Gastrointestinal manifestations of Henoch-Schonlein Purpura

Henoch-Schönlein Purpura Complicated by Hepatocellular Carcinoma

Although Henoch-Schönlein purpura (HSP) is known to be accompanied by malignancies, cases with hepatobiliary cancer are extremely rare. A 62-year-old man with palpable purpura rapidly extending to both lower legs was admitted to our hospital. He was undergoing follow-up for cirrhosis caused by chronic hepatitis B virus infection and hepatocellular carcinoma (HCC). He had renal dysfunction with hematuria and proteinuria and abdominal pain. Based on the clinical presentation and skin biopsy findings, he was diagnosed with HSP. The administration of steroids resulted in the rapid improvement of the patient's symptoms and he was discharged 12 days after admission.

Adult-Onset Henoch-Schonlein Purpura Duodenitis

Henoch-Schonlein purpura (HSP) is an immune-mediated vasculitis. HSP presents with purple spots on the skin (purpura), arthralgia, digestive problems, and kidney injury. HSP is most commonly seen in children, and rarely presents in adults. The pathogenesis involves the deposition of immune complexes in small to medium size blood vessels which leads to necrosis and inflammation. Most patients recover after symptomatic treatment, while more severe cases are treated with steroids. We report a 28-year-old female patient who presented with two episodes of hematemesis, worsening abdominal pain, and bloody diarrhea. Physical examination showed erythematous, palpable, purpuric rashes on her thighs and lower legs. Contrast-enhanced computed tomography (CT) scan showed thickening of the duodenal wall, and upper endoscopy revealed mild gastric erythema and diffuse erythematous, hemorrhagic, friable mucosa with superficial, thick, adherent white exudate seen in the second portion of the duodenum, consistent with the diagnosis of HSP. We report on the clinical presentation of our patient, and review adult-onset HSP.

Endoscopic Findings of Upper Gastrointestinal Involvement in Primary Vasculitis

Background/Aims

Gastrointestinal involvement in vasculitis may result in life-threatening complications. However, its variable clinical presentations and endoscopic features, and the rarity of the disease, often result in delayed diagnosis.

Methods

Clinical characteristics, endoscopic features, and histopathological findings were reviewed from medical records.

Results

Of 6,477 patients with vasculitis, 148 were diagnosed as primary vasculitis with upper gastrointestinal involvement. Of these, 21 cases (14.2%) were classified as large-vessel vasculitis, 17 cases (11.5%) as medium-vessel vasculitis, and 110 cases (74.3%) as small-vessel vasculitis. According to the specific diagnosis, IgA vasculitis (Henoch-Schönlein purpura) was the most common diagnosis (56.8%), followed by Takayasu arteritis (14.1%), microscopic polyangiitis (10.1%), and polyarteritis nodosa (6.8%). Gastrointestinal symptoms were present in 113 subjects (76.4%), with abdominal pain (78.8%) the most common symptom. Erosion and ulcers were striking endoscopic features, and the second portion of the duodenum was the most frequently involved site. Biopsy specimens were obtained from 124 patients, and only eight (5.4%) presented histopathological signs of vasculitis.

Conclusions

Diagnosis of vasculitis involving the upper gastrointestinal tract is difficult. Because of the widespread use of endoscopy, combining clinical features with endoscopic findings may facilitate making appropriate diagnoses; however, the diagnostic yield of endoscopic biopsy is low.

A review of case and case series reports on Henöch-Schönlein syndrome-related pancreatitis

To summarize the experience of diagnosing and treating patients with Henoch–Schönlein purpura (HSP)-related pancreatitis, a systematic review of previously published cases was conducted. Among 13 reported cases, there were six males and seven females whose age from 3 to 70 years. The clinical features of these patients indicated that acute pancreatitis could be the initial manifestation of HSP, the radiological change was atypical, and most cases were alleviated with steroidal treatment. Good outcomes can be achieved in patients who are diagnosed early with HSP-related pancreatitis, and it is vital to begin timely treatment of HSP-related pancreatitis with corticosteroid.

