Efficacy and Safety of Plasma Exchange as an Adjunctive Therapy for Rapidly Progressive IgA Nephropathy and Henoch-Schönlein Purpura Nephritis: A Systematic Review

Patients with IgA nephropathy (IgAN), including Henoch-Schönlein purpura nephritis (HSP), who present with rapidly progressive glomerulonephritis (RPGN) have a poor prognosis despite aggressive immunosuppressive therapy. The utility of plasmapheresis/plasma exchange (PLEX) for IgAN/HSP is not well established. This systematic review aims to assess the efficacy of PLEX for IgAN and HSP patients with RPGN. A literature search was conducted using MEDLINE, EMBASE, and through Cochrane Database from inception through September 2022. Studies that reported outcomes of PLEX in IgAN or HSP patients with RPGN were enrolled. The protocol for this systematic review is registered with PROSPERO (no. CRD42022356411). The researchers systematically reviewed 38 articles (29 case reports and 9 case series articles) with a total of 102 RPGN patients (64 (62.8%) had IgAN and 38 (37.2%) had HSP). The mean age was 25 years and 69% were males. There was no specific PLEX regimen utilized in these studies, but most patients received at least 3 PLEX sessions that were titrated based on the patient's response/kidney recovery. The number of PLEX sessions ranged from 3 to 18, and patients additionally received steroids and immunosuppressive treatment (61.6% of patients received cyclophosphamide). Follow-up time ranged from 1 to 120 months, with the majority being followed for at least 2 months after PLEX. Among IgAN patients treated with PLEX, 42.1% (n = 27/64) achieved remission; 20.3% (n = 13/64) achieved complete remission (CR) and 18.7% (n = 12/64) partial remission (PR). 60.9% (n = 39/64) progressed to end-stage kidney disease (ESKD). Among HSP patients treated with PLEX, 76.3% (n = 29/38) achieved remission; of these, 68.4% (n = 26/38) achieved CR and 7.8% achieved (n = 3/38) PR. 23.6% (n = 9/38) progressed to ESKD. Among kidney transplant patients, 20% (n = 1/5) achieved remission and 80% (n = 4/5) progressed to ESKD. Adjunctive plasmapheresis/plasma exchange with immunosuppressive therapy showed benefits in some HSP patients with RPGN and possible benefits in IgAN patients with RPGN. Future prospective, multi-center, randomized clinical studies are needed to corroborate this systematic review's findings.

IgA vasculitis following COVID-19 vaccination

Immunoglobulin A (IgA) vasculitis is generally triggered by infectious causes, but it has also been reported after immunisation with various vaccines. Herein, we report two cases of IgA vasculitis after receiving the first or second dose of the Pfizer-BioNTech BNT16B2b2 mRNA vaccine. Two men, aged 22 and 30 years, developed palpable purpura on the extremities and arthritis. One patient also complained of fever and gastrointestinal symptoms. Laboratory findings revealed mild leucocytosis and slightly elevated C-reactive protein levels, although the platelet count and coagulation profile were within normal levels in both cases. Proteinuria and microhaematuria were seen in one patient. Skin biopsies were performed in both patients and revealed leucocytoclastic vasculitis. The deposits of IgA and C3 were shown in immunofluorescence studies in one patient. Both patients were diagnosed with IgA vasculitis and treated with prednisolone, and their symptoms resolved within 1 week after initiation of treatment. The coronavirus disease 2019 mRNA vaccine could trigger IgA vasculitis; however, a coincidence cannot be ruled out.

A child with Henoch-Schonlein purpura secondary to a COVID-19 infection

Henoch-Schonlein purpura (HSP) is a common IgA-mediated small vessel vasculitis of childhood that affects several systems. It is characterised by a tetrad of dermatological, abdominal, joint and renal manifestations. HSP can occur secondary to upper respiratory tract infections, medications, vaccinations and malignancies. COVID-19 is caused by SARS-CoV-2, a single-stranded RNA virus from the Beta-Coronaviridae family, and often presents as a respiratory infection with symptoms ranging from a mild common cold-like illness to severe pneumonia. It has also been reported to exhibit extrapulmonary manifestations, including but not limited to cardiac, thrombotic, hepatocellular and dermatological complications. We report a case of a 4-year-old boy who presented with clinical features of HSP, with detailed history that revealed a recent recovery from a COVID-19 upper respiratory tract infection, indicating a possible correlation between the two.

