Schönlein-henoch purpura in children and adults: diagnosis, pathophysiology and management

A case report of Henoch-Schönlein purpura in the elderly complicated by multisystem involvement

RATIONALE

Henoch-Schönlein purpura (HSP), a vasculitis caused predominantly by immunoglobulin A vasculitis deposition in the blood vessel wall. It frequently affects multiple organs, however, intussusception and cardiac involvement in the elderly is extremely rare. Currently, the diagnosis of patients with atypical HSP is very difficult. Drugs and treatments lack adequate evidence-based medical proof to improve patients' long-term outcomes. We report a case of an elderly patient with allergic purpura involving the intestines, kidneys and heart, and discuss the diagnosis and treatment of patients with atypical clinical symptoms.

PATIENT CONCERNS

A 72-year-old woman whose initial symptoms were unusual, and the progression of the disease is irregular.

DIAGNOSES

The patient with HSP gradually developed intussusception, renal failure and cardiac involvement.

INTERVENTIONS AND OUTCOMES

The patient developed kidney injury and intussusception, we sequentially administered surgical intervention, glucocorticoids, hemofiltration and hemoperfusion, and her condition showed improvement. Unfortunately, by the time cardiac complications develop, the patient's condition deteriorated rapidly. At last, the patient died.

LESSONS

HSP with renal failure, intussusception, and cardiac complication is extremely rare. When patients with atypical HSP, we should always be alerted to changes in their condition. And take into account factors such as the severity of symptoms, patient preferences and complications in order to determine the most suitable therapies.

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.

Age-specific causes of upper gastrointestinal bleeding in children

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

IgA vasculitis mimicking drug-induced skin reaction and infectious colitis in an elderly patient: A case report

RATIONALE

Immunoglobulin A vasculitis (IgAV) in adults is rare and shows worse symptoms and prognosis. In real-life clinics, IgAV in elderly patients may be difficult to diagnose because of its rarity and other common diseases to consider. This study reports a case of IgAV mimicking drug-induced skin reaction in an elderly patient.

PATIENT CONCERNS

A 74-year-old female without any underlying disease presented to our emergency department as she was suffering from lower abdominal pain and diarrhea for 3 weeks. The patient was diagnosed with infectious colitis, and antibiotic treatment was administered at a local clinic. At presentation, the patient had rashes on both lower legs that developed after the antibiotic treatment, which was assumed as a drug eruption. Although antibiotic treatment was continued, the patient had persistent abdominal pain, diarrhea, hematochezia, and rashes. Proteinuria was developed on urinalysis.

DIAGNOSES

Infectious colitis, IgAV.

INTERVENTIONS

Sigmoidoscopy revealed easily bleeding erythematous mucosal lesions from the descending colon to the rectum. IgAV was suspected, and thus skin biopsy was performed. Histological findings of the skin biopsy showed leukocytoclastic vasculitis, which is compatible with IgAV. A nonsteroidal anti-inflammatory drug was administered for abdominal pain. The patient showed persistent proteinuria and a systemic steroid (prednisolone 50 mg [1 mg/kg]) was started.

OUTCOMES

After administration of the nonsteroidal anti-inflammatory drug, the patient's abdominal pain was resolved rapidly. Under systemic steroid treatment, the patient showed significant symptomatic improvements, and after 2 weeks, the skin and colonic mucosal lesions were completely resolved.

LESSONS

We present a case of adult-onset IgAV, which was initially diagnosed with infectious colitis and drug eruption. The history of skin reaction development after antibiotic treatment and the rarity of IgAV in elderly patients masked the diagnosis of IgAV. Despite its rarity, IgAV should be highly suspected in elderly patients with rashes, proteinuria, and signs of colitis.

IgA vasculitis

IgA vasculitis (IgAV) is an inflammation of small vessels caused by perivascular deposition of IgA and activation of neutrophils. It may present as systemic vasculitis (IgAV - Henoch-Schönlein purpura) or as a variant restricted to the skin (skin-limited IgAV), while IgA nephropathy presents a variant restricted to the kidneys. Systemic IgAV affects children more frequently than adults (150 to 200 for 1; incidence 1 in 1 million/year). In the latter, disease more often leads to chronic renal disease. The dominant clinical features include round or oval and retiform palpable purpura predominantly on the lower legs, arthralgia or arthritis, gastrointestinal bleeding or pain and glomerulonephritis with mesangial IgA deposits (IgAVN). Pulmonary, cardiac, genital and neurological involvement occurs, but is rare. Immune complexes containing galactose-deficient IgA1 play a pivotal role in the pathophysiology of IgAV; via the Fc alpha receptor (CD89), they induce neutrophilic inflammation around cutaneous vessels and mesangial proliferation and inflammation in the glomerulus. In case of self-limited disease, only symptomatic treatment is recommended. Treatment of severe IgAV, nephritis or gastrointestinal manifestations, is not established, but some studies reported a benefit of corticosteroids, combined with immunosuppressive drugs. Short-term outcome depends on the severity of gastrointestinal manifestations, while long-term prognosis depends on the severity of nephritis.

Predictability of the Oxford classification of IgA nephropathy in Henoch-Schonlein purpura nephritis

BACKGROUND

Whether the Oxford classification of immunoglobulin A nephropathy can be utilized to predict the adverse renal outcome of Henoch-Schonlein purpura nephritis (HSPN) has been long-debated. We, therefore, performed a meta-analysis to evaluate the prognostic value of Oxford classification lesions in HSPN.

