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Luciana B, Ilaria C, Isabella C, Gentile C, Grasso EA, Di Donato G, Francesco C, Verrotti A. Epidemiological and clinical aspects of immunoglobulin A vasculitis in childhood: a retrospective cohort study. Ital J Pediatr 2021; 47:237. [PMID: 34911536 PMCID: PMC8672591 DOI: 10.1186/s13052-021-01182-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/09/2021] [Indexed: 12/31/2022] Open
Abstract
Background A retrospective study was conducted in order to investigate and describe the characteristics of Immunoglobulin A vasculitis (IgAV), previously known as Henoch-Schӧnlein purpura, in the paediatric population of a community-based healthcare delivery system in the Italian region of Abruzzo. Methods This is a population-based retrospective chart review of the diagnosis of IgAV in children ages 0 to 18, admitted to the Department of Paediatrics of Chieti and Pescara between 1 January 2000 and 31 December 2016. All children enrolled presented with clinical symptoms and laboratory findings and met the EULAR/PRINTO/PRES 2008 criteria. Results Two-hundred-eight children met the criteria for IgAV, with the highest incidence reported among children below 7-years of age. A correlation with recent infections was found in 64% of the cohort; the onset was more frequently during the winter and fall. Purpura had a diffuse distribution in the majority of patients; joint impairment was the second most frequent symptom (43%), whereas the gastrointestinal tract was involved in 28% of patients. Conclusions Hereby, we confirm the relative benignity of IgAV in a cohort of Italian children; with regards to renal involvement, we report a better outcome compared to other studies. However, despite the low rate of renal disease, we observed a wide use of corticosteroids, especially for the treatment of persistent purpura.
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Affiliation(s)
- Breda Luciana
- Department of Paediatrics, University of Chieti, Via dei Vestini 31, Chieti, Italy.
| | - Carbone Ilaria
- Department of Paediatrics, University of Chieti, Via dei Vestini 31, Chieti, Italy
| | - Casciato Isabella
- Department of Paediatrics, University of Chieti, Via dei Vestini 31, Chieti, Italy
| | - Cristina Gentile
- Department of Paediatrics, University of Chieti, Via dei Vestini 31, Chieti, Italy
| | | | - Giulia Di Donato
- Department of Paediatrics, University of Chieti, Via dei Vestini 31, Chieti, Italy
| | - Chiarelli Francesco
- Department of Paediatrics, University of Chieti, Via dei Vestini 31, Chieti, Italy
| | - Alberto Verrotti
- Department of Paediatrics, University of Perugia, Piazza dell'Università 1, Perugia, Italy
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2
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Okura Y, Hiramatsu Y, Shimomura M, Taniguchi K, Nawate M, Takahashi Y, Kobayashi I. Successful Treatment of IgA Vasculitis With Prolonged Cutaneous Manifestation With Colchicine in a 10-Year-Old Boy. Mod Rheumatol Case Rep 2021; 6:97-100. [PMID: 34730811 DOI: 10.1093/mrcr/rxab041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/06/2021] [Accepted: 10/05/2021] [Indexed: 12/17/2022]
Abstract
We report a 10-year-old boy with IgA vasculitis (IgAV) with prolonged cutaneous manifestations who was successfully treated with colchicine. At the age of 9, he was diagnosed as having IgAV by typical purpura, abdominal pain, and hematochezia. Initially, his severe gastrointestinal manifestation subsided by prednisolone 60 mg/day and intravenous methylprednisolone pulse therapy. However, his gastrointestinal manifestation was glucocorticoid-dependent and refractory to factor XIII concentrate, intravenous immunoglobulin G, and mycophenolate mofetil. His abdominal pain and hematochezia responded to the combination therapy with dapsone and low dose of prednisolone 5 mg/day and did not relapse even after discontinuation of dapsone. On the other hands, the effect of dapsone on his cutaneous manifestation was dose-dependent. As well dapsone had no glucocorticoid-sparing effect. Approximately 12 months after onset, colchicine treatment was started, which resulted in remission of his chronic cutaneous manifestation. After prednisolone was tapered off, his cutaneous manifestation is currently well-controlled on colchicine 0.5 mg/day without adverse events. He had never complicated by kidney involvements. In conclusion, colchicine treatment exerts a beneficial effect in IgAV patients with prolonged cutaneous manifestation refractory to multiple drugs.