Therapeutic Potential of Carbon Monoxide (CO) and Hydrogen Sulfide (H2S) in Hemolytic and Hemorrhagic Vascular Disorders-Interaction between the Heme Oxygenase and H2S-Producing Systems

Over the past decades, substantial work has established that hemoglobin oxidation and heme release play a pivotal role in hemolytic/hemorrhagic disorders. Recent reports have shown that oxidized hemoglobins, globin-derived peptides, and heme trigger diverse biological responses, such as toll-like receptor 4 activation with inflammatory response, reprogramming of cellular metabolism, differentiation, stress, and even death. Here, we discuss these cellular responses with particular focus on their mechanisms that are linked to the pathological consequences of hemorrhage and hemolysis. In recent years, endogenous gasotransmitters, such as carbon monoxide (CO) and hydrogen sulfide (H₂S), have gained a lot of interest in connection with various human pathologies. Thus, many CO and H₂S-releasing molecules have been developed and applied in various human disorders, including hemolytic and hemorrhagic diseases. Here, we discuss our current understanding of oxidized hemoglobin and heme-induced cell and tissue damage with particular focus on inflammation, cellular metabolism and differentiation, and endoplasmic reticulum stress in hemolytic/hemorrhagic human diseases, and the potential beneficial role of CO and H₂S in these pathologies. More detailed mechanistic insights into the complex pathology of hemolytic/hemorrhagic diseases through heme oxygenase-1/CO as well as H₂S pathways would reveal new therapeutic approaches that can be exploited for clinical benefit.

Henoch-Schönlein purpura in a patient with oesophageal cancer: A case report

RATIONALE

Understanding the association between Henoch-Schönlein purpura (HSP) and malignancy is essential for early diagnosis and treatment of the potential lethal disease. To the best of our knowledge, there has been only one published case of HSP coexisting with oesophageal cancer. Here, we report another patient diagnosed with HSP and oesophageal squamous carcinoma simultaneously.

PATIENT CONCERNS

A 60-year-old Chinese male was referred to our hospital because of intermittent abdominal pain, abdominal distension, melena, lower extremities purpura. Positive laboratory values included pancytopenia, microscopic hematuria, nephrotic proteinuria, hematochezia, hypoalbuminemia, hyperlipidaemia, hypocomplementemia, and increased levels of hepatobiliary enzymes and immunoglobulin (Ig) A. Gastrocolonoscopy showed multiple erosion lesion on descending duodenum, terminal ileum, and ileal flap. Biopsy of these lesions suggested non-specific inflammation.

DIAGNOSES

HSP (IIIb type) was diagnosed based on renal pathology examination in accordance with the International Study of Kidney Disease in Children (ISKDC) classification. Liver biopsy confirmed the diagnosis of nodular cirrhosis (Ishak 5). Gastroscopy unintentionally revealed three oesophagus lesions. Pathology study suggested intermediate differentiated squamous cell carcinoma (cTNM IB).

INTERVENTIONS

Before admission, he was administered intravenous Ig 10 g once daily(qd) for 10 days, methylprednisolone 40 mg qd for a week, followed by prednisolone 50 mg qd for almost 8 weeks. Endoscopic submucosal dissection (ESD) was performed to remove all lesions with negative margin after prednisolone was tapered (5 mg per week until 10 mg qd).

OUTCOMES

Despite prednisone being tapered to 2.5 mg qd within 2 months, complete remission of HSP and esophageal malignancy was achieved after the resection of the esophagus lesions during 12 months follow-up.

LESSONS

We report a rare case of oesophageal squamous cell carcinoma initially presented as HSP. This case suggests the importance of evaluating adult patients with HSP for an underlying malignancy.

Pulmonary tuberculosis presenting as henoch-schönlein purpura: Case report and literature review

INTRODUCTION

Henoch-Schönlein purpura (HSP) is an extremely rare condition in patients with pulmonary tuberculosis, with only a few reported cases. Compared to patients with typical clinical symptoms, it is difficult to make a definitive diagnosis when HSP presents as an initial manifestation in pulmonary tuberculosis patients. Herein, a case of pulmonary tuberculosis that showed HSP at first was reported, and the related literatures were reviewed.

PATIENT CONCERNS

A 24-year-old man presented with palpable purpura on the extremities, accompanied by abdominal pain, bloody stools, and knee pain.

DIAGNOSES

The patient was diagnosed with pulmonary tuberculosis based on the results of interferon gamma release assays, purified protein derivative test, and computed tomography.

INTERVENTIONS

The patient was treated with vitamin C and chlorpheniramine for 2 weeks, and the above-mentioned symptoms were relieved. However, 3 weeks later, the purpura recurred with high-grade fever and chest pain during the inspiratory phase. The patient was then treated with anti-tuberculosis drugs, and the purpura as well as the high fever disappeared.

OUTCOMES

The patient recovered well and remained free of symptoms during the follow-up examination.

CONCLUSION

Pulmonary tuberculosis presenting with HSP as an initial manifestation is not common. Therefore, it is difficult to clinically diagnose and treat this disease. When an adult patient shows HSP, it is important to consider the possibility of tuberculosis to avoid misdiagnosis and delayed treatment.