METHODS

We systematically searched Medline, EMBASE, Web of Science, and the Cochrane Library for articles published from January 1970 to August 2020. Cohort and case-control studies investigating the correlation between the Oxford classification and renal outcome were included, the quality of which was assessed by the Newcastle-Ottawa scale criteria. The pooled odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated with a random-effects model or a fixed-effects model depending on the heterogeneity.

RESULTS

A total of 485 papers were reviewed and eventually 9 comparisons were included, providing data of 1688 patients with HSPN. ORs for adverse renal events were 2.83 (95% CI 1.84-4.35; P < 0.001), 1.96 (95% CI 1.28-2.98; P < 0.05), and 5.45 (95% CI, 3.15-9.45; P < 0.001) for patients with lesions of endocapillary hypercellularity (E), segmental sclerosis (S), and tubular atrophy /interstitial fibrosis (T), respectively, without significant heterogeneity (E: I² = 0.0%; P = 0.498; S: I² = 22.4%; P = 0.258; T: I² = 33.6%; P = 0.171). Subgroup analysis adjusted for age also supported the results that E, S, and T lesions could serve as poor predictors (P < 0.05). Additionally, crescents (C) were strongly associated with renal outcome (OR 2.22; 95% CI 1.62-3.04; P < 0.001), with moderate heterogeneity (I² = 49.3%; P = 0.066). However, it should be noted that it is not the presence but the proportions of crescent lesions that were related to the high risk of progression to adverse renal events, because the predictability of lower rates of crescent (C1, with crescents > 0 and ≤ 25%) was uncertain (OR 2.21; 95% CI 0.75-6.51; P > 0.05). Although the pooled OR revealed that lesions of mesangial hypercellularity (M) were correlated with poor renal prognosis (OR 2.41; 95% CI 1.07-5.43; P < 0.05), subgroup analysis separating children from adults indicated that there seemed to be no significant difference.

CONCLUSIONS

Oxford classification, especially for E, S, T, and C, might be recommended for patients with HSPN, regardless of children and adults.

Immunoglobulin A Vasculitis in a Patient on Hemodialysis and With a Metastatic Liver Lesion

We present the case of a 79-year-old man on hemodialysis with immunoglobulin A (IgA) vasculitis. He developed palpable purpura three weeks after having pneumonia. A skin biopsy showed leukocytoclastic vasculitis with IgA and C3 deposition. He received a topical corticosteroid for his IgA vasculitis. He was also diagnosed with a metastatic liver lesion, which was thought to be of colorectal origin because of the elevations in carcinoembryonic antigen and cancer antigen 19-9 levels. The skin biopsy played an important role in the diagnosis of the patient on hemodialysis. Pneumonia and a metastatic liver lesion thought to be from colorectal cancer might be related to the pathogenesis of IgA vasculitis.

Influence of transitional nursing on the compliance behavior and disease knowledge of children with purpura nephritis

BACKGROUND

Purpura nephritis, also called Henoch-Schönlein purpura nephritis, is a systemic disease with small dead vasculitis as the main pathological change.

AIM

To observe the influence of transitional nursing activities on the compliance behaviors and disease knowledge of children with purpura nephritis.

METHODS

A total of 82 children with purpura nephritis were included and divided into a general nursing group (41 children) and transitional nursing group (41 children) using the envelope method. The general nursing group received routine nursing care, while the transitional nursing group received transitional nursing care. The behaviors, knowledge of the disease, and self-management ability of the two groups were evaluated after nursing care was provided.

RESULTS

The scores of four items (self-care ability, self-responsibility, health knowledge level, and self-concept) in the transitional nursing group were significantly higher than those in the general nursing group.

CONCLUSION

Transitional nursing can directly improve the disease knowledge level and self-management ability of children with purpura nephritis and effectively reduce complications.

Efficacy of montelukast for the treatment of pediatric allergic purpura

BACKGROUND

This study aims to evaluate the efficacy and safety of montelukast for the treatment of patients with pediatric allergic purpura (PAP).

METHODS

We will retrieve the following electronic databases from inception to the present: MEDILINE, Embase, CENTRAL, CINAHL, AMED, Chinese Biomedical Literature Database, China National Knowledge Infrastructure Database, Wanfang, and VIP database without language limitation. Two authors will carry out study selection, data extraction, and quality evaluation independently. RevMan V5.3 software will be used for statistical software.

RESULTS

This study will summarize high-quality evidence-based medicine to evaluate the efficacy and safety of montelukast for the treatment of PAP.

CONCLUSION

This study will provide strong evidence to determine whether montelukast is an effective and safety treatment for PAP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019145472.

Petechia of the Penis: Sexual Habits or Adverse Drug Reaction?

To the best of our knowledge, we report the first case of recurring small red macules (petechia), exclusively localized on the gland secondary to fellatio in an adult man, who is on therapy with acetylsalicylic acid. No previous studies have been ever conducted on the possible onset of penis petechia after oral sex. Petechia are nonspecific cutaneous lesions appearing as circumscribed sub-epithelial hemorrhages, or appearing as small dark red or purplish spots as a result of capillaries rupture.