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Affiliation(s)
- Yuka Okura
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Yasuyoshi Hiramatsu
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Masaki Shimomura
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Kota Taniguchi
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Mitsuru Nawate
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Yutaka Takahashi
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
| | - Ichiro Kobayashi
- Department of Pediatrics, KKR Sapporo Medical Center, Sapporo, Hokkaido, Japan
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3
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic bullous IgA vasculitis (Schönlein-Henoch purpura), does it have a worse prognosis? REUMATOLOGIA CLINICA 2021; 17:549-551. [PMID: 34756318 DOI: 10.1016/j.reumae.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/08/2020] [Indexed: 06/13/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, Spain; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, Spain
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4
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Morotti F, Bracciolini G, Caorsi R, Cattaneo L, Gattorno M, Ravelli A, Felici E. Intravenous immunoglobulin for corticosteroid-resistant intestinal Henoch-Schönlein purpura: worth a controlled trial against corticosteroids? Rheumatology (Oxford) 2021; 60:3868-3871. [PMID: 34340243 DOI: 10.1093/rheumatology/keaa743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/01/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Henoch-Schönlein purpura (HScP) may present in children with severe, occasionally refractory, gastrointestinal (GI) involvement. The use of corticosteroids (CSs) is commonplace in the management of the disease, but to date no standardized protocol is available and, although rare, resistance to CS therapy may be challenging to clinicians. IVIG has been proposed as an effective alternative to CSs, but to date no controlled trial has been conducted to ascertain their real efficacy. We share our personal experience of successful IVIG treatment in two cases of GI HScP, comparing it with similar experiences reported in literature. METHODS Retrospective clinical data collection, comparison with available literature. RESULTS We describe two children with severe HScP GI vasculitis refractory to high-dose intravenous CSs that responded rapidly to IVIG administration, with complete recovery within a few days. Patient characteristics and response to IVIG administration were comparable to those of other previously reported cases. CONCLUSION Our observation confirms that IVIG may be useful in the treatment of CS-resistant HScP-related GI vasculitis in children, and highlights the need for more structured research, including a randomized trial against CSs, in order to ascertain their real effectiveness.
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Affiliation(s)
- Francesco Morotti
- SCDU of Pediatrics, Department of Health Sciences, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Giulia Bracciolini
- Pediatrics and Pediatric Emergency Unit, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Roberta Caorsi
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Lorella Cattaneo
- Pediatrics and Pediatric Emergency Unit, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Marco Gattorno
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Felici
- Pediatrics and Pediatric Emergency Unit, The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.,'Umberto Bosio' Centre for Digestive Diseases, The Children Hospital, Azienda Ospedaliera Nazionale SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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5
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Intravenous γ Globulin for Intractable Abdominal Pain due to IgA Vasculitis. Case Rep Pediatr 2020; 2020:8867621. [PMID: 33123401 PMCID: PMC7586148 DOI: 10.1155/2020/8867621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/17/2022] Open
Abstract
IgA vasculitis (formerly known as Henoch–Schönlein purpura or anaphylactoid purpura) is a usually benign vasculitis that affects children of school age. The disease is characterized by the tetrad of palpable purpura, arthralgia/arthritis, abdominal pain, and hematuria. Treatment of IgA vasculitis is mainly supportive, with administration of simple analgesics. Corticosteroids have been shown to reduce and/or ameliorate the occurrence of abdominal pain which may be severe. We present two children with IgA vasculitis and severe abdominal pain despite corticosteroid administration, who responded promptly to intravenous γ globulin (IVIg) with complete resolution of their symptoms and review of the relevant medical literature. Given the toxicity and/or need for long-term administration of other second-line immunosuppressive therapies in corticosteroid-resistant IgA vasculitis, such as rituximab, cyclosporine, cyclophosphamide, azathioprine, or colchicine, we propose that IVIg may be a useful and safe treatment option, although randomized controlled clinical trials are needed in order to clarify its role in the treatment of abdominal pain in IgA vasculitis.
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6
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Alonso de la Hoz J, Martínez Antequera CE, Fernández Manso B, Llorente Otones L, de Inocencio Arocena J. Hemorrhagic Bullous IgA Vasculitis (Schönlein-Henoch purpura), Does it Have a Worse Prognosis? REUMATOLOGIA CLINICA 2020; 17:S1699-258X(20)30195-9. [PMID: 32893147 DOI: 10.1016/j.reuma.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/17/2020] [Accepted: 07/08/2020] [Indexed: 06/11/2023]
Abstract
Haemorrhagic bullous form of IgA vasculitis (IgAV), or Schönlein-Henoch purpura, is an unusual presentation of the disease in paediatric patients (<2%). Blistering eruptions can sometimes be very striking, leading to hospital admissions and administration of high-dose steroids and even immunosuppressants. Review of the literature, however, does not suggest that this clinical form carries a worse prognosis than the other forms of IgAV. In fact, the prognosis of the disease depends on the organic involvement. We present the case of a 5-year-old girl that is very representative. She developed palpable purpura and four days later the skin lesions evolved into blistering lesions. She did not receive any anti-inflammatory nor immunosuppressive treatment and the lesions spontaneously subsided within 14 days. She did not develop any extracutaneous nor systemic involvement.