Gastrointestinal aspects of vasculitides

Systemic vasculitides are caused by inflammation of blood vessels and can affect any organ and any part of the gastrointestinal tract, hepatic and biliary system, as well as the pancreas. These disorders can cause a wide array of gastrointestinal manifestations, from asymptomatic elevated transaminase levels and mild abdominal pain to potentially life-threatening bowel perforations and peritonitis. A diagnosis based solely on gastrointestinal symptoms is challenging as these manifestations are not specific. Conversely, diagnostic and therapeutic delays can be rapidly detrimental. In this article, we review the epidemiology, characteristics and management of the main gastrointestinal manifestations of systemic vasculitides, including polyarteritis nodosa and antineutrophil cytoplasm antibody-associated vasculitides, as well as isolated vasculitides limited to the gastrointestinal tract.

Henoch-Schönlein purpura as a rare cause of an acute abdomen

A 52-year-old man presented with a purpuric rash affecting his legs and hypertension. He was diagnosed with Henoch-Schönlein purpura and discharged with non-steroidal anti-inflammatory drugs. Three weeks later, he presented again with loss of appetite and vomiting before developing abdominal pain with pyrexia of 38.5°C and rigors. On examination, he was hypotensive with a distended abdomen and a national early warning score of 6. Computed tomography revealed enteropathy of Henoch-Schönlein purpura. The patient deteriorated and went for an emergency laparotomy, where 30cm of ischaemic small bowel was resected.

Ultrasound of the duodenum in children

Ultrasound is well suited for examining the pediatric duodenum, given the small size of the patients, the lack of ionizing radiation and high-resolution imaging potential. Technical considerations, normal anatomy, congenital and acquired pathology of the duodenum, and the advantages and limitations of US are discussed and illustrated in this review.

Henoch-Schönlein Purpura in the ED

Diagnosing and treating a child with the most common form of pediatric vasculitis.

Intravenous immunoglobulins for severe gastrointestinal involvement in pediatric Henoch-Schönlein purpura: A French retrospective study

OBJECTIVE

Severe gastrointestinal involvement of Henoch-Schönlein purpura (HSP) is rare but potentially life-threatening. Management of severe gastrointestinal involvement in HSP is not codified. Symptomatic care and steroids are a first-line therapy. Nonsteroidal immunomodulatory therapies have been anecdotally used to treat steroid-refractory forms. The aim of this study was to describe the outcome of patients with severe gastrointestinal involvement of HSP who required nonsteroidal immunomodulatory therapy.

METHODS

A French retrospective case series study was conducted. Pediatric consultants at 31 French academic pediatric centers were contacted. Patients were identified from memory or via an informatics diagnosis-related code system. Clinical, paraclinical, and therapeutic data were collected.

RESULTS

Twenty-nine responding centers provided nine cases, one of which was excluded. Five boys and three girls, aged 3-15years (median: 5.5years) from seven centers were included. Severe gastrointestinal involvement of HSP mainly included intense pain, digestive bleeding, and protein-losing enteropathy. All children had been treated with steroids at first line and intravenous immunoglobulins (IVIg) at second line. Six out of eight showed a complete response to IVIg within 7days and two out of eight had a partial response. Two out of eight relapsed with less severe gastrointestinal involvement requiring a second dose of IVIg and they did not relapse thereafter. Tolerance was good, but two out of eight developed high proteinuria on the day following IVIg infusion.

CONCLUSION

Although a possible link with a flare-up of proteinuria needs to be addressed, IVIg appears to be a good candidate for treatment of severe gastrointestinal involvement of HSP.