Adult IgA vasculitis (Henoch-Schönlein purpura)

IgA vasculitis is a systemic vasculitis affecting small vessels. IgA vasculitis usually affect children whereas it is rare in adults (150 to 200 for 1) in which the disease is often more serious with more frequent and severe nephritis. Prevalence of adult IgA vasculitis is unknown and its annual incidence is 1 in 1 million. The dominant clinical features include cutaneous purpura, arthritis and gastrointestinal symptoms. Sometimes nephritis can add, typically as glomerulonephritis with IgA mesangial deposits. Pulmonary, cardiac, genital and neurological symptoms have also been observed. Although the cause is unknown, it is clear that IgA plays a pivotal role in the immunopathogenesis of IgA vasculitis. Only symptomatic treatment is advised in case of self-limited disease. Treatment of severe IgA vasculitis, nephritis or gastrointestinal manifestations, is not established but some studies, which need to be confirmed, reported the benefit of corticosteroids combined with immunosuppressive drugs. Short-term outcome depends of the severity of the gastro-intestinal manifestations. The long-term prognosis is heavily dependent on the presence and severity of nephritis. Studies with prolonged follow-up show up to one third of adult patients reaching end stage renal failure, as for IgA nephropathy. Some authors even suggest that IgA nephropathy and IgA vasculitis would be the same disease.

[Renal prognosis of IgA vasculitis nephritis in adult patients: a monocentric study of 25 cases]

La néphropathie de la vascularite à IgA conditionne le pronostic de cette affection chez l’adulte. Le but de notre étude était d’étudier les caractéristiques cliniques de cette atteinte rénale chez l’adulte et d’identifier les facteurs de pronostic rénal. Il s’agit d’une étude monocentrique rétrospective portant sur les patients ayant une vascularite à IgA (purpura rhumatoïde) (critères de l’EULAR) avec une atteinte rénale prouvée histologiquement et classée selon la classification de Pillebout. Nous avons analysé la survie rénale et identifier les facteurs de pronostic rénal. Vingt cinq patients ont été inclus (genre ratio M/F = 2,57) d’âge moyen au diagnostic du purpura rhumatoïde de 35,76 ans. Un purpura était présent dans 100% des cas avec une atteinte articulaire dans 28%. Une insuffisance rénale était présente dans 44% des cas. La classification histologique la plus fréquente était la classe II. Une rémission clinique a été observée dans 44% des cas et une évolution vers le stade terminal de l’insuffisance rénale chronique dans 36% des cas. La survie rénale à 195 mois était de 57%. Les facteurs pronostiques identifiés étaient l’atteinte digestive (p = 0,022), l’insuffisance rénale initiale (p = 0,0004), la classification glomérulaire (p = 0001) et la sévérité des lésions histologiques, le traitement par bloqueurs du système rénine angiotensine (p = 0,01) et les échanges plasmatiques (p = 0,03). Notre étude montre que l’atteinte rénale au cours des vascularites à IgA peut être relativement sévère avec un mauvais pronostic rénal. L’identification des facteurs pronostiques cliniques et histologiques pourrait guider l’élaboration d’études thérapeutiques prospectives.

Clinical and Pathological Characteristics of Elderly Japanese Patients with IgA Vasculitis with Nephritis: A Case Series

Objective This case series aimed to identify the clinical and pathological characteristics of elderly patients (≥60 years) with biopsy-proven IgA vasculitis with nephritis (IgAVN). Methods The clinical and pathological presentation and treatment outcomes were compared between two groups. Patients Patients with IgAVN who were ≥19 years old at the time of their renal biopsy were divided into elderly (≥60 years) and adult (19-59 years) groups. Results Of the 23 patients in our study, 13 were elderly. In the elderly group, the median age at the diagnosis was 68 years (range, 60-85 years), with a median follow-up period of 15 months (range, 3-80 months). Twelve elderly patients had comorbidities, including hypertension, diabetes mellitus, chronic kidney disease, cardiovascular disease, and malignancies. A decrease in the estimated glomerular filtration rate, as well as massive proteinuria and rapidly progressive nephritic syndrome, were more frequent in the elderly group than in the adult group. Furthermore, renal pathological changes, including cellular or fibrocellular crescents, interstitial fibrosis, tubular atrophy, and arteriosclerosis, were more severe among elderly patients than adult patients. All elderly patients were treated with glucocorticoids and had no incidence of end-stage renal disease at the final follow-up; in addition, nine elderly patients had reduced proteinuria with a preserved renal function. Adverse events, including infection, diabetes mellitus, and vascular disorders, were identified in nine patients. Three elderly patients died from severe infections. Conclusion IgAVN in elderly patients is characterized by severe renal involvement. Elderly patients are at higher risk than adults for treatment-related adverse events.

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.