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Affiliation(s)
- Julia Alonso de la Hoz
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España.
| | | | | | - Lucía Llorente Otones
- Servicio de Pediatría, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Jaime de Inocencio Arocena
- Unidad de Reumatología Pediátrica, Hospital Universitario 12 de Octubre, Madrid, España; Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, España
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7
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Maritati F, Canzian A, Fenaroli P, Vaglio A. Adult-onset IgA vasculitis (Henoch-Schönlein): Update on therapy. Presse Med 2020; 49:104035. [PMID: 32645417 DOI: 10.1016/j.lpm.2020.104035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/05/2019] [Indexed: 12/22/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV, formerly Henoch-Schönlein purpura) is a systemic inflammatory disease affecting small vessels. While it is common and usually benign in childhood, in adults it is rarer has a more severe course. Its main manifestations are cutaneous purpura, arthralgias or arthritis, acute enteritis and glomerulonephritis. Renal involvement is associated with a poor prognosis in adults. The treatment of adult-onset IgAV is still a matter of debate: although in patients with a non-severe phenotype remission can occur spontaneously, more severe cases may need immunosuppressive therapy. There are some areas of uncertainty with respect to the efficacy of immunosuppressive regimens: almost all data come from studies performed in children or from patients with IgA nephropathy and/or IgA-crescentic glomerulonephritis. The only randomised study performed in adults with IgAV and renal involvement showed that immunosuppressive therapy with cyclophosphamide did not improve renal outcome nor did it affect patient survival. The possible efficacy of other drugs is reported only in small case series. Recent evidences show that rituximab could be an effective therapeutic option for adult-onset IgAV, but this also needs to be confirmed in controlled trials. In this review, we focus on therapeutic options for adult-onset IgAV treatment, and discuss the main results of the studies performed so far.
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Affiliation(s)
| | - Alice Canzian
- Nephrology Unit, Parma University Hospital, Parma, Italy
| | | | - Augusto Vaglio
- Department of Biochemical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, and Meyer Children's Hospital, Firenze, Italy.
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8
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Zheng C, Childers J, Rabinovich E, Nazareth-Pidgeon K. Recurrent Henoch-Schönlein Purpura with bullous rash and pulmonary nodules. Pediatr Rheumatol Online J 2020; 18:40. [PMID: 32448396 PMCID: PMC7245848 DOI: 10.1186/s12969-020-00436-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/06/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. It has a characteristic rash described as palpable purpura that most frequently affects the distal lower extremities and buttocks. HSP rarely presents with bullous rash nor pulmonary nodules. CASE PRESENTATION We present a novel case of a 12-years-old female with recurrent pediatric HSP with a combination of the rare manifestations of bullous rash and pulmonary nodules. She initially presented with the bullous rash, chest pain, cough, and abdominal pain. Patient was successfully treated with intravenous pulse corticosteroids followed by a high dose oral corticosteroid taper, with resolution of the bullous rash and pulmonary nodules. CONCLUSION The rare manifestations of scarring bullous rash and pulmonary nodules can be presenting features of pediatric HSP, the combination of which has not been previously reported. The treatment of intravenous corticosteroid resolved patient's abdominal symptoms, rash and pulmonary nodules.
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Affiliation(s)
- Christopher Zheng
- grid.189509.c0000000100241216Department of Pediatrics, Duke University Hospital, 2301 Erwin Rd, Durham, NC 27705 USA
| | - Julie Childers
- grid.189509.c0000000100241216Department of Pediatrics, Duke University Hospital, 2301 Erwin Rd, Durham, NC 27705 USA
| | - Egla Rabinovich
- grid.189509.c0000000100241216Department of Pediatrics, Duke University Hospital, 2301 Erwin Rd, Durham, NC 27705 USA
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9
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Djakovic I, Butorac D, Vucicevic Z, Kosec V, Kuna AT, Lugović-Mihić L. Henoch-Schönlein purpura in the third trimester of pregnancy. Biochem Med (Zagreb) 2018; 28:010801. [PMID: 29472804 PMCID: PMC5806616 DOI: 10.11613/bm.2018.010801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/28/2017] [Indexed: 11/30/2022] Open
Abstract
Henoch-Schönlein purpura (HSP) is an IgA-mediated small vessels’ vasculitis that affects the skin, intestines and kidneys. Pregnancy has been reported as an exacerbating factor. We present the case of a 24-year-old primigravida with HSP that occurred in the third trimester and lasted up to the end of the successful delivery. She had pruritic maculopapular exanthema on her legs. Biopsy of a cutaneous lesion was performed for histopathologic features and direct immunofluorescence (DIF) for the presence of perivascular IgA deposition. Histopathology of the cutaneous lesion confirmed leukocytoclastic vasculitis. A DIF examination of the skin lesion confirmed deposits of fibrinogen in the small blood vessel walls. Six weeks following delivery, the skin lesions almost completely disappeared. Control laboratory findings were normal. This case of HSP might have been primarily associated with a preceding respiratory infection but this should first be carefully investigated due to a possible severe immunological disease in the patient’s background requiring special attention since nephrotic symptoms may occur.