Primary IgA Vasculitis with Nephritis in a Patient with Rheumatoid Arthritis Diagnosed by Anti-galactose-deficient IgA1 Immunostaining

Renal disease is a common complication of rheumatoid arthritis (RA) and can occur secondary to RA or be induced by therapeutic agents. Recently, glomerular deposition of galactose-deficient IgA1 (Gd-IgA1) was identified as a feature of primary IgA vasculitis with nephritis (IgA-VN). We herein report a case of IgA-VN in an RA patient whose disease activity was controlled by treatment with etanercept. To distinguish between primary IgA-VN and secondary IgA-VN caused by RA or etanercept, we performed immunostaining of renal biopsy sections with the Gd-IgA1-specific antibody KM55. Positive KM55 staining confirmed the diagnosis of primary IgA-VN in a patient with RA.

Association of the infectious triggers with childhood Henoch-Schonlein purpura in Anhui province, China

BACKGROUND

Although the specific etiology of Henoch-Schonlein purpura (HSP) is still unknown, several kinds of infectious triggers have been proved to participate in its pathogenesis. The objectives of present study were to analyze the association of the infectious triggers with childhood HSP in Anhui province, China.

METHODS

1200 HSP children were recruited from January 2015 to December 2017. Serum antistreptolysin O titer, TORCH, Epstein-Barr virus, helicobacter pylori (HP), Mycoplasma antibodies (MP-Ab), tubercle bacillus antibody (TB-Ab), respiratory pathogens (legionella pneumophila, chlamydia pneumoniae, adenovirus, respiratory syncytial virus, influenza A virus, influenza B virus, rickettsia, parainfluenza virus) were determined. Patients' histories were obtained by interviews and questionnaires.

RESULTS

The annual incidence of HSP was 8.13-9.17 per 100,000. HSP occurred more commonly in spring and winter than in summer with an obvious west-to-east gradient. On admission, several potential infections were identified in 611 cases (50.92%). The infectious agents including streptococcus, HP, MP, parainfluenza, respiratory syncytial virus, TB and toxoplasma gondii were identified in 205 cases (17.08%), 71 cases (5.92%), 58 cases (4.83%), 6 cases (0.5%), 1 case (0.08%), 1 case (0.08%) and 1 case (0.08%) respectively. 123 cases (10.25%) relapsed or recurred more than one time; the mean number was 2.92, and the mean interval was 11.4 weeks. The infection was the most frequent trigger regardless of clinical phenotypes and relapse/recurrence. Symptomatic treatment plus adjunctive anti-infectious agents could significantly improve the remission rate of purpura in the infectious cases (x²=24.60, p<0.01).

CONCLUSIONS

Streptococcus is the most frequent infectious agent in HSP children regardless of clinical phenotype or relapse/recurrence. The complete elimination of infectious triggers may help relieve cutaneous purpura.

Coagulopathy of sepsis

Disseminated intravascular coagulation (DIC) is a common phenomenon in patients with sepsis, but the clinical implications of this condition are not clear. Clinical trials with coagulation inhibitors have failed to show a significant benefit concerning survival. DIC is primarily a laboratory diagnosis, based on the combination of elevated fibrin-related markers (FRM), with decreased procoagulant factors and platelets. Non-overt DIC is observed in most patients with sepsis, whereas overt DIC is less frequent. Patients with overt DIC may display consumption coagulopathy and purpura fulminans. Consumption coagulopathy is a bleeding disorder caused by low levels of platelets and procoagulant factors associated with massive coagulation activation. Purpura fulminans is caused by widespread microvascular thrombosis, resulting in tissue necrosis. Treatment with drotrecogin alfa (activated) improves survival and other outcome parameters in severe sepsis, including a subgroup of patients fulfilling the laboratory criteria of overt DIC. No randomized trials demonstrating effective therapies in consumption coagulopathy have been published. Bleeding patients with consumption coagulopathy are most frequently treated with platelet transfusions and various plasma products including fresh frozen plasma and coagulation factor concentrates. Based on case reports, treatment with drotrecogin alfa (activated) or substitution of protein C have been recommended for adjuvant treatment of sepsis-related purpura fulminans.

Henoch Schönlein Purpura Nephritis Associated with Intravesical Bacillus Calmette-Guerin (BCG) Therapy

Henoch Schönlein purpura (HSP), also known as IgA vasculitis (IgAV), is a systemic small-vessel vasculitis that predominantly affects adolescents and is rare in adults. In many cases, the onset of HSP has been causally linked to an infectious disease. We encountered a case of HSP with severe renal involvement diagnosed by renal biopsy following bacillus Calmette-Guerin (BCG) therapy for bladder cancer. This is of clinical relevance, as intravesical BCG administration is becoming an established therapy for superficial bladder cancer and is supposed to be safe. It is important for all clinicians to recognize that BCG therapy has this rare but potentially serious systemic complication.

Henoch-Schonlein purpura without typical lesions, presenting with gastrointestinal manifestations and kidney involvement following influenza - A case report

We report a case of Henoch-Schonlein purpura (HSP) presenting without typical skin lesion; atypical symptoms initially appeared following influenza infection. A 4-year-old girl with influenza presented with epigastric pain and vomiting. On physical examination, there was epigastric tenderness, but no other signs, such as skin rash. On the second day, she vomited blood 10 times. Ultrasonography indicated focal bowel wall thickening in the right upper quadrant. Esophagogastroduodenoscopy showed oedematous and purpuric mucosa in the gastric pylorus and duodenum. Steroid therapy was initiated, and symptoms improved, but microscopic haematuria persisted. Even in the absence of typical purpura, if any gastrointestinal symptoms are observed and HSP is suspected, aggressive diagnostic tools must be considered, including ultrasonography or endoscopy. With only a few reported cases of HSP associated with influenza infection, this is the first reported case with gastrointestinal involvement and renal impairment, but without typical skin lesions.

HENOCH-SCHÖNLEIN PURPURA NEPHRITIS FOLLOWING INFLUENZA VACCINATION: A CASE REPORT AND REVIEW OF THE LITERATURE

We reported a 16-year-old boy who developed Henoch-Schönlein purpura (HSP) 15 days after receiving a seasonal influenza vaccine. His symptoms improved temporally with treatment but he developed HSP nephritis (HSPN) that relapsed multiple times over the following three years. This case of Henoch-Schönlein purpura may have been due to the seasonal influenza vaccine. The mechanism for this association is unclear. Practitioners should be aware of this possible complication.

[Association of Cosmc gene mutation with susceptibility to Henoch-Schönlein purpura in children]

OBJECTIVE

To investigate the presence of Cosmc gene mutation in children with Henoch-Schönlein purpura (HSP) and the association between Cosmc gene mutation and the susceptibility to HSP.

MESULTS

Eighty-four children who were diagnosed with HSP between March 2014 and December 2015 were selected as the HSP group. Fifty-eight healthy volunteers matched for age and sex were enrolled as the control group. Fasting venous blood (5 mL) from the two groups was collected in EDTA anticoagulated tubes, followed by the isolation of peripheral blood mononuclear cells (PBMCs) through density gradient centrifugation. Genomic DNA was extracted from PBMCs according to the manufacturer's protocol, and the whole exon region of Cosmc gene was amplified by touch-down polymerase chain reaction (touch-down PCR). The PCR products were identified by 1% agarose gel and sequenced in order to further examine the association between Cosmc gene mutation and the susceptibility to HSP.

RESULTS

Sequencing results showed two mutations (c.393T>A and c.72A>G) of Cosmc gene in children with HSP. There were no significant differences in the genotype and allele frequencies at the two loci between the HSP and control groups, and this distribution was not associated with sex.

CONCLUSIONS

The mutations c.393T>A and c.72A>G in the exon region of Cosmc gene in children with HSP are not associated with the onset of HSP.

Atopic Dermatitis and Association of Risk for Henoch-Schönlein Purpura (IgA Vasculitis) and Renal Involvement Among Children: Results From a Population-Based Cohort Study in Taiwan

Elevation of Th2 cytokine-driven inflammatory mediators has been reported in acute stage of Henoch-Schönlein purpura (HSP). However, the temporal interaction between Th2-mediated allergic diseases and HSP with renal involvement remains unknown. Herein, we conducted a population-based cohort analysis to investigate the risk of HSP and renal involvement in children with atopic dermatitis (AD) as 1 of the first steps in the atopic march.From 2000 to 2007, 95,208 children with newly diagnosed AD and 190,416 randomly selected non-AD controls were included in the study. By the end of 2008, incidences of HSP in both cohorts and the AD cohort to non-AD cohort hazard ratios (HRs) and confidence intervals (CIs) were measured. Comparison of renal involvement in HSP between children with and without AD was analyzed.The incidence of HSP during the study period was 1.75-fold greater (95% CI: 1.27-2.42) in the AD cohort than in the non-AD cohort (14.2 vs 8.11 per 100,000 person-years). The AD to non-AD HR of HSP was greater for girls (1.92, 95% CI: 1.18-3.13), children older than 6 years (2.54, 95% CI: 1.15-5.59), and those living in less urbanized area (2.74, 95% CI: 1.10-6.82). Concurrent allergic rhinitis or asthma did not increase the HR of HSP further. The HR for HSP in AD children increased from 0.67 (95% CI: 0.41-1.11) for those with ≤2 AD-related visits to 9.77 (95% CI: 6.44-14.8) for those with >4 visits (P < 0.0001, by the trend test). The risk of developing HSP in the AD cohort was highest within first year after AD diagnosis (HR: 3.99; 95% CI: 1.61-9.89). AD cohort with HSP had higher occurrence rate of renal involvement, particular hematuria, than non-AD cohort with HSP.AD children had a greater risk of developing HSP and HSP with renal involvement. Further research is needed to clarify the role of allergy in the pathogenesis of HSP and renal involvement.