Vascularite à IgA (purpura rhumatoïde) de l’adulte

La vascularite à IgA (VIgA), anciennement purpura rhumatoïde (PR), est une vascularite systémique des petits vaisseaux à dépôts d’immunoglobulines A (IgA). Elle est beaucoup plus fréquente chez l’enfant que chez l’adulte (150 à 200 pour 1). La prévalence du PR chez l’adulte n’est pas connue et son incidence est estimée à 1/million. La maladie de l’adulte semble en effet différer de celle de l’enfant par l’incidence et la gravité des manifestations cliniques. La VIgA est caractérisée par l’association d’un purpura vasculaire cutané à des signes articulaires et gastro-intestinaux. Une atteinte rénale s’associe parfois à ces signes. Il s’agit alors d’une glomérulonéphrite à dépôts mésangiaux d’IgA. Plus rarement des localisations neurologiques, pulmonaires, cardiaques ou urogénitales peuvent s’observer. Sa physiopathologie demeure inconnue, mais les IgA joueraient un rôle central. Lorsque la symptomatologie est peu sévère, seul un traitement symptomatique est conseillé. À l’opposé, dans les formes digestive ou rénale sévères, des traitements plus agressifs associant, le plus souvent, des corticostéroïdes à du cyclophosphamide ont été proposés. Leur efficacité est en cours d’évaluation. Le pronostic à court terme de la maladie dépend de la sévérité de l’atteinte digestive, et à long terme de la sévérité de l’atteinte rénale. Les études ayant un suivi suffisamment prolongé montrent qu’un tiers des malades adultes évoluent vers l’insuffisance rénale terminale.

Usefulness of urinary collagen IV excretion for predicting the severity of Henoch-Schönlein nephropathy children

The aim of the study

The aim of the study was to evaluate the usefulness of urinary collagen IV (Col IV) excretion for predicting the severity of autoimmune renal inflammation in children with HSN (Henoch-Schönlein nephritis).

Material and methods

We studied 26 children, in whom HSN was diagnosed based on kidney biopsy. In all patients, urinalysis was performed and 24-hour urinary protein excretion was measured at the onset of the disease. All kidney biopsies were also scored using the Oxford classification: M – mesangial hypercellularity score (M0 absent, M1 present); E – presence of endocapillary proliferation (E0 absent, E1 present), S – segmental glomerulosclerosis/adhesion (S0 absent, S1 present), T – tubular atrophy/interstitial fibrosis (T0 ≤ 25%, T1 26-50%, T2 > 50%). The MEST score was calculated as the sum of M + E + S + T.

Results

Urinary Col IV level was significantly higher in the study group than in control group. Urinary Col IV level was insignificantly higher in group A (nephrotic proteinuria) compared to the B (non-nephrotic proteinuria) and C (without proteinuria).We found no significant differences in the age at the disease onset, severity of proteinuria, and Col IV between groups 1 (S0, T0) and 2.(S1,T1/T2). The MEST score was significantly higher in group 2 than group 1.

Conclusions

Urinary Col IV excretion in children with HSN may be related to the lesions severity by the Oxford classification but seems to be associated with the mean value (the MEST score).

In younger children, a more aggressive disease course is observed, and thus earlier and more aggressive treatment should be considered in this group.

Vasculitis: Kids are not just little people

Cutaneous vasculitis, inflammatory destruction of blood vessels, can present with a wide range of clinical and pathologic findings across a number of heterogeneous conditions. Although some vasculitides are present in both children and adults, some important differences exist in clinical presentation, etiology, management, and prognosis in childhood vasculitis versus adult vasculitis. Cutaneous vasculitis is rare in children, and most childhood vasculitides, of which Henoch-Schönlein purpura is the most common, histologically are small vessel leukocytoclastic vasculitis. In children, infectious etiologies are more common than in adults. Childhood cutaneous vasculitis is most often self-limited with a good prognosis, and treatment is mainly supportive. © 2017 Elsevier Inc. All rights reserved.

A Case of Henoch-Schonlein Purpura Associated with Rotavirus Infection in an Elderly Asian Male and Review of the Literature

Patient: Male, 73

Final Diagnosis: Henoch-Schönlein purpura (HSP)

Symptoms: Abdominal pain • bloating • blood in stool • nausea • vomiting

Medication: —

Clinical Procedure: EGD • colonoscopy • kidney biopsy • skin biopsy • arthrocentesis

Specialty: Rheumatology

Clinical features and outcomes of diffuse endocapillary proliferation Henoch-Schönlein purpura nephritis in children

OBJECTIVE

To investigate the outcomes of childhood diffuse endocapillary proliferation Henoch-Schönlein purpura nephritis (DEP-HSPN) in response to early diagnosis and prompt treatment.

METHODS

Eleven cases of DEP-HSPN in children were investigated in comparison to HSPN without diffuse endocapillary proliferation (non-DEP-HSPN).

RESULTS

DEP-HSPN had a higher prevalence of nephrotic syndrome but a lower prevalence of hematuria compared to non-DEP-HSPN. IgA, IgG and IgM antibody deposition was found in DEP-HSPN by histopathological examination. Proteinuria cleared in all 11 cases through treatment with steroids and/or immunosuppressive drugs. However, half of the DEP-HSPN patients continuously had hematuria after treatment.

CONCLUSION

The early diagnosis and prompt initiation of immunosuppressive treatment based on renal biopsy are important for achieving favorable outcomes.

Henoch-Schonlein Purpura in Children Hospitalized at a Tertiary Hospital during 2004-2015 in Korea: Epidemiology and Clinical Management

PURPOSE

To investigate the epidemiology, clinical manifestations, investigations and management, and prognosis of patients with Henoch-Schonlein purpura (HSP).

METHODS

We performed a retrospective review of 212 HSP patients under the age of 18 years who were admitted to Inje University Sanggye Paik Hospital between 2004 and 2015.