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Affiliation(s)
- Ivka Djakovic
- Department of Gynaecology and Obstetrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Drazan Butorac
- Department of Gynaecology and Obstetrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Zeljko Vucicevic
- Department of Internal Medicine, Intensive Care Unit, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Vesna Kosec
- Department of Gynaecology and Obstetrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Andrea Tesija Kuna
- University Department of Chemistry, Medical School Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Liborija Lugović-Mihić
- Clinical Department of Dermatovenereology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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10
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Dasgeb B, Kornreich D, McGuinn K, Okon L, Brownell I, Sackett DL. Colchicine: an ancient drug with novel applications. Br J Dermatol 2018; 178:350-356. [PMID: 28832953 PMCID: PMC5812812 DOI: 10.1111/bjd.15896] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 12/20/2022]
Abstract
Colchicine is a treatment for gout that has been used for more than a millennium. It is the treatment of choice for familial Mediterranean fever and its associated complication, amyloidosis. The 2009 U.S. Food and Drug Administration approval of colchicine as a new drug had research consequences. Recent investigations with large cohorts of patients with gout who have been taking colchicine for years have demonstrated novel applications within oncology, immunology, cardiology and dermatology. Some emerging dermatological uses include the treatment of epidermolysis bullosa acquisita, leucocytoclastic vasculitis, aphthous stomatitis and others. In this work we relate the history and the new horizon of this ancient medicine.
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Affiliation(s)
- B Dasgeb
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA, U.S.A
- Section of Analytical and Functional Biophotonics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, U.S.A
| | - D Kornreich
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - K McGuinn
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - L Okon
- Department of Dermatology and Cutaneous Biology, Thomas Jefferson University, Philadelphia, PA, U.S.A
| | - I Brownell
- Division of Basic and Translational Biophysics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, U.S.A
| | - D L Sackett
- Dermatology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, U.S.A
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11
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Nothhaft M, Klepper J, Kneitz H, Meyer T, Hamm H, Morbach H. Hemorrhagic Bullous Henoch-Schönlein Purpura: Case Report and Review of the Literature. Front Pediatr 2018; 6:413. [PMID: 30723709 PMCID: PMC6349767 DOI: 10.3389/fped.2018.00413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 12/11/2018] [Indexed: 12/27/2022] Open
Abstract
Henoch-Schönlein Purpura (HSP) or IgA vasculitis is the most common systemic vasculitis of childhood and may affect skin, joints, gastrointestinal tract, and kidneys. Skin manifestations of HSP are characteristic and include a non-thrombocytopenic palpable purpura of the lower extremities and buttocks. Rarely, HSP may initially present as or evolve into hemorrhagic vesicles and bullae. We present an otherwise healthy 5-year-old boy with an acute papulovesicular rash of both legs and intermittent abdominal pain. After a few days the skin lesions rapidly evolved into palpable purpura and hemorrhagic bullous lesions of variable size and severe hemorrhagic HSP was suspected. A histological examination of a skin biopsy showed signs of a small vessel leukocytoclastic vasculitis limited to the upper dermis and direct immunofluorescence analysis revealed IgA deposits in vessel walls, compatible with HSP. To further characterize the clinical picture and treatment options of bullous HSP we performed an extensive literature research and identified 41 additional pediatric patients with bullous HSP. Two thirds of the reported patients were treated with systemic corticosteroids, however, up to 25% of the reported patients developed skin sequelae such as hyperpigmentation and/or scarring. The early use of systemic corticosteroids has been discussed controversially and suggested in some case series to be beneficial by reducing the extent of lesions and minimizing sequelae of disease. Our patient was treated with systemic corticosteroids tapered over 5 weeks. Fading of inflammation resulted in healing of most erosions, however, a deep necrosis developing from a large blister at the dorsum of the right foot persisted so that autologous skin transplantation was performed. Re-examination 11 months after disease onset showed complete clinical remission with re-epithelialization but also scarring of some affected areas.
