbance of immune tolerance induced by Vδ2⁺ T cells plays an important role in the pathophysiology of the disease.

Changes in clinical features in Henoch-Schönlein purpura during three decades: an observational study at a single hospital in Korea

OBJECTIVE

It is unknown whether epidemiological or clinical characteristics of Henoch-Schönlein purpura (HSP) have changed over time. This study aimed at evaluating the epidemiological and clinical changes of HSP during 3 decades.

METHODS

We retrospectively analyzed the data of 515 children with HSP (0-15 years of age) between 1987 and 2015. We compared the two HSP patient groups: those admitted from 1987 to 1996 (group A, 238 cases) and those admitted from 2006 to 2015 (group B, 98 cases), apart a decade.

RESULTS

In total 515 patients, the mean age was 6.5 ± 3.0 years and the male-to-female ratio was 1.2:1 (278:237). The age distribution showed a peak at age 5 with a bell-shaped distribution pattern. The annual number of cases varied in each year with a trend of reduced cases in the recent decade. There were less cases during the summer season. Purpura, gastrointestinal involvement, joint involvement, and renal involvement were found in 100%, 56%, 38%, and 18% of the patients, respectively. In comparison between the two groups, there were similar findings in mean age, age distribution, and seasonal distribution. However, the hospitalization stay was longer, and the proportion of recurrent cases (14 cases vs. 0 case) and proteinuria (15% vs. 3%) were higher in the group A than in the group B.

CONCLUSIONS

Long-term epidemiologic features of HSP were similar to those in other countries. Clinical manifestations of HSP showed a trend towards a less severe clinical phenotype over time in Deajeon, Korea. Key Points • It is unknown whether epidemiological and clinical traits of Henoch-Schönlein purpura (HSP) have changed over time. • We reported that clinical manifestations of HSP have changed to milder phenotype through a long-term observation of three decades at a single hospital in Daejeon, South Korea. • Clinical phenotype of infection-related diseases, including HSP, may be changed over time, and the etiology and the reason of clinical changes over time remain to be solved.

RhACE2 - playing an important role in inhibiting apoptosis induced by Ang II in HUVECs

BACKGROUND

Henoch-Schonlein purpura (HSP) is a common hemorrhagic disease, which manifests the inflammation in the body's most microvasculars. Angiotensin II (Ang II) can induce the damage and apoptosis of vascular endothelial cells while angiotensin converting enzyme 2 (ACE2) can antagonist the action of Ang II. However, the effect of ACE2 on Ang II-induced endothelial damage remains unknown.

OBJECTIVE

To evaluate the effect of recombinant human angiotensin converting enzyme 2 (rhACE2) on the Ang II-induced damage of human umbilical vein endothelial cells (HUVECs) and the release of inflammatory mediator in vitro.

METHODS

Cultured HUVECs were randomly divided into 6 groups: the control group, rhACE2 group, Ang II group, and Ang II+ rhACE2 groups (3 subgroups). The cell vitality, cell cycle, apoptosis rate of the HUVECs and the levels of reactive oxygen species (ROS), interleukin 8 (IL-8), tumor necrosis factor-α (TNF-α), transforming growth factor-β1 (TGF-β1) and lactate dehydrogenase (LDH) were measured, respectively.

RESULTS

Compared with the control group, the cell viability and the rate of S phase cells in Ang II group significantly decreased (P < .05) while the apoptosis percentage and the levels of ROS, IL-8, TNF-α, TGF-β1, and LDH in Ang II group significantly increased (P < .05). There were no significant differences between the control group and rhACE2 group. Compared with the Ang II group, the cell viability and the rate of S phase cells in Ang II+rhACE2 groups were higher (P < .05) and the apoptosis percentage, the level of ROS, IL-8, TNF-α, TGF-β1, LDH in Ang II+rhACE2 groups were lower (P < .05).

CONCLUSIONS

Ang II can induce the apoptosis of HUVECs and the release of inflammatory mediator, while rhACE2 can inhibit the detrimental effects of Ang II. The results of this study suggest that rhACE2 has a protective effect on HSP, which is probably a new way for the prevention and treatment of HSP.

Do practical laboratory indices predict the outcomes of children with Henoch-Schönlein purpura?

Objectives: Henoch Schönlein Purpura (HSP) is the most common systemic vasculitis of childhood and often has a self-limiting course. We aimed to study whether practical laboratory parameters at the diagnosis predict disease course including recurrence and nephritis in addition to severe gastrointestinal involvement in children with HSP. Methods: This retrospective cohort study included 214 HSP patients, 43.5% (n = 93) female and 56.5% (n =121) male, who were diagnosed in our department. Laboratory parameters before treatment, including neutrophil, lymphocyte and platelet counts, mean platelet volume (MPV), neutrophil-to-lymphocyte (NLR), and platelet-to-lymphocyte ratios (PLR) were obtained retrospectively. Age at diagnosis, duration of follow-up, gender, preceding infections, medications, arthritis and arthralgia, abdominal pain, severe GI involvement, invagination, renal involvement and presence of nephritis, outcomes, and presence of recurrences were retrospectively recorded from medical files. Severe GI involvement was determined as severe colicky abdominal pain, bowel edema in ultrasonography or overt GI bleeding. A relapse was defined as a new flare of cutaneous lesions or other manifestations in a patient at least four asymptomatic weeks after the initial HSP episode. Results: Mean age at diagnosis was 7.6 ± 3.1 years. Biopsy-proven nephritis was found in 16 (7.5%) patients. Severe GI involvement was present in 77 (36%) patients, whereas only 12 (5.6%) patients were diagnosed with intussusception and in 29 (13.5%) patients, HSP recurred. Neutrophil count and NLR were found higher in HSP patients with severe gastrointestinal involvement and biopsy-proven nephritis. Additionally, only platelet count was lower and MPV was higher in patients with recurrent HSP. Conclusion: Elevated neutrophil count and NLR may be relevant markers for severe GI involvement and nephritis, whereas platelet count and MPV were the only laboratory parameters associated with disease recurrence.

The clinical spectrum of Henoch-Schönlein purpura in children: a single-center study

OBJECTIVES

Henoch-Schönlein purpura (HSP) is the most common vasculitis of children. The aim of this study is to evaluate the demographic and clinic findings of patients with HSP and also to determine predictive factors for assessing the development of gastrointestinal system (GIS) and renal involvement.

METHODS

This study was performed prospectively among children with HSP who are under 18 years of age and being followed-up in the Pediatric Rheumatology Unit of Health Sciences University Kanuni Sultan Süleyman Training and Research Hospital between January 2016 and January 2018.

RESULTS

A total of 265 patients, 137 boys (51.7%) and 128 girls (48.3%), were involved to the study. The mean ± standard deviation of age at the diagnosis was 7.5 ± 3.2. The most common disease onset season was spring (31.7%). The rate of arthritis, GIS involvement, and renal involvement were 54%, 51.3%, and 29.1%, respectively. GIS bleeding was more frequent in males than females (p = 0.007). Boys over 7 years of age had significantly more common GIS bleeding (p = 0.04). Intussusception, relapse, and serious GIS involvement requiring hospitalization and steroid treatment were highly associated with severe renal involvement.

CONCLUSIONS

We demonstrated that patients suffering intussusception, relapse, and serious GIS involvement or requiring hospitalization and steroid treatment had tendency to present with severe renal involvement. Therefore, these patients should be followed up carefully for not overlooking renal involvement of HSP.

Childhood IgA Vasculitis (Henoch Schonlein Purpura)-Advances and Knowledge Gaps

Immunoglobulin A vasculitis (IgAV; formerly Henoch Schonlein Purpura) is the most common form of childhood vasculitis. It can occur in any age and peaks around 4-6 years old. It demonstrates seasonal variation implicating a role for environmental triggers and geographical variation. The diagnosis is made clinically and 95% of patients will present with a rash, together with any from a triad of other systems-gastrointestinal, musculoskeletal, and renal. Most cases of IgAV in children have an excellent outcome. Treatment may be required during the acute phase for gastrointestinal involvement and renal involvement, termed IgAV nephritis (previously HSP nephritis), is the most serious long-term manifestation accounting for ~1-2% of all childhood end stage kidney disease (ESKD). It therefore requires a period of renal monitoring conducted for 6-12 months. Patients presenting with nephrotic and/or nephritic syndrome or whom develop significant persistent proteinuria should undergo a renal biopsy to evaluate the extent of renal inflammation and there are now international consensus guidelines that outline the indications for when to do this. At present there is no evidence to support the use of medications at the outset in all patients to prevent subsequent renal inflammation. Consensus management guidelines suggest using oral corticosteroids for milder disease, oral, or intravenous corticosteroids plus azathioprine or mycophenolate mofetil or intravenous cyclophosphamide for moderate disease and intravenous corticosteroids with cyclophosphamide for severe disease. Angiotensin system inhibitors act as adjunctive treatment for persisting proteinuria and frequently relapsing disease may necessitate the use of immunosuppressant agents. Renal outcomes in this disease have remained static over time and progress may be hindered due to many reasons, including the lack of reliable disease biomarkers and an absence of core outcome measures allowing for accurate comparison between studies. This review article summarizes the current evidence supporting the management of this condition highlighting recent findings and areas of unmet need. In order to improve the long term outcomes in this condition international research collaboration is urgently required.