Anaphylactoid Purpura Manifested after Acute Gastroenteritis with Severe Dehydration in an 8-Year-Old Male Child: A Case Report

Anaphylactoid purpura, also known as Henoch-Schönleinpurpura (HSP), is an IgA-mediated vasculitis that tends to be a benign disease of childhood. Up to 50% of cases are preceded by an upper tract respiratory infection caused by group-A beta-hemolytic streptococcus and present with the common tetrad of abdominal pain, arthritis, purpuric rash, and renal involvement. The majority of patients recover completely. Here we document a rare case of anaphylactoid purpura which manifested with skin lesions in the form of palpable purpura following about of acute gastroenteritis with severe dehydration; it was treated with a short regimen of steroid therapy, which resulted in the complete remission of the disease. We conclude that prompt diagnosis and multidisciplinary intervention will lead to appropriate management-consisting of the installation of early short-course steroid therapy and thus, prevent further complications and the recurrence of the disease.

[Roles of follicular helper T cells and follicular regulatory T cells in pathogenesis of Henoch-Schönlein purpura in children]

OBJECTIVE

To study the roles of follicular helper T (Tfh) cells and follicular regulatory T (Tfr) cells in the pathogenesis of Henoch-Schönlein purpura (HSP) in children.

METHODS

Peripheral blood samples were collected from 40 HSP children and 25 healthy controls. The percentages of Tfh and Tfr cells were measured by flow cytometry; the mRNA expression levels of Bcl-6, c-MAF, Blimp-1, and PD-1 in peripheral blood were measured by real-time polymerase chain reaction.

RESULTS

Compared with the controls, the children with HSP had significantly increased percentage of Tfh cells and Tfh/Tfr ratio but a significantly reduced percentage of Tfr cells in the peripheral blood (P<0.05). Compared with the controls, the children with HSP had significantly increased mRNA expression of Bcl-6 and c-MAF but significantly reduced mRNA expression of Blimp-1 in CD4+ T cells (P<0.05), and had significantly increased mRNA expression of PD-1 but significantly reduced mRNA expression of Blimp-1 in CD4+CD25+ regulatory T cells (P<0.05).

CONCLUSIONS

Abnormal percentages of Tfh and Tfr cells may be involved in the pathogenesis of HSP in children, and over-expression of Bcl-6, c-MAF, and PD-1 mRNA and inhibited expression of Blimp-1 mRNA may be considered as important reasons for abnormal percentages of Tfh and Tfr cells.

[Clinical analysis of childhood Henoch-Schonlein purpura on the Tibetan Plateau, China]

OBJECTIVE

To study the clinical characteristics of childhood Henoch-Schonlein purpura (HSP) on the Tibetan Plateau, China.

METHODS

One hundred and twenty-five HSP children admitted to Shannan People's Hospital, Tibet, were assigned to the observation group, and 96 HSP children admitted to Wuhan Children's Hospital were assigned to the control group. The disease characteristics, clinical manifestations, treatment, and prognosis in both groups were retrospectively analyzed and compared.

RESULTS

The mean age of HSP onset and the female-to-male ratio in the observation group were both significantly higher than in the control group (P<0.05). There was a significant difference in seasonal onset between two groups. Significant differences in the etiological factors were observed between the two groups (P<0.05). The gastrointestinal manifestation was more prominent in the observation group compared with that in the control group (P<0.05). Laboratory findings showed that the mean erythrocyte sedimentation rate, counts of white blood cells and platelets, and percentage of neutrophil leucocytes were significantly lower, while the hemoglobin level was significantly higher in the observation group than in the control group (P<0.05). A total of 124 HSP patients (99.2%) in the observation group had a full recovery or improvement, and the overall cure rate and improvement rate showed no significant differences between two groups (P>0.05). Only 2.4% of the patients (3 cases) in the observation group had recurrent attack during follow-up, which was significantly lower than that in the control group (16.7%; P<0.05).

CONCLUSIONS

Childhood HSP on the Tibetan Plateau shows partial differences in disease characteristics, clinical manifestations, and laboratory measurements compared with that in the plain area. The overall prognosis is better and the recurrent rate is lower among HSP children on the Tibetan Plateau.