Pathogenesis and gastrointestinal manifestations of IgA vasculitis

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

IgA vasculitis (formerly Henoch-Schönlein purpura) in an adult with systemic lupus erythematosus

We report a case of a 65-year-old man with systemic lupus erythematosus (SLE) and antiphospholipid syndrome, presenting palpable purpuric lesions, necrotic blisters and swelling ankles, after a previous tracheobronchitis episode. Laboratory data were remarkable for mild proteinuria and imaging studies were normal. A skin biopsy showed IgA deposits on superficial dermal capillaries and IgA vasculitis (IgAV) (former Henoch-Schönlein purpura) was assumed. The patient was treated with colchicine, deflazacort and azathioprine, but as a regression in the purpuric lesions was noted, a decline in renal function was detected. A kidney biopsy revealed mesangial proliferation with IgA deposition and IgAV nephritis was considered. Immunosuppressive treatment was adjusted, with progressive normalisation of renal function and disappearance of proteinuria over a monthly follow-up; after 6 months, total remission was achieved. To the best of our knowledge, this is the first reported case of IgAV in an adult patient with SLE.

[Vasculitis: New nomenclature of the Chapel Hill consensus conference 2012]

Within the last years, many advances have been made in the understanding of the etiopathology of vasculitis as well as of different disease courses. The revised 2012 Chapel Hill consensus conference (CHCC) nomenclature reflects current knowledge on the etiopathology in addition to the descriptive principles of vessel size and types of inflammation. The anti-neutrophil cytoplasmic antibody (ANCA)-associated forms of vasculitis have been separated as a group, as opposed to immune complex small vessel vasculitis. When consensus was achieved eponyms have been replaced by systematic names, such as granulomatosis with polyangiitis (Wegener's granulomatosis) or eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Moreover, clinically important but less well-known types of vasculitis have now been included in the CHCC nomenclature. This article presents the changes and summarizes the results of important new articles on the clinical picture and morphology of vasculitis.

Management of intestinal bleeding with single-dose cyclophosphamide in Henoch-Schönlein purpura

In these case series, we report on six children (3 girls, 3 boys) aged 5-13 years with Henoch-Schönlein purpura (HSP) who developed severe gastrointestinal (GI) bleeding resistant to both 2 mg/kg or pulse (10-30 mg/kg) i.v. methylprednisolone. All patients responded to single-dose (500 mg/m(2) ) i.v. cyclophosphamide (CPA) and none of them developed new GI bleeding after CPA treatment. No patients required surgical intervention. Single high-dose CPA may be beneficial in HSP with severe GI involvement, in which bleeding is non-responsive to high-dose steroids.

High-dose methylprednisolone pulse therapy for treatment of refractory intestinal involvement caused by Henoch-Schönlein purpura: a case report

Introduction

Henoch–Schönlein purpura is an immunoglobulin A-mediated, small vascular inflammatory disease that can be associated with palpable purpura, arthralgia, abdominal pain, or nephritis. The presence of purpura facilitates the diagnosis of Henoch–Schönlein purpura at the onset of associated symptoms, whereas the absence of purpura makes the diagnosis challenging. It is important to diagnose Henoch–Schönlein purpura with delayed-onset skin purpura to avoid unnecessary surgery for acute abdomen. Most cases of Henoch–Schönlein purpura with severe abdominal pain are treated with low-dose steroids and intravenous immunoglobulin.

Case presentation

A 15-year-old Korean girl complained of severe abdominal pain and delayed-onset purpura on admission. Henoch–Schönlein purpura was diagnosed based on endoscopic findings of hemorrhagic duodenitis and duodenal vasculitis and abdominal computed tomography findings of edematous bowels. Two common initial treatments, a low-dose steroid and intravenous immunoglobulin, were administered, but there was no improvement for 1 month. Subsequently, we used high-dose intravenous methylprednisolone pulse therapy (30mg/kg/day, with a maximum of 1g/day), which dramatically alleviated her abdominal symptoms.

Conclusions

High-dose intravenous methylprednisolone pulse therapy can be used as the ultimate treatment for delayed-onset Henoch–Schönlein purpura with severe abdominal pain when symptoms do not improve after low-dose steroid and intravenous immunoglobulin treatments.

Faecal calprotectin levels in children with Henoch-Schönlein purpura: is this a new marker for gastrointestinal involvement?

AIM

We aimed to investigate the significance of faecal calprotectin (FC) levels in children diagnosed with Henoch-Schönlein purpura (HSP) and examine its relationships with gastrointestinal system (GIS), renal involvement and with clinical findings.