Recurrent Henoch Schönlein purpura without renal involvement successfully treated with methotrexate

Introduction

Henoch Schönlein purpura is characterised by palpable purpura, abdominal pain, arthritis/arthralgia, often with a self-limiting course. Herein, we report a patient with recurrent Henoch Schönlein purpura and severe gastrointestinal involvement, successfully treated with methotrexate.

Case presentation

A 12-year-old boy was admitted to our department with palpable purpura, abdominal pain and arthralgia. Since gastrointestinal complaints were severe, systemic steroids were administered, with tapering of dosage. Henoch Schönlein purpura recurred several times with severe abdominal pain, maelena and purpura during next two months. Colchicine and hydroxychloroquine were initiated. After four months, we also introduced methotrexate, which enabled discontinuation of previous medications including corticosteroids. Methotrexate was ceased four months later, and remission was sustained without any medications for 24 months.

Conclusion

Besides the conflicting data regarding the use of methotrexate in recurrent Henoch Schönlein purpura, our case introduces successful methotrexate experience in a child with Henoch Schönlein purpura and recurrent severe gastrointestinal involvement.

Rituximab treatment for chronic steroid-dependent Henoch-Schonlein purpura: 8 cases and a review of the literature

BACKGROUND

Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that is characterized by non-thrombocytopenic purpura, abdominal pain, arthritis, and glomerulonephritis. Typically, HSP is self-limited requiring only supportive care, but more severe cases may require corticosteroid (CS) treatment. Rarely, a subset of these patients has persistent rash, arthritis, abdominal involvement, or renal disease despite treatment with CS, or has disease recurrence on CS tapering. Refractory HSP has been effectively treated with a variety of CS sparing therapies. For life-threatening refractory HSP, the B cell depleting agent, rituximab (RTX), has been reported as beneficial for children with substantial renal or central nervous system involvement. However, RTX use for children with less severe HSP, but chronic CS dependent disease refractory to CS sparing immunomodulatory agents, has been less well explored. Herein, we describe 8 children treated with RTX for chronic refractory HSP and report a reduction in recurrent hospitalizations and eventual CS discontinuation.

METHODS

This is a retrospective analysis of eight children who were treated with RTX for chronic CS dependent HSP during the years 2006-2014 at a single institution. A chart review of the electronic medical record was performed to determine the presenting symptoms, the type and duration of treatment received, and the number of hospitalizations prior to and after RTX. The number of hospitalizations and oral corticosteroid burden were analyzed using the Wilcoxon signed rank test.

RESULTS

Prior to receiving RTX, seven patients had at least one hospitalization for HSP (median 1.5, range 0-3). Following RTX, only two patients were hospitalized, each a single time for recurrent abdominal pain. The median oral CS burden was 0.345 mg/kg/day before RTX and 0 mg/kg/day at 6 months (p = 0.078), 1 year (p = 0.0625), and 2 years (p = 0.03) following RTX infusion. Seven out of eight children met remission criteria, defined as no active rash, arthritis, nephritis (hematuria and proteinuria), or gastrointestinal distress following RTX. No serious adverse events were noted.

CONCLUSION

Overall, RTX effectively reduced the number of hospital admissions and oral CS burden. RTX also helped most all children achieve clinical remission. RTX appears to be an effective and safe alternative for chronic CS dependent and immunomodulatory refractory childhood HSP.

Late Relapse of Henoch-Schönlein Purpura in an Adolescent Presenting as Severe Gastroduodenitis

Henoch-Schönlein purpura is a systemic vasculitis, commonly affecting children. Gastrointestinal manifestations are observed in 50-75% of patients; it is well known they may occur before skin lesions in about 20% of cases during the first vasculitic episode. Relapses occur in about one third of patients, typically within 4 months from the initial presentation and with milder symptoms. We report the case of a 17-year old girl with an atypical relapse of Henoch-Schönlein purpura, presenting with acute abdominal symptoms 5 years after the first episode. Esophagogastroduodenoscopy showed duodenal multiple hyperemic and hemorrhagic lesions. To our knowledge this is the first case of hemorrhagic-erosive duodenitis representing a relapse of Henoch-Schönlein purpura occurring several years after the initial episode. Duodenojejunal inflammation should be considered as primary manifestation of Henoch-Schönlein purpura, not only during the first episode, but also in relapses. Endoscopy can be helpful for differential diagnosis, especially in patients with atypical manifestations. Further studies are needed to evaluate risk factors for Henoch-Schönlein purpura recurrence and the possible role of fecal calprotectin as an early marker for gastrointestinal involvement.