Revisiting clinical differences between hypersensitivity vasculitis and Henoch-Schönlein purpura in adults from a defined population

OBJECTIVES

Hypersensitivity vasculitis (HV) and Henoch-Schönlein purpura (HSP) are the most common entities included within the category of cutaneous vasculitis (CV). Palpable purpura and histological changes characterised by the presence of leukocytoclastic vasculitis are common in both conditions. Therefore, considerable overlap between them is often seen. It is especially true when the CV occurs in adults. To further establish clinical differences between these two conditions, in the present study we assessed the main clinical differences between HV and HSP in a wide and unselected series of adults with CV from a defined population.

METHODS

We reviewed the clinical records of 297 consecutive adults (age >20 years) seen at a single centre between January 1975 and December 2012 that were classified as having HSP or HV according to the criteria proposed by Michel et al. (J Rheumatol 1992; 19: 721-8).

RESULTS

Based on the inclusion criteria, 102 adult patients (71 men/31 women) were classified as HSP and 195 (104 men/91 women) as HV. The mean age was similar in both groups (55.8±16.5 years in HSP and 56.8±18.3 years in HV). Precipitating events, usually an upper respiratory tract infection and/or drug intake, were more frequently observed in HV. Both at the beginning of the disease and when the CV was established clinical manifestations were more frequent in patients with HSP than in those with HV. It was the case for gastrointestinal (57.4% vs. 6.8%; p<0.001), joint (51.5% vs. 36.6%; p=0.01) and renal involvement (86.3% vs. 18.3%; p<0.001). Corticosteroid (56.7% vs. 22%; p<0.001) and cytotoxic drug (19.4% vs. 3.2%; p<0.001) use was also more common in patients with HSP. After a median follow-up of 15.5 (interquartile range- IQR; 3-37) months in HSP and 4 (IQR; 2-12) months in HV, the outcome was better in HV than in HSP. In this regard, complete recovery (72.6% vs. 85.4%; p=0.01) was more commonly observed in HV while residual renal involvement (15.3% vs. 4.2%; p<0.001) was more common in HSP. The disease relapsed in 35.3% of patients with HSP and in 24.4% with HV (p=0.07).

CONCLUSIONS

Our results confirm the claim that these two diseases presenting with similar cutaneous involvement are certainly two separate entities with greater systemic involvement and less favourable outcome in HSP.

[Prognostic analysis of children with Henoch-Schonlein purpura treated by Helicobacter pylori eradication therapy]

OBJECTIVE

To investigate the effect of Helicobacter pylori (Hp) eradication therapy on prognosis in children with Henoch-Schonlein purpura (HSP).

METHODS

A total of 153 children with HSP were divided into Hp infection treatment group (n=22), Hp infection control group (n=21), and Hp infection-negative group (n=110). The Hp infection treatment group received one-week triple therapy for Hp eradication in addition to conventional treatment, while the Hp infection control group and Hp infection-negative group received conventional treatment. All patients were followed up for prognostic evaluation.

RESULTS

The response rates of the Hp infection treatment, control, and negative groups were 86% (19/22), 90% (19/21) and 85% (94/110), respectively (P>0.05). The recurrence rates of HSP in the Hp infection treatment, control, and negative groups were 14% (3/22), 24% (5/21) and 31% (34/110), respectively (P>0.05). The incidence of Henoch-Schonlein purpura nephritis (HSPN) in the Hp infection-negative group (36%, 40/110) and control group (33%, 7/21) was significantly higher than that in the Hp infection treatment group (5%, 1/22) (P<0.05 for both), but no significant difference in the incidence of HSPN was found between the control and negative groups (P>0.05).

CONCLUSIONS

One-week triple therapy for Hp eradication may be useful to reduce the incidence of HSPN in children with HSP infected with Hp.

[Henoch-Schönlein purpura developed after radical cystectomy]

We report a case of Henoch-Schönlein purpura that developed after radical cystectomy. The patient was a 70-year-old man who visited our hospital with a chief complaint of asymptomatic macroscopic hematuria and was diagnosed with invasive bladder cancer. After providing one course of gemcitabine and cisplatin therapy as neoadjuvant chemotherapy, radical cystectomy was performed. Due to postoperative formation of an abscess just beneath the rectus abdominis muscle, the patient was administered antibiotic treatment. Purpura developed on postoperative day 23, and was diagnosed as Henoch-Schönlein purpura based on skin biopsy. Symptoms disappeared approximately 3 weeks later, after initiating treatment with diaphenylsulfone and prednisolone.