RESULTS

The mean age of the HSP patients was 6.93 years, and the ratio of boys to girls was 1.23:1. HSP occurred most frequently in the winter (33.0%) and least frequently in the summer (11.3%). Palpable purpura spots were found in 208 patients (98.1%), and gastrointestinal (GI) and joint symptoms were observed in 159 (75.0%) and 148 (69.8%) patients, respectively. There were 57 patients (26.9%) with renal involvement and 10 patients (4.7%) with nephrotic syndrome. The incidence of renal involvement and nephrotic syndrome was significantly higher in patients with severe GI symptoms and in those over 7 years old. The majority of patients (88.7%) were treated with steroids. There was no significant difference in the incidence of renal involvement or nephrotic syndrome among patients receiving different doses of steroids.

CONCLUSION

In this study, the epidemiologic features of HSP in children were similar to those described in previous studies, but GI and joint symptoms manifested more frequently. It is essential to carefully monitor renal involvement and progression to chronic renal disease in patients ≥7 years old and in patients affected by severe GI symptoms. It can be assumed that there is no direct association between early doses of steroids and prognosis.

Urological manifestations and treatment of the primary systemic vasculitides

The primary systemic vasculitides (PSV) are a group of rare inflammatory disorders affecting blood vessels of varying size and multiple organs. Urological manifestations of PSV are uncommon. Testicular vasculitis is the most commonly reported finding and is associated with Polyarteritis Nodosa (PAN), Henoch-Schönlein Purpura (HSP), anti-neutrophil cytoplasm antibody associated Vasculitides (AAV), Giant Cell Arteritis (GCA) and Kawasaki disease. Prostatic vasculitis has been reported in association with GCA and AAV. Ureteric involvement has been noted in PAN, HSP and AAV. Other urogenital manifestations of PSV include genital ulceration and bladder dysfunction in Behçets Disease and haematuria which is commonly seen in many of the PSV. Finally, therapies used to treat the PSV, especially cyclophosphamide, are associated with urological side-effects including haemorrhagic cystitis and urothelial malignancy. The aim of this review is to examine how the urological system is involved in the PSV. Each PSV is examined in turn, with a brief clinical description of the disease followed by a description of the urological manifestations and management. Identification of urological manifestations of PSV is important as in many cases symptoms may improve with immunosuppressive therapy, avoiding the need for invasive surgery. Additionally, patients who present with isolated urogenital PSV are at higher risk of developing subsequent systemic vasculitis and will need to be followed up closely.

Korean herbal medicine for treating henoch-schonlein purpura with yin deficiency: five case reports

Objectives:

The purpose of this study is to report the clinical effect of Korean medicine (KM) treatment for Henoch-Schonlein purpura (HSP).

Methods:

Five HSP patients who demonstrated a Yin deficiency and who had a history of a previous upper respiratory tract infection were included in this study. Four patients had arthritis and three had severe stomachache. One of them appeared to have proteinuria and hematuria before starting KM treatment.

Results:

All patients were improved with only herbal medicine, Jarotang (JRT). Purpura in the lower extremities and abdominal pain, which were not treated by using a corticosteroid, disappeared and had not recurred after 6 months.

Conclusion:

These cases indicate that JRT may be effective in treating HSP in patients who demonstrate Yin deficiency, even though the number of cases was limited to five.

Diagnosis and management of cutaneous vasculitis in children

Cutaneous vasculitis in children is rare. Causes of cutaneous vasculitis are varied and are typically differentiated by the affected vessel size. A skin biopsy remains the gold standard for diagnosis but other causes for vasculitis, including systemic conditions, should be considered. This article discusses the childhood conditions commonly presenting with cutaneous vasculitis (leukocytoclastic vasculitis, cutaneous polyarteritis nodosa), biopsy recommendations and findings, and management and potential differential diagnoses, and includes a brief summary of other diseases that may include cutaneous symptoms as a constellation of other systemic findings.

Gastroenterology cases of cutaneous leukocytoclastic vasculitis

Rarely, leukocytoclastic vasculitis can result from ischemic colitis, inflammatory bowel disease, and cryoglobulinemia. There is no established standard for the treatment of leukocytoclastic vasculitis associated with gastroenterologic diseases. This paper presents three cases of leukoytoclastic vasculitis, each of which is associated with a different gastroenterologic condition: ischemic colitis, Crohn's disease, and chronic hepatitis C. Each condition went into remission by treatment of leukocytoclastic vasculitis, regardless of the underlying disease.

[Henoch-Schönlein purpura : most frequent form of vasculitis in childhood and adolescence]

Henoch-Schönlein purpura is the most common form of vasculitis in childhood and adolescence. It is manifested as palpable purpuras in the region of position-dependent extremities with otherwise good clinical general condition. The expression on the skin can, however, be variable so that sometimes other differential diagnoses must be included. In typical cases an extensive diagnostic procedure is unnecessary but the short-term complications of abdominal symptoms as well as the long-term complications of nephritis should be pursued. If musculoskeletal symptoms occur paracetamol or non-steroidal anti-inflammatory drugs are effective as are steroids for reducing the duration of abdominal pain. The effectiveness of steroid prophylaxis of renal damage is still controversial.

Serum Interleukin-18 in Children with Henoch-Schönlein Purpura: A Promising Marker of Disease Activity?