PATIENTS AND METHODS

In total, 66 children diagnosed with HSP for the first time and a control group of 25 healthy children were included. The cases were divided into mild and severe groups on the basis of GIS findings. FC was measured twice in all patients with HSP: within 3 days of onset of disease (FC1) and on day 15 (FC2). These results were compared with those of the control group. Faecal occult blood, gastric wall thickness and duodenal wall thickness were measured at the same time as FC1 in all patients, and the presence of renal involvement was recorded.

RESULTS

Of the 66 patients, 37 (56%) were females (mean age, 7.5±2.9 years; range, 2.5-14.5 years) and were diagnosed with HSP. Renal involvement was detected in 19 (28%) cases and GIS involvement was found in 28 (43%) cases. GIS involvement was mild in 16 (53%) cases and severe in 12 (43%). A significant difference was detected in FC1 levels between the groups with and without GIS involvement (P=0.01). A marked difference was observed in FC1 levels between the groups with and without renal involvement (P=0.017).

CONCLUSION

FC may be a reliable marker for HSP, particularly for identifying GIS and renal involvement as well as disease severity.

Henoch-Schönlein purpura complicated with severe gastrointestinal bleeding

Bleeding from the gastrointestinal tract is one of the common determinants of morbidity and mortality in the ordinary clinical setting. The gastrointestinal involvement of Henoch-Schönlein purpura (HSP) has often been described as self-limiting, with no long-term morbidity. In this report, we describe our experience with a male HSP patient who presented with abdominal pain, loss of appetite and deteriorated renal function associated with nephrotic syndrome. Despite the use of aggressive immunomodulatory treatments, including corticosteroids and plasmapheresis, he developed lethal gastrointestinal hemorrhage. We believe that the accumulation of more experience with additional cases similar to ours is mandatory for the establishment of optimal management for HSP patients with severe gastrointestinal manifestations.

Pneumatosis intestinalis associated with Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is the most common vasculitis in children. It is a disorder of the inflammatory cascade leading to immunoglobulin A deposition and leukocytoclastic vasculitis of small vessels of skin, kidneys, joints, and gastrointestinal (GI) tract. A wide variety of GI manifestations are seen in ∼50% to 75% of patients with HSP. Diffuse colicky abdominal pain is the most common GI symptom. The small bowel is the most frequently involved GI site. Intussusception is rare but is the most common surgical complication. We report the case of a 2-year-old girl with a 5-day history of abdominal pain followed by a palpable purpuric rash. Her urinalysis, complete blood cell count, and tests of renal function were normal. An acute abdominal series was unremarkable initially, and abdominal ultrasound imaging showed ascites and thickened small bowel loops. She was diagnosed with HSP. The abdominal pain worsened, and an abdominal computed tomography scan demonstrated distal small bowel wall thickening and pneumatosis intestinalis in the descending colon. She was started on total parenteral nutrition and antibiotics and placed on bowel rest. She was given 2 mg/kg of intravenous immunoglobulin. Her abdominal pain gradually improved over the next week, and a repeat computed tomography scan showed significant improvement of the small bowel wall thickening and pneumatosis. The purpuric rash improved, and her abdominal pain resolved. We report a case of HSP and pneumatosis intestinalis, an association that has not been reported previously.

[Vasculitis. New nomenclature of the Chapel Hill consensus conference 2012]

In recent years, many advances have been made in our understanding of vasculitis etiopathology as well as of different disease courses. The revised Chapel Hill Consensus Conference (CHCC) 2012 nomenclature reflects current knowledge about etiopathology, in addition to the descriptive principles of vessel size and type of inflammation. Anti-neutrophil cyptoplasmic antibody (ANCA)-associated vasculitides have been classified as a separate group, as opposed to immune complex small vessel vasculitis. In cases where consensus was achieved, eponyms have been replaced by systematic names, such as granulomatosis with polyangiitis (Wegener's) or eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome). Moreover, clinically important but less well-known types of vasculitis have now been included in the CHCC nomenclature. This article presents the changes, focussing on those types that are relevant to the histopathologist, and summarizes the results of important new articles on morphology and clinical picture of vasculitis.