[Case of purpura nephritis accompanied by idiopathic cholesterol embolism]

A 69-year-old man with a history of hypertension was admitted to our hospital because of proteinuria, renal dysfunction, and both purpura and edema in the lower extremities. Laboratory data on admission revealed proteinuria (3.4 g/day), microscopic hematuria (3+), and renal dysfunction (serum creatinine 1.47 mg/dL). In the renal biopsy, all glomeruli showed mild mesangial proliferation. A few glomeruli showed mild segmental endocapillary proliferation. Crescent was not found in any glomeruli. Immunofluorescent study revealed the deposition of IgA and C3 in the mesangial area. In addition, jagged-edged angular cholesterol clefts of atheromatous emboli were seen in a small artery with tubular atrophy and fibrosis. He was diagnosed as Henoch-Schonlein purpura nephritis accompanied by idiopathic cholesterol crystal embolism, because he previously had not undergone any cardiac procedures (e. g., percutaneous coronary intervention and coronary artery bypass grafting) and anticoagulating therapy. Oral prednisolone (40 mg/day) effectively decreased proteinuria and improved his renal dysfunction. In this case, renal dysfunction may be related to the ischemic interstitial damage caused by cholesterol crystal embolism, as well as purpura nephritis.

Atypical Henoch-Schonlein purpura: a forerunner of familial Mediterranean fever

Insuception is the most common cause of intestinal obstruction in early childhood. The cause of most intussusceptions is unknown but it can complicate the course of Henoch-Schonlein purpura (HSP) as a result of the vasculitic process. Familial Mediterranean fever (FMF), a common disease in Israel, is also associated with HSP. In a few patients, particularly in children, HSP has been reported to precede the diagnosis of FMF. We describe two patients with an unusual clinical course of severe abdominal pain as a result of intusucception. The correlation between intusucception, HSP and FMF are discussed.

[P-selectin gene -2123 polymorphism in children with Henoch-Sch-nlein purpura]

OBJECTIVE

To investigate whether P-selectin gene -2123 polymorphism is associated with the pathogenesis of Henoch-Sch-nlein purpura (HSP) in children.

METHODS

Polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) is used to identify the distribution of allele and genotype frequencies of P-selectin gene promoter -2123 polymorphism in 86 children with HSP (including 40 cases of purpura nephritis) and 70 healthy controls.

RESULTS

Compared with the healthy controls, the frequencies of GG genotype and G allele of P-selectin promoter -2123 in children with HSP increased significantly (P<0.05). There were no significant differences in P-selectin promoter -2123 genotype and allele frequencies between the patients with and without nephritis.

CONCLUSIONS

P-selectin gene promoter -2123 polymorphism appears to be associated with the pathogenesis of HSP in children.

Rare association of Henoch-Schönlein Purpura with recurrent endocarditis

We report a rare association of Henoch-Schönlein Purpura with recurrent endocarditis in a 36-year-old man presenting with rash and renal failure. Bacterial endocarditis can be complicated by renal failure of various etiologies. Biopsy may distinguish these and guide therapy as seen in this case. Here, timely diagnosis of Henoch-Schönlein Purpura in the setting of recurrent methacillin sensitive staphylococcus endocarditis led to steroid therapy and renal recovery. This is a rare reported case of Henoch-Schönlein Purpura during an episode of recurrent adult endocarditis that also highlights the complex interplay between genetic susceptibility and immune responses.

Henoch-Schönlein purpura in a patient with bowel bypass syndrome

Henoch-Schönlein purpura (HSP) is a common vasculitis being characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. Antigen-antibody (IgA) complexes activate the alternative complement pathway, resulting in inflammation and small vessels vasculitis. We present the case of a 53 years old Italian woman with HSP who was previously hospitalized for purpura skin lesions of the lower legs and diarrhea; a skin biopsy showed a leukocytoclastic vasculitis with perivascular accumulation of neutrophils and mononuclear cells. She was treated with immunosuppressive therapy. After 8 months she was hospitalized again for a recurrent episode of purpura skin lesions of the lower legs. At age 49 she was affected by obesity (BMI = 41.6 Kg/m2), treated via a bilio-pancreatic diversion that led, within a year, to a BMI reduction (25 Kg/m2). We suppose that bariatric surgery played a role on the development of autoimmune phenomena and that the formation of immunecomplexes is secondary to the excess of intestinal bacterial antigens. A cyclic therapy with Paromomicine 500 mg twice daily and Metronidazole 250 mg twice daily was performed with a clear up of the clinical picture. In medical literature are described numerous complications which include arthritis, erythema nodosum-like lesions, eruptions and other skin manifestations in patients who have undergone jejunocolic bypass. This case report describes for the first time the presence of HSP in a patient with bowel bypass syndrome and it is also able to demonstrate the relationship between the intestinal bacterial overgrowth and the systemic autoimmune system.