Henoch-Schönlein purpura (HSp) is the most common systemic vasculitis of childhood with typical skin involvement and concurrent signs involving joints, gastrointestinal tract, and kidney. HSp pathogenesis is still far from being completely understood, though a knotty cytokine complex is believed to contribute to its intimate processes. The aim of our evaluation is to establish the relationship between serum levels of interleukin (IL)-18 and disease outcome and establish its feasibility to provide a marker of disease activity or even a prognostic tool in clinical practice. We examined clinical/laboratory variables and serum IL-18 in 17 children hospitalized during a year for HSp, diagnosed by EULAR/PRINTO/PRES criteria; the same patients were re-evaluated after 6 months. All results were compared with 25 age-matched healthy controls. IL-12 and IL-6 were also evaluated in a cohort of the same patients and compared with controls. General and clinical variables (sex, edema of the extremities, gastrointestinal or renal complications, relapses and renal involvement at 6 months) had no relationship with cytokine levels. Serum IL-18 and IL-6 levels were found significantly increased at diagnosis in HSp patients when compared with healthy controls. After 6 months, serum IL-18 and IL-12 levels were significantly decreased in patients, while IL-12 and IL-6 levels were significantly increased compared to healthy controls. Though preliminary and expecting further confirmation on a larger sample, our data support the conclusion that serum IL-18 levels reflect HSp activity.

Gastrointestinal manifestations of Henoch-Schonlein purpura in children

Henoch-Schonlein purpura (HSP) is the most common systemic vasculitis in childhood. The etiology and pathogenesis of HSP are still not very clear. The diagnostic criteria for HSP include palpable purpura with at least one other manifestation-abdominal pain, IgA deposition, arthritis or arthralgia, or renal involvement. Bacterial and viral infections are the most common triggers for HSP involving the gastrointestinal (GI) tract. The clinical manifestations of HSP include purpura, colicky abdominal pain and bloody stools. Some HSP patients have severe complications. Ultrasound is usually the first choice because it permits prompt detection of the involved gut and complications. Endoscopy permits direct observation of the mucous and biopsy of affected areas to detect abnormal IgA deposition or leukocytoclastic vasculitis (LCV). There are two types of diseases that should be differentiated from HSP involving the GI: diseases demonstrating purpura and those demonstrating thickened bowel wall. The majority of children with HSP improve spontaneously, and few patients need medications. Surgical intervention is usually not recommended.

Corticosteroids may improve clinical outcomes during hospitalization for Henoch-Schönlein purpura

OBJECTIVE

To characterize the effect of corticosteroid exposure on clinical outcomes in children hospitalized with new-onset Henoch-Schönlein purpura (HSP).

PATIENTS AND METHODS

We conducted a retrospective cohort study of children discharged with an International Classification of Diseases, Clinical Modification code of HSP between 2000 and 2007 by using inpatient administrative data from 36 tertiary care children's hospitals. We used stratified Cox proportional hazards regression models to estimate the relative effect of time-varying corticosteroid exposure on the risks of clinical outcomes that occur during hospitalization for acute HSP.

RESULTS

During the 8-year study period, there were 1895 hospitalizations for new-onset HSP. After multivariable regression modeling adjustment, early corticosteroid exposure significantly reduced the hazard ratios for abdominal surgery (0.39 [95% confidence interval (CI): 0.17-0.91]), endoscopy (0.27 [95% CI: 0.13-0.55]), and abdominal imaging (0.50 [95% CI: 0.29-0.88]) during hospitalization.

CONCLUSIONS

In the hospital setting, early corticosteroid exposure was associated with benefits for several clinically relevant HSP outcomes, specifically those related to the gastrointestinal manifestations of the disease.

Temporal association of Streptococcus, Staphylococcus, and parainfluenza pediatric hospitalizations and hospitalized cases of Henoch-Schönlein purpura

OBJECTIVE

To determine if hospitalizations for specific infectious exposures are associated with hospital admissions for Henoch-Schönlein purpura (HSP).

METHODS

We conducted a retrospective cohort study using administrative data of children admitted to 40 children's hospitals between January 1, 2002, and December 31, 2008. We examined the association of standardized rates of group A ß-hemolytic Streptococcus (GABS), Staphylococcus aureus, parainfluenza, influenza, adenovirus, and respiratory syncytial virus (RSV)-associated hospital admissions with standardized rates of HSP hospital admissions on a month by month basis using autoregressive moving average process models to account for temporal autocorrelation and clustering by hospital.

RESULTS

Among the 3,132 admissions for HSP observed over the 7-year study period, hospital admissions were most frequent September through April, but with substantial variability between hospitals for each month. Accounting for these month by month differences within each hospital, the rate of HSP admissions in a given month increased significantly as the standardized rates of GABS (p = 0.01), S. aureus (p < 0.01), and parainfluenza (p = 0.03) admissions increased.

CONCLUSION

Our results demonstrate a local month by month temporal association between hospitalization for GABS, S. aureus, and parainfluenza and hospitalization for HSP. Future investigations will be required to determine causality.