Histologic mimics of inflammatory bowel disease

This review summarizes a variety of clinical and histologic mimics of idiopathic inflammatory bowel disease. All the entities that are included demonstrate one or more histologic features typical of idiopathic inflammatory bowel disease that may lead to potential diagnostic confusion and misinterpretation by the pathologist. The elements of the clinical history, laboratory test results, and endoscopic findings that are helpful to the surgical pathologist in considering a diagnosis other than idiopathic inflammatory bowel disease are emphasized. On occasion, a poor response to standard treatment for idiopathic inflammatory bowel disease is the clue that prompts reconsideration of the initial diagnosis. Subtle histologic features, special stains, or other diagnostic methodologies that can aid in proper diagnosis are also discussed.

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.

Henoch-Schonlein purpura with intestinal perforation and cerebral hemorrhage: A case report

Henoch-Schonlein purpura (HSP) with intestinal perforation and cerebral hemorrhage is a very rare clinical condition. There has been no report of HSP complicated with both intestinal perforation and cerebral hemorrhage until October 2012. Here we describe a case of HSP with intestinal perforation and cerebral hemorrhage in a 5-year-old girl. Plain abdominal radiograph in the erect position showed heavy gas in the right subphrenic space with an elevated diaphragm. Partial resection of the small intestine was performed, and pathological analysis suggested chronic suppurative inflammation in all layers of the ileal wall and mesentery. Seventeen days after surgery, cerebral hemorrhage developed and the patient died.

Cutaneous vasculitis in ulcerative colitis mimicking Henoch-Schönlein purpura

To the best of our knowledge, no cases of ulcerative colitis (UC) mimicking Henoch-Schönlein purpura (HSP) have been reported so far. During a 28-year period 5635 patients were followed up at our Pediatric Rheumatology Unit and 357 had HSP according to the European League Against Rheumatism, the Paediatric Rheumatology International Trials Organisation and the Paediatric Rheumatology European Society validated classification criteria. At the same period, 148 patients with IBD according to the European Society for Paediatric Gastroenterology, Hepatology and Nutrition criteria were followed up at the Pediatric Gastroenterology Unit in our University Hospital. Only two of them had vasculitis, as an extra intestinal manifestation of UC mimicking HSP, and fulfilled both disease criteria. A 2-year old girl had bloody diarrhoea, severe abdominal pain, arthritis in ankles, petechiae and palpable purpura not related to thrombocytopenia in lower limbs. A 5-year old boy had bloody diarrhoea, palpable purpura in buttocks, lower limbs, penis and scrotum associated with arthritis in knees, orchitis in right testicle and periarticular swelling in hands and feet. Their ileocolonoscopy showed diffuse mucosal erythema, oedema, friability and multiple irregular ulcers, and histopathological examination of colonic specimen revealed diffuse chronic mucosal inflammation, crypt distortion and crypt abscesses suggesting ulcerative colitis. There were no signs of intestinal vasculitis in both cases. In conclusion, this is the first study in a paediatric population that evidenced palpable purpura associated with UC mimicking HSP.

Should intussusception in children prompt screening for celiac disease?

OBJECTIVES

An association between adult celiac disease (CD) and intussusceptions (ISs) has been described. Although more common among children, intussusception has not been linked with childhood CD aside from isolated case reports. Our aim was to investigate the frequency of IS among children with CD.

METHODS

A patient database containing children with biopsy-proven CD was reviewed, in addition to radiology records contained in a hospital-maintained clinical data repository.

RESULTS

Of 254 children with biopsy-proven CD and complete records available for review, abdominal imaging was performed in 21%, mainly because of abdominal pain. Among children with CD, 1.2% experienced an IS <9 months before their diagnosis with CD. Among children seen at our institution in the same time period, 0.07% experienced an IS. The majority of those children with CD who were found to have IS had no evidence of nutritional deficit at the time of IS. IS was not identified in any children with CD who had been treated with a gluten-free diet.

CONCLUSIONS

IS was far more common among children in our cohort with untreated CD than in the general pediatric population simultaneously seen at our center. The diagnosis of CD should be considered in children with IS, even in the absence of signs of nutritional compromise.

Intestinal infarction and portal vein thrombosis in a patient with henoch schonlein purpura

Henoch Schonlein purpura is a systemic vasculitis that commonly affects children and teenagers but also affects adults of all ages. In most instances it has a benign course. Organ involvement, particularly in adults, and notably the kidneys and gastrointestinal tract may require therapeutic intervention and may have a less favorable outcome. We report a case of a 58-year-old man who presented with purpura and who rapidly developed catastrophic intestinal vasculitis, leading to his demise.

Blocking Fcα receptor I on granulocytes prevents tissue damage induced by IgA autoantibodies

IgA represents the most prominent Ab class at mucosal surfaces and the second most prevalent Ab in human blood after IgG. We recently demonstrated that cross-linking of the granulocyte IgA FcR (FcαRI) by IgA induces a chemotactic-driven positive-feedback migration loop, hereby amplifying recruitment of granulocytes to IgA deposits. Therefore, we postulated that aberrant IgA-Ag complexes, which can be found in tissues in IgA-mediated diseases, are responsible for tissue damage by inducing continuous granulocyte migration and activation. Using an IgA-dependent skin-blistering disease as a model system, we demonstrated colocalization of FcαRI-positive granulocyte infiltrates with IgA in cryosections of lesional skin of patients suffering from this disease. Furthermore, we showed granulocyte migration to IgA deposits injected in human skin explants and in murine skin of FcαRI transgenic mice in vivo. Importantly, ex vivo migration and tissue damage were inhibited by blocking FcαRI, indicating that these events are dependent on the interaction of IgA autoantibodies with FcαRI. Thus, interrupting the granulocyte migration loop by blocking FcαRI reduces tissue damage in diseases with aberrant IgA-immune complexes. As such, our results may lead to development of new therapies for IgA-mediated chronic inflammatory diseases, hereby decreasing severe morbidity and improving quality of life for these patients.

Paroxysmal drastic abdominal pain with tardive cutaneous lesions presenting in Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is a small-vessel vasculitis mediated by IgA-immune complex deposition. It is characterized by the clinical tetrad of non-thrombocytopenic palpable purpura, abdominal pain, arthritis and renal involvement. The diagnosis of HSP is difficult, especially when abdominal symptoms precede cutaneous lesions. We report a rare case of paroxysmal drastic abdominal pain with gastrointestinal bleeding presented in HSP. The diagnosis was verified by renal damage and the occurrence of purpura.

[A case of idiopathic recurrent duodenojejunitis]

There are various etiologies of duodenojejunitis such as Henoch-Schönlei purpura (H-S purpura), vasculitis, Crohn's disease, celiac sprue, ischemia, lymphoma, Zollinger-Ellison syndrome, bacteria or parasite infection, radiation, drug induced jejunitis, eosinophilic jejunitis, and toxins. A 31-year-old man presented with left upper quadrant pain. He did not have febrile sense, hematochezia, melena, diarrhea, arthralgia and hematuria. He had neither drug history nor traveling history. Esophagogastroduodenoscopy showed diffuse mucosal erythema and segmental hemorrhagic erosions on the distal area to the descending portion of the duodenum and proximal jejunum, which were commonly observed in the gastrointestinal involvement of H-S purpura. However, he showed no skin lesions, joint and urologic problems until the discharge. Autoimmune markers such as antinuclear antibody and antineutrophil cytoplasmic antibody were negative. Celiac and mesenteric angiogram showed no vascular abnormality. After the administration of oral prednisolone 40 mg daily for therapeutic trial, abdominal pain and endoscopic lesions were improved. He experienced relapses of same episode without skin lesions 16 times during follow-up of 8 years, which were also treated with prednisolone. The abdominal computed tomography during the follow-up also showed no significant finding. We report a case of primary recurrent duodenojejunitis similar to the gastrointestinal involvement of H-S purpura without purpura.

Gastrointestinal involvement revealing Henoch Schonlein purpura in adults: Report of three cases and review of the literature

The diagnosis of Henoch-Schönlein purpura (HSP) is difficult, especially when abdominal symptoms precede cutaneous lesions.

We report three cases of adult HSP revealed by gastrointestinal (GI) involvement.

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.

Henoch-schonlein purpura-a case report and review of the literature

We describe a case of an adolescent male with Henoch-Schonlein purpura (HSP), presenting with cutaneous and gastrointestinal manifestations. Endoscopy revealed diffuse ulcerations in the stomach, duodenum, and right colon. Biopsies revealed a leukocytoclastic vasculitis in the skin and gastrointestinal tract. Steroid therapy led to complete resolution of the symptoms. HSP is the most common childhood vasculitis, and is characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. It is a systemic disease where antigen-antibody (IgA) complexes activate the alternate complement pathway, resulting in inflammation and small vessel vasculitis. Mild disease resolves spontaneously, and symptomatic treatment alone is sufficient. Systemic steroids are recommended for moderate to severe HSP. The prognosis depends upon the extent of renal involvement, which requires close followup. Early recognition of multiorgan involvement, especially outside of the typical age group, as in our adolescent patient, and appropriate intervention can mitigate the disease and limit organ damage.

Henoch-Schönlein purpura with intussusception: a case report

Gastrointestinal symptoms in Henoch-Schönlein purpura (HSP) are common and occur in about two-thirds of HSP patients. Surgical intervention is only required in a minority of cases. Intussusception is a rare complication and the most common surgical indication for HSP. We report a 3-year-old boy with HSP and clinical manifestations of palpable skin rash Lasting for 4 days, fever for 3 days, intermittent abdominal cramping pain, and left ankle arthralgia Lasting for several hours. Abdominal sonography revealed characteristic signs of intussusception including a doughnut sign and a pseudo-kidney sign in the right upper quadrant of the abdomen. After unsuccessful initial reduction by air enema, surgical reduction was arranged and manual reduction of the ileocecal intussusception without bowel resection was carried out.

A case of IgA-related enteropathy complicated with gastrointestinal bleeding and progressive IgA nephropathy: a possible variant Henoch-Schönlein purpura?

Here, we report an adult patient with IgA-related enteropathy complicated with massive intestinal bleeding and acute renal failure, but without skin lesions. Surgical resection of the small intestine and steroid pulse therapy was performed. Histopathology revealed significant deposition of IgA and C3 in the small vessels of the intestine and the kidney mesangium. Although skin purpura was absent, the histopathology and clinical manifestations suggested that the pathophysiology was similar to Henoch-Schönlein purpura (HSP), implying IgA-related enteropathy as a subclass of HSP. Retrospective analysis indicates that terminal ileum lesions may be a poor prognostic indicator.

Vasculitis in children

Primary systemic vasculitides of the young are relatively rare diseases, but can have a significant morbidity and mortality. The purpose of this review is to provide an overview of the paediatric vasculitides. Vasculitides that predominantly affect children will be considered in more detail than vasculitic diseases that although are seen in children affect adults more commonly, such as the ANCA associated vasculitides. New classification criteria for childhood vasculitis have recently been proposed and are currently undergoing validation. Epidemiological clues continue to implicate infectious triggers in Kawasaki Disease and Henoch Schönlein purpura. Several genetic polymorphisms have now been described in the vasculitides that may be relevant in terms of disease predisposition or development of disease complications. Treatment regimens continue to improve, with the use of different immunosuppressive medications and newer therapeutic approaches such as biologic agents. However new challenges are looming in regards to the role of inflammation in endothelial health and the long term cardiovascular morbidity for children with primary systemic vasculitis. International multicenter collaboration is of utmost importance in order for us to further advance our understanding and improve the treatment and outcome of systemic vasculitis in the young.