[A case of Anaphylactoid purpura suggested to Empedobacter (flavobacterium) brevis infection concerned]

The patient was an 83 Year-old woman with purpura on her right foot and on both crura starting from the end of November 2005. First, she took medical advice from a nearby doctor, but it did not improve. Since blisters were formed besides purpura, she visited Nagoya City Midori Municipal Hospital. When she visited, she had many purpura on her both legs, her right lower crus and her right foot was swelling with redness, blisters and erosion. Histopathological finding showed leukocytoclastic vasculitis, deposit of fibrin and hemorrhage. Only Empedobacter brevis was cultured from right feet lesion. This strain was sensitive to minocycline hydrochloride. Her purpura and right foot swelling were improved just after internal use of minocycline hydrochloride, so Empedobacter brevis infection was speculated to be a trigger, or at least concerned to this Anaphylactoid purpura.

[Roles of serum and urinary interleukins 13Ralpha2 and other cytokines in pediatric Henoch-Schonlein purpura]

OBJECTIVE

To study the roles of serum and urinary interleukins (IL)-13Ralpha2, IL-4, IL-6, IL-8 and tumor necrosis factor-alpha(TNF-alpha) in pediatric Henoch-Schonlein purpura (HSP).

METHODS

Serum and urinary levels of IL-13Ralpha2, IL-4, IL-6, IL-8 and TNF-alpha were examined using ELISA in 52 children with HSP and 45 healthy children. The results were compared between the two groups.

RESULTS

Serum levels of IL-13Ralpha2, IL-4, IL-6, IL-8 and TNF-alpha in HSP patients with or without renal lesions were higher than those in the control group (p<0.01 or 0.05). Urinary levels of IL-6 and TNF-alpha in HSP patients without renal lesions were higher than those in the control group (p<0.05). Except for urinary levels of IL-6 and TNF-alpha, urinary IL-13Ralpha2 levels in HSP patients with renal lesions (HSPN) were higher than those in the control group (p<0.05).

CONCLUSIONS

Cytokines IL-13Ralpha2, IL-4, IL-6, IL-8 and TNF-alpha may play roles in the pathogenesis of pediatric HSP/HSPN.

Adult onset Schönlein-Henoch purpura associated with Helicobacter pylori infection

Schönlein-Henoch purpura (SHP) is a systemic vasculitis, primarily involving the skin, gastrointestinal (GI) tract, joints, and kidneys. A wide variety of different conditions may be implicated in the pathogenesis of SHP. We report a 33-year-old man who presented with SHP accompanied by gastric Helicobacter pylori (Hp) infection. The GI manifestations and purpuric rashes were dramatically resolved after Hp eradication therapy. To date, very few publications have focused on the possible pathogenetic relationship between Hp infection and SHP.

[A case of anaphylactoid purpura associated with nephrosis followed by pulmonary tuberculosis]

A 54-year old man was admitted to our hospital because of high fever, productive cough and purpura in both legs in June 2005. Urinalysis showed microscopic hematuria and proteinuria. Chest radiograph showed consolidation of right upper field. Because acid-fast bacilli and polymerase chain reaction test for Mycobacterium tuberculosis were positive in bronchial lavage fluid, we made a diagnosis of pulmonary tuberculosis, and prescribed antituberculosis therapy with isoniazid, rifampicin, ethambutol and pyrazinamide. In addition, anaphylactoid purpura was diagnosed by skin biopsy. In July 2005, renal function was deteriorated and nephrosis appeared. We treated with corticosteroid in addition to antituberculosis therapy. His symptoms and renal dysfunction improved. We report a rare case of an anaphylactoid purpura following occurence of pulmonary tuberculosis.

Necrotizing haemorrhagic pneumonia proves fatal in an immunocompetent child due to Panton-Valentine Leucocidin, toxic shock syndrome toxins 1 and 2 and enterotoxin C-producing Staphylococcus aureus

Panton-Valentine leucocidin (PVL) toxin-producing strains of Staphylococcus aureus (S. aureus) are associated with skin abscesses and furunculosis, with necrotizing pneumonia being a relatively rare problem. Here, we describe a fatal case of necrotizing pneumonia in a 14-year-old child who presented initially with sore throat and pyrexia. He deteriorated rapidly, developing hypotension, multiple organ failure and purpura fulminans. S. aureus was isolated from the tracheal aspirate, which was found to be positive for PVL, toxic shock syndrome toxins (TSST) 1 and 2 and staphylococcal enterotoxin C (SEC). It was postulated that purpura fulminans and toxic shock syndrome were a result of the abovementioned exotoxins.

CONCLUSION

This case highlights the emergence of PVL-positive community-acquired S. aureus infection and association of purpura fulminans with superantigens. Practitioners should be aware of this illness in order to initiate appropriate treatment.

Purpura fulminans in a complicated Falciparum malaria

A 19-year-old male presented with fever, oliguria and purpuric lesions involving both hands. The patient was diagnosed as a case of purpura fulminans with disseminated intravascular coagulation due to complicated Falciparum malaria. The case is presented to sensitize the physicians to keep malaria as a differential in cases of fever with purpura fulminans.