Predictors of outcome in Henoch-Schönlein nephritis

Factors predictive of renal outcome were studied in 78 children with Henoch-Schönlein nephritis followed up for as long as 17 (mean 5.2) years. Patients with a good outcome (74%) were healthy or had microalbuminuria or mild proteinuria at the final follow-up (FU), and those with poor outcome (26%) had active renal disease or chronic kidney disease at stages IV-V. Patients with mild symptoms at onset (hematuria + or - mild proteinuria) had a poor outcome in 15% of cases versus 41% of those with severe symptoms (nephritic or nephrotic syndrome or nephritic-nephrotic picture) (p = 0.011). However, among patients with mild proteinuria at onset, 18% showed a poor prognosis; non-nephrotic proteinuria with a urine albumin/creatinine ratio at a cut-off value of >144 mg/mmol at the 1-year FU was predictive of a poor outcome. Among 59 biopsied patients, 37% of those with advanced histological findings [International Study of Kidney Disease in Children (ISKDC) stages III-V] had a poor outcome compared to none of those with mild findings (ISKDC stages I-II) (p = 0.0015). Patients with a poor outcome were older at onset, had more proteinuria, and lower glomerular filtration rate at the 1-year FU compared with patients with a good outcome. Multivariate analysis showed that proteinuria at the 1-year FU and the ISKDC grading score of the renal biopsy were the two most discriminant factors of a poor prognosis.

Addition of cyclophosphamide to steroids provides no benefit compared with steroids alone in treating adult patients with severe Henoch Schönlein Purpura

Henoch Schönlein Purpura (HSP) is a common disease in children, usually associated with a good prognosis. In adults there are no prospective studies concerning its prognosis or treatment, especially in cases of severe visceral involvement. Here we compared steroid therapy without or with cyclophosphamide co-treatment in adults with severe HSP in a 12-month, multi-center, prospective, open-label trial that treated 54 adults with biopsy-proven HSP including proliferative glomerulonephritis and severe visceral manifestations. All received steroids; however, 25 were randomized to also receive cyclophosphamide. The primary endpoint that occurred in three patients in each group was complete disease remission defined as zero on the Birmingham Vasculitis Activity Score with no persistent or new clinical and/or biological vasculitis at 6 months. No patient had active visceral involvement. The secondary endpoints were renal outcome, deaths, and adverse events at 12 months. Renal function, proteinuria, safety data, incidence of diabetes, and severe infections were similar between the two groups. At the last follow-up, renal function remained stable. The small population size of our study does not permit definitive conclusions; however, we suggest that treatment of adults with severe HSP by adding cyclophosphamide provides no benefit compared with steroids alone.

Henoch-Schönlein purpura nephritis in children: risk factors, prevention and treatment

AIM

To identify risk factors for a child with Henoch-Schönlein purpura (HSP) either to develop nephritis (HSPN) or to contract progressive course and to obtain the currently available evidence on the efficacy of treatment options in both preventing and treating the established renal disease.

METHOD

Review of the literature published over the last two decades.

RESULTS

Persistent or recurrent purpura, severe abdominal symptoms and an older age proved as the most significant risk factors for later HSPN. The risks of long-term renal impairment are the highest in children having at presentation nephritic/nephrotic syndrome and/or more than 50% of glomeruli occupied by large crescents or sclerosing lesions. Randomized controlled trials (RCT) do not support short course prednisone at presentation of HSP in preventing persistent renal disease. Many uncontrolled studies using various treatment regimens have reported outcomes considered better than expected. However, the data from RCTs are sparse and no treatment options for the established renal disease can be currently recommended based on RCTs.

CONCLUSION

Severity and/or duration of extrarenal HSP symptoms and an older age are the most significant risk factors for developing HSPN, whereas clinical and histological severity at HSPN onset are in general predictive of a long-term renal impairment. The existing evidence does not support of short course prednisone in preventing persistent renal disease. A well-designed RCTs are needed in children with moderately severe or rapidly progressive (crescentic) HSPN.

Longitudinal study of microvascular involvement by nailfold capillaroscopy in children with Henoch-Schönlein purpura

The aim of this study is to describe by video-nailfold capillaroscopy the microvascular involvement and capillary changes in children with Henoch-Schönlein purpura (HSp) and to establish a possible correlation with clinical outcome. Thirty-one patients underwent capillaroscopic evaluation through a videomicroscope during the acute phase and after 6 months. Twenty sex/age-matched controls were also examined. All capillaroscopic variables were statistically examined in combination with laboratoristic/clinical data. Architectural and morphological changes recorded during the acute phase were statistically significant in comparison to the controls (p < 0.01). At the follow-up, oedema was still observed in all patients, whereas, morphological changes only in two. There was a no significant correlation between capillaroscopy changes, laboratoristic/clinical data, and outcome. Video-nailfold capillaroscopy can be a simple tool to evaluate microvascular abnormalities in the acute phase of HSp, and the persistence of oedema could suggest an incomplete disease resolution at a microvascular level.

Clinical manifestations and outcomes of Henoch-Schönlein purpura: comparison between adults and children

BACKGROUND

Henoch-Schönlein purpura (HSP) primarily affects children, but age at onset is thought to be important in determining disease severity and outcome. This study compared the clinical and laboratory data from children and adults with HSP.

METHODS

This retrospective 5-year study enrolled 65 children and 22 adult HSP patients attending a medical center.

RESULTS

Gross hematuria and lower-extremity edema were significantly more frequent in adults (p < 0.05). All the children developed renal involvement within 2 weeks, while 67% of the adult patients developed hematuria by the fifth week of disease onset. Elevated white blood cell count and increased erythrocyte sedimentation rate were significantly more common in children (p < 0.05). Adults had a higher frequency of renal involvement (p < 0.05), though this was also present in 14 children (21.54%), 12 with isolated hematuria and proteinuria and two with nephrotic syndrome. All the children maintained normal renal function. Twelve adults had renal involvement (52.6%), six with progression to renal insufficiency. Patients with abdominal pain at disease onset had a significantly higher probability of developing nephrotic syndrome (p < 0.05). Logistic regression revealed that age >20 years, male, bloody stools, clinical course with relapse of purpuric rash, and persistent rash for >1 month were poor prognostic indicators for HSP nephritis (p < 0.05).