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Affiliation(s)
- Matthias Nothhaft
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Joerg Klepper
- Department of Pediatrics, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Hermann Kneitz
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Meyer
- Department of Pediatric Surgery, Pediatric Traumatology and Pediatric Urology, University Hospital Würzburg, Würzburg, Germany
| | - Henning Hamm
- Department of Dermatology, Venereology and Allergology, University Hospital Würzburg, Würzburg, Germany
| | - Henner Morbach
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
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12
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Ramelli V, Lava SAG, Simonetti GD, Bianchetti MG, Ramelli GP, Milani GP. Blistering eruptions in childhood Henoch-Schönlein syndrome: systematic review of the literature. Eur J Pediatr 2017; 176:487-492. [PMID: 28161822 DOI: 10.1007/s00431-017-2858-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/02/2016] [Accepted: 01/16/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED The occurrence of blistering eruptions in childhood Henoch-Schönlein syndrome has been so far addressed exclusively in individual case reports. To describe epidemiology, clinical presentation, and therapeutic options in Henoch-Schönlein patients ≤18 years of age with blistering eruptions, we completed a systematic literature search. For the final analysis, we retained 39 reports. Ten children with blisters were found in 7 (1.5%) case series containing a total of 666 unselected pediatric Henoch-Schönlein cases. We also found 41 individually documented cases of Henoch-Schönlein syndrome with blistering eruptions. Blistering eruptions and purpura were distributed very similarly, blisters developed concomitantly with palpable purpura or with a latency of ≤14 days, and 80% of the cases remitted within 4 weeks with a similar course in children managed expectantly and in those managed with steroids. CONCLUSION Blistering eruptions are rare in Henoch-Schönlein syndrome. They can be a source of diagnostic dilemma but do not have any prognostic value since they almost always spontaneously subside within 4 weeks. What is known: • Textbooks and reviews marginally refer to the occurrence of blistering eruptions in children with Henoch-Schönlein syndrome. What is new • Blistering eruptions occur in <2% of cases. • Blisters and purpura are distributed similarly, blisters develop concomitantly with purpura or with a latency of ≤14 days. • Almost all cases remit within 4 weeks with a similar course in children managed expectantly and in those managed with systemic steroids.
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Affiliation(s)
- Vera Ramelli
- Pediatric Department of Southern Switzerland, 6500, Bellinzona, Switzerland
| | - Sebastiano A G Lava
- University Children's Hospital Bern and University of Bern, Bern, Switzerland.,Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, Paris, France
| | - Giacomo D Simonetti
- Pediatric Department of Southern Switzerland, 6500, Bellinzona, Switzerland.,University Children's Hospital Bern and University of Bern, Bern, Switzerland
| | - Mario G Bianchetti
- Pediatric Department of Southern Switzerland, 6500, Bellinzona, Switzerland. .,Università della Svizzera Italiana, Lugano, Switzerland.
| | - Gian Paolo Ramelli
- Pediatric Department of Southern Switzerland, 6500, Bellinzona, Switzerland
| | - Gregorio P Milani
- Pediatric unit, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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13
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Azathioprine therapy for steroid-resistant Henoch-Schönlein purpura: a report of 6 cases. Pediatr Rheumatol Online J 2016; 14:37. [PMID: 27333803 PMCID: PMC4918135 DOI: 10.1186/s12969-016-0100-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/15/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND A small percentage of children with Henoch-Schönlein purpura (HSP) develop a chronic form of the disease that often requires prolonged corticosteroid therapy. Disease modifying anti-rheumatic agents (DMARDs) or biologics have been successfully used to treat those refractory cases. Azathioprine is a DMARD that has been reported to be effective in HSP nephritis and in adult cutaneous leukocytoclastic vasculitis, a condition with cutaneous histology similar to HSP. CASE PRESENTATION A description of 6 cases with relapsing HSP without significant renal involvement, treated with azathioprine are reported. All 6 cases met the classification criteria for the diagnosis of HSP, had relapsing symptoms despite corticosteroid use, were successfully treated with azathioprine and were tapered off of corticosteroids. The duration of azathioprine therapy ranged from 7-21 months and no adverse events were reported. CONCLUSIONS Azathioprine is effective in controlling prolonged relapsing symptoms of HSP, allowing earlier discontinuation of corticosteroids. This report shows that azathioprine can be included in the therapeutic options for relapsing HSP and is the first case series in the literature of azathioprine use in HSP without significant renal involvement.
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