Pulmonary vasculitis with hemorrhage in anaphylactoid purpura

A delayed diagnosis of late-onset pulmonary hemorrhage in a toddler with Henoch-Schönlein purpura after regression of skin rash: A case report and literature review

RATIONALE

Pulmonary hemorrhage is a rare but fatal complication of Henoch-Schönlein purpura (HSP), and more easily ignored in children than in adults due to the absence of clinically evident hemoptysis. Moreover, despite being sporadically reported, given that pulmonary hemorrhage may develop after regression and even disappearance of skin rash, the asynchronous progression of skin and lung lesions poses escalating challenges in the timely diagnosis. We herein presented a delayed diagnosis of late-onset pulmonary hemorrhage in a child with HSP after regression of purpuric rash.

PATIENT CONCERNS

A 6-year and 3-month child with a history of self-resolved purpuric rash three weeks ago, presented acutely with cough and dyspnea but without fever.

DIAGNOSES

The decreased hemoglobin and diffuse ground-glass opacities of both lungs on CT scan weren't comprehensively evaluated. The child was initially misdiagnosed as pneumonia.

INTERVENTIONS

Antibiotic treatment was initiated. However, no improvement of respiratory status was found following aggressive combination therapy. Bronchoscopy was subsequently performed.

OUTCOMES

An diffuse alveolar hemorrhage with low inflammatory profile was noted after a bronchoscopy. Considering the history of HSP, the diagnosis of HSP-associated pulmonary hemorrhage was ultimately confirmed and the patient received corticosteroids with satisfactory results.

LESSONS

Pulmonary hemorrhage could occur in children with HSP at late onset of disease after regression of skin rash. New-onset respiratory symptoms in patients with a history of HSP should heighten suspicion for pulmonary hemorrhage, particularly if presenting with lack of fever, sudden drop of hemoglobin, new pulmonary infiltrates and unresponsiveness to antibiotics therapy. Bronchoscopy should be performed early to confirm the diagnosis, specifically for children.

Henoch-Schönlein Purpura in children: not only kidney but also lung

BACKGROUND

Henoch-Schönlein Purpura (HSP) is the most common vasculitis of childhood and affects the small blood vessels. Pulmonary involvement is a rare complication of HSP and diffuse alveolar hemorrhage (DAH) is the most frequent clinical presentation. Little is known about the real incidence of lung involvement during HSP in the pediatric age and about its diagnosis, management and outcome.

METHODS

In order to discuss the main clinical findings and the diagnosis and management of lung involvement in children with HSP, we performed a review of the literature of the last 40 years.

RESULTS

We identified 23 pediatric cases of HSP with lung involvement. DAH was the most frequent clinical presentation of the disease. Although it can be identified by chest x-ray (CXR), bronchoalveolar lavage (BAL) is the gold standard for diagnosis. Pulse methylprednisolone is the first-line of therapy in children with DAH. An immunosuppressive regimen consisting of cyclophosphamide or azathioprine plus corticosteroids is required when respiratory failure occurs. Four of the twenty-three patients died, while 18 children had a resolution of the pulmonary involvement.

CONCLUSIONS

DAH is a life-threatening complication of HSP. Prompt diagnosis and adequate treatment are essential in order to achieve the best outcome.

Pulmonary Hemorrhaging as a Fatal Complication of IgA Vasculitis

A 64-year-old man was admitted to our hospital for purpuric rash, joint pain, and a fever. He had earlier undergone a follow-up examination for interstitial lung disease. At the current visit, the diagnosis was immunoglobulin A (IgA) vasculitis, based on skin and renal biopsy findings. He developed sudden breathlessness and hemoptysis. Chest computed tomography revealed ground glass opacity in the right lower lung fields, suggesting pulmonary hemorrhaging associated with IgA vasculitis. Despite steroid and cyclophosphamide therapy, and plasma exchange, he died 52 days after admission. Early aggressive therapies may be recommended for old patients with IgA vasculitis who have an additional comorbidities.

IgA Vasculitis with Simultaneous Cardiopulmonary Involvement

A 60-year-old man with a history of hypertension, type 2 diabetes, and reflux esophagitis was admitted to our hospital with hemoptysis, dyspnea, and leg edema. We diagnosed him with adult IgA vasculitis based on the presence of purpura, elevated serum IgA fibronectin complexes, pathophysiological findings, a skin biopsy showing leukocytoclastic vasculitis, and immunofluorescence studies demonstrating granular IgA and C3 deposits in the blood vessel wall. He showed concurrent cardiopulmonary involvement without involvement of the gastrointestinal system and kidneys, which are commonly affected in IgA vasculitis patients. Following treatment with prednisolone, the patient recovered with improvement in cardiopulmonary manifestations.

A case of anaphylactoid purpura nephritis accompanied by pulmonary hemorrhage and review of the literature

Cases of Henoch-Schönlein purpura and purpura nephritis accompanied by pulmonary hemorrhage are rare. Mild cases are easily ignored due to a lack of evident bleeding, and severe cases may be fatal. We have only treated one patient with Henoch-Schönlein nephritis (HSPN), a female child. The clinical manifestations were not evident, however, the imaging manifestations were clear. Finally, the patient was definitively diagnosed with HSPN accompanied by pulmonary hemorrhage. Following treatment with antiinflammatory and steroidal agents, tripterygium glycosides and traditional Chinese medicine, the patient recovered. In the present study, we report the diagnosis and treatment of this disease, with a review of the literature.

Vasculitis in the intensive care unit

The systemic vasculitides are a diverse set of diseases linked by the presence of blood-vessel inflammation and are often associated with life-threatening or critical complications, including glomerulonephritis, diffuse alveolar haemorrhage, pulmonary arterial hypertension and airway compromise. The protean manifestations of the systemic vasculitides make them challenging to diagnose. Early recognition, however, is crucial to improving outcomes. This article serves as an introduction to these complex diseases, reviewing the manifestations of systemic vasculitis that may be encountered in an intensive care setting, and outlines an overall approach to their treatment.

Henoch-Schönlein purpura: a case with atypical presentation

We report on a case of Henoch-Schönlein purpura (HSP) with pulmonary hemorrhage and severe renal involvement. The patient also had active carditis related to acute rheumatic fever. He died despite intensive treatment. Regarding this case, we discuss the pathogenesis and clinical findings of pulmonary hemorrhage and active carditis in HSP.

Pulmonary involvement in Henoch-Schönlein purpura

OBJECTIVE

To describe pulmonary involvement in Henoch-Schönlein purpura (HSP).

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with HSP who were seen at the Mayo Clinic in Rochester, Minn, during a 6-year period (January 1, 1997, to December 31, 2002). Patients with HSP and pulmonary involvement were identified through a review of clinical records, radiological studies, pulmonary function data, and lung biopsy findings.

RESULTS

We identified 124 patients with HSP during the study period; 72 (58.1%) were males. The median age was 15 years (range, 8 months to 81 years). Among the 124 patients with HSP, 3 (2.4%), all adults, had pulmonary involvement. Of these 3 patients, aged 20, 67, and 76 years, 2 were women. Pulmonary manifestations consisted of diffuse alveolar hemorrhage (DAH) (2 patients) and usual interstitial pneumonia that improved with corticosteroid therapy (1 patient).

CONCLUSIONS

Pulmonary involvement in HSP is rare. It occurs more often in adults and commonly manifests as DAH and occasionally as usual interstitial pneumonia or interstitial fibrosis. Our cases and previously reported cases suggest that DAH is the most common manifestation of pulmonary involvement in HSP.

Cardiopulmonary manifestations of Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is usually a mild condition involving the skin, gut, joints, and kidneys and has a good prognosis. We present a 63-year-old Hispanic man who had an unusually severe form of HSP with a fatal outcome attributable to vasculitis causing myocardial necrosis. There is only one citation in the literature of HSP-related myocardial vasculitis, which involved the right ventricle and was successfully treated with steroids. Our patient had severe HSP-related myocardial necrosis, tracheobronchitis, and nephritis. The bronchial lesions resolved, presumably because of steroid therapy. This probably is the first case of fatal myocardial necrosis related to HSP. We conclude that HSP can, in some cases, have an aggressive course. It becomes imperative to recognize the involvement of the other organ systems, such as the heart, so that appropriate therapy may be initiated. Immunosuppression may have a beneficial effect on extrarenal lesions. Controlled clinical trials are needed to establish the efficacy of such treatment.

Pulmonary hemorrhage in children with glomerulonephritis

Pulmonary hemorrhage may occur in patients with immune-mediated glomerulonephritis. This association can be seen in a variety of disorders including systemic lupus erythematosus, vasculitis, Wegener's granulomatosis, anaphylactoid purpura and Goodpasture's syndrome. Immune mechanisms, such as immune complexes and/or autoantibodies, play a role in the pathogenesis of pulmonary and glomerular injury. Acute pulmonary hemorrhage can lead to respiratory failure and has a high mortality. Therapy with immunosuppressive agents such as pulse methylprednisolone and cyclophosphamide will control the hemorrhage and improve pulmonary function in most cases.