CONCLUSIONS

HSP nephritis in adults had a higher risk of progression to renal insufficiency. More aggressive treatment and extended follow-up with repeated urinalysis for at least 6 weeks were often necessary, especially in older patients.

Atypical presentation of Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is the most common form of vasculitis found in the pediatric population. The most common presenting complaint for children with HSP is a purpuric rash on the lower extremities. Many other organ systems beyond the skin can be involved for children with HSP. We report a case of a 7-year-old girl with HSP who presented with status epilepticus and onset of rash 2 weeks after her initial symptoms.

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.

Mycophenolate mofetil treatment of crescentic Henoch–Schönlein nephritis with IgA depositions

Mycophenolate mofetil (MMF) is considered to be a promising therapeutic agent in primary glomerulonephritis but there are no data on the use of MMF in Henoch-Schönlein nephritis (HSN). Herein we report the first adult crescentic HSN patient in whom long-term complete remission was achieved after MMF therapy.

[Henoch-Shönlein purpura]

Henoch-Shönlein purpura (HSP) is an immunoglobulin A (IgA) vasculitis that affects the small vessels. It is a multi-organ system disease that may include cutaneous purpura, arthralgia, acute enteritis and nephritis. Nephritis is characterized by mesangial proliferation with IgA deposits. Neurological, pulmonary, cardiac or genitourinary complications occur rarely. The acute stage progresses by successive flare-ups of limited duration. Although the cause is unknown, it is clear that IgA plays a central role in the immunopathogenesis of HSP. The syndrome usually affects children in which evolution is generally favourable. In adults the disease is rare and seems different from children with much more severe manifestations and prognosis. Short-term outcome, in children as in adults, depends on the severity of gastrointestinal manifestations. Long-term outcome depends on renal involvement. In studies with enough observation time, as much as one third of the patients will progress to end stage renal failure. The benign manifestations of the disease are managed by appropriate symptomatic measures. In case of severe involvement, including severe gastrointestinal complications or proliferative glomerulonephritis, immunosuppressive drugs may be required including steroids. These specific treatments are still controversial and their efficacy has to be evaluated.

Gastrointestinal manifestations of Henoch-Schonlein Purpura

Henoch-Schonlein Purpura (HSP) is the most common systemic vasculitis in childhood. The diagnostic criteria include palpable purpura with at least one other manifestation -- abdominal pain, IgA deposition, arthritis or arthralgia, or renal involvement. Immune complex deposits result in necrosis of the wall of small- and medium-sized arteries with infiltration of tissue by neutrophils and deposition of nuclear fragments, a process called leukocytoclastic vasculitis (LCV). It is often associated with infections, medications, or tumors. It may coexist with or mimic Crohn's disease. Periumbilical and epigastric pain worsens with meals, from bowel angina. Bleeding is usually occult or, less commonly, associated with melena. Intussusception, the most common surgical complication, is usually ileo-ileo or ileo-colic. Perforations, usually ileal, may occur spontaneously or be associated with intussusception. Ultrasound, recommended as the first diagnostic test, and CT scans may show intussusception and asymmetric bowel wall thickening mainly involving the jejunum and ileum. There are a range of endoscopic findings including gastritis, duodenitis, ulceration, and purpura, with the second portion of the duodenum characteristically being involved more than the bulb. Intestinal biopsies show IgA deposition and LCV in the submucosal vessels. Superficial biopsies may show inflammation, ulceration, edema, hemorrhage, and vascular congestion, presumably due to vasculitis-induced mucosal ischemia. The efficacy of corticosteroids in preventing severe complications or relapses is controversial. The majority of patients, however, improve spontaneously.

Effects of corticosteroid on Henoch-Schönlein purpura: a systematic review

OBJECTIVE

No consensus exists among general pediatricians or pediatric rheumatologists regarding whether corticosteroid therapy ameliorates the acute manifestations of Henoch-Schönlein purpura or mitigates renal injury. Therefore, we sought to synthesize the reported experimental and observational data regarding corticosteroid use.

METHODS

We performed a meta-analysis based on a comprehensive review of the literature in the Medline database (1956 to January 2007) and the Cochrane Controlled Trials Register. On the basis of reported outcomes among patients with Henoch-Schönlein purpura who were treated at diagnosis with corticosteroids compared with patients treated with supportive care only, we calculated odds ratios for the resolution of abdominal pain, the need for surgical intervention secondary to severe pain or intussusception, the likelihood of Henoch-Schönlein purpura recurrence, and the development of transient or persistent renal disease.

RESULTS

Of 201 articles retrieved from the initial literature search, 15 were eligible for inclusion. Corticosteroid treatment did not reduce the median time to resolution of abdominal pain but did significantly reduce the mean resolution time and increased the odds of resolution within 24 hours. Early corticosteroid treatment significantly reduced the odds of developing persistent renal disease. In addition, although the results were not statistically significant, the prospective data suggest reduced odds of both surgical intervention and recurrence.

CONCLUSIONS

Corticosteroids, given early in the course of illness, seem to produce consistent benefits for several major clinically relevant Henoch-Schönlein purpura outcomes.