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

SARS-CoV-2 as a trigger of IgA vasculitis: a clinical case and literature review

Coronavirus Disease 2019 (COVID-19), caused by SARS-CoV-2, has negatively affected global health. COVID-19 has been associated with a variety of autoimmune and inflammatory disorders, complicating its respiratory manifestations. SARS-CoV-2 triggers inflammatory reactions which may involve multiple organs and systems. The proof for IgA involvement in the immune reactions to coronavirus infection is growing, particularly in the case of IgA immune complex deposition diseases such as IgA vasculitis (IgAV) and IgA nephropathy.This report presents a case of IgAV caused by SARS-CoV-2 in a 53-year-old man. His symptoms included papillomatous, bright red rashes, urticaria throughout the body, aphthous stomatitis, pain in all joints and muscles, weakness, malaise, abdominal pain, face swelling, and arterial hypertension (160/100 mmHg). He received intravenous methylprednisolone (250 mg) and then oral methylprednisolone (16 mg) treatment, which improved his condition. This improvement included the disappearance of abdominal and joint pain and skin rashes.This article also provides an overview of published cases of IgAV after SARS-CoV-2. It may alert rheumatologists and allied specialists of clinical features of IgAV and guide them how to diagnose and treat this disease.

National recommendations for the management of children and young people with IgA vasculitis: a best available evidence, group agreement-based approach

OBJECTIVE

IgA vasculitis (IgAV) is the most frequently experienced subtype of vasculitis seen in children. Most children fully recover, however, complications including chronic kidney disease are recognised. The aim of this project was to use a best available evidence, group agreement, based approach to develop national recommendations for the initial management of IgAV and its associated complications.

METHODS

A fully representative multiprofessional guideline development group (GDG), consisting of 28 members, was formed and met monthly. Graded recommendations were generated using nationally accredited methods, which included a predefined scope, open consultation, systematic literature review, evidence appraisal, review of national or international guidelines and a period of open consultation. Audit measures and research priorities were incorporated.

RESULTS

The IgAV GDG met over a 14-month period. A total of 82 papers were relevant for evidence synthesis. For the initial management, four topic areas were identified with five key questions generating six graded recommendations related to classification, specialist referral and musculoskeletal involvement. For the associated complications, five topic areas with 12 key questions generated 15 graded recommendations covering nephritis, gastrointestinal and testicular involvement, atypical disease and follow-up. Open consultation feedback was incorporated. The guidelines were endorsed by the UK Kidney Association and Royal College of Paediatrics and Child Health and are available online.

CONCLUSION

Despite IgAV being a rare disease with limited evidence, a national standardised approach to the clinical management for children and young people has been achieved. This should unite approaches to care and act as a foundation for improvement.

Recalcitrant intussusception: exploring potential associations with Helicobacter pylori infection - a case report and literature review

BACKGROUND

Intussusception, a common cause of abdominal pain in children, often lacks clear underlying causes and is mostly idiopathic. Recurrence, though rare, raises clinical concerns, with rates escalating after each episode. Factors like pathological lead points and Henoch-Schönlein purpura (HSP) are associated with recurrent cases. On the other hand, the prevalence of Helicobacter pylori (H. pylori), often asymptomatic, in children has been declining. Although its infection is reported to be linked with HSP, its role in recurrent intussusception remains unexplored. Further research is needed to understand the interplay among H. pylori (culprit pathogen), HSP (trigger), and intractable intussusception so as to develop effective management strategies.

CASE PRESENTATION

A two-year-old girl experienced four atypical episodes of intussusception at distinct locations, which later coincided with HSP. Despite treatment with steroids, recurrent intussusception persisted, suggesting that HSP itself was not a major cause for intractable presentations. Subsequent identification of H. pylori infection and treatment with triple therapy resulted in complete resolution of her recalcitrant intussusception.

CONCLUSION

This instructive case underscored a sequence wherein H. pylori infection triggered HSP, subsequently resulting in recurrent intussusception. While H. pylori infection is not common in young children, the coexistence of intractable intussusception and steroid-resistant recurrent HSP necessitates consideration of H. pylori infection as a potential underlying pathogen.

Common Seasonal Pathogens and Epidemiology of Henoch-Schönlein Purpura Among Children

Importance

Henoch-Schönlein purpura (HSP) is the most common type of vasculitis in children. The factors that trigger the disease are poorly understood. Although several viruses and seasonal bacterial infections have been associated with HSP, differentiating the specific associations of these pathogens with the onset of HSP remains a challenge due to their overlapping seasonal patterns.

Objective

To analyze the role of seasonal pathogens in the epidemiology of HSP.

Design, Setting, and Participants

This cohort study comprised an interrupted time-series analysis of patient records from a comprehensive national hospital-based surveillance system. Children younger than 18 years hospitalized for HSP in France between January 1, 2015, and March 31, 2023, were included.

Exposure

Implementation and relaxation of nonpharmaceutical interventions (NPIs) for the COVID-19 pandemic, such as social distancing and mask wearing.

Main Outcomes and Measures

The main outcomes were the monthly incidence of HSP per 100 000 children, analyzed via a quasi-Poisson regression model, and the estimated percentage of HSP incidence potentially associated with 14 selected common seasonal pathogens over the same period.

Results

The study included 9790 children with HSP (median age, 5 years [IQR, 4-8 years]; 5538 boys [56.4%]) and 757 110 children with the infectious diseases included in the study (median age, 0.7 years [IQR, 0.2-2 years]; 393 697 boys [52.0%]). The incidence of HSP decreased significantly after implementation of NPIs in March 2020 (-53.6%; 95% CI, -66.6% to -40.6%; P < .001) and increased significantly after the relaxation of NPIs in April 2021 (37.2%; 95% CI, 28.0%-46.3%; P < .001). The percentage of HSP incidence potentially associated with Streptococcus pneumoniae was 37.3% (95% CI, 22.3%-52.3%; P < .001), the percentage of cases associated with Streptococcus pyogenes was 25.6% (95% CI, 16.7%-34.4%; P < .001), and the percentage of cases associated with human rhino enterovirus was 17.1% (95% CI, 3.8%-30.4%; P = .01). Three sensitivity analyses found similar results.

Conclusions and Relevance

This study found that significant changes in the incidence of HSP simultaneously with major shifts in circulating pathogens after NPIs for the COVID-19 pandemic indicated that approximately 60% of HSP incidence was potentially associated with pneumococcus and group A streptococcus. This finding suggests that preventive measures against these pathogens could reduce the incidence of pediatric HSP.

An Investigation of the Relationship between Henoch-Schönlein Purpura and Viral Infection in Korea Using the Health Insurance Database

(1) Background: This study investigated the epidemiology and viral connections of Henoch-Schönlein purpura (HSP) using information from the Korea Disease Control and Prevention Agency and the Health Insurance Review and Assessment database. (2) Method: Between 2016 and 2019, a total of 25,443 patients with HSP were identified, with 51.3% of patients under the age of 20 years and the highest incidence in March. (3) Results: The autoregressive integrated moving average model and Granger causality test were used to analyze the association between the virus positivity detection rate and HSP incidence. (4) Conclusions: The incidence of HSP was associated with rotavirus, bocavirus, parainfluenza virus, and respiratory syncytial virus in individuals under 20 years of age, whereas adenovirus, respiratory syncytial virus, and norovirus were associated with individuals above that age.

New insights into epidemiological data and impact of the COVID-19 pandemic on IgA vasculitis in children and adults: a French nationwide cohort

IgA vasculitis (IgAV) is a small size vasculitis for which epidemiologic data are strikingly lacking, especially about the adult form. Additionally, the COVID-19 pandemic seems to have profoundly modified the incidence of this disease. Here, we aimed to establish some relevant epidemiological data in both pediatric and adult IgAV. We performed an observational study using a national database called "BNDMR" on IgAV, which gathers patients managed in the French network of experts on rare diseases. We primarily performed descriptive statistics over the 2010-2022 period. Then, we compared the North-South geographical areas, the seasonality, and the impact of COVID-19 with that of other patients reported in the same centers. We collected data from 1988 IgAV patients. The sex ratio was 1.57 for adults and 1.05 for children. The annual incidence in 2021 was 0.06 for 100,000 adults and 0.50 for 100,000 children. Compared with other diseases reported into the BNDMR, IgAV was more common in the South than in the North of France (OR 4.88 [4.17-5.74] in adults and OR 1.51 [1.35-1.68] in children). IgAV was also observed more frequently in winter and autumn. Strikingly, we observed a decrease in incidence during the COVID-19 pandemic period in children (OR 0.62 [0.47-0.81]). Our study provides both new insights and confirmations of IgAV epidemiological data: winter and autumn seasonality, more pronounced male predominance in adults, decreasing incidence of pediatric IgAV during the COVID-19 pandemic and increasing incidence in the South of France.

Causal relationships between circulating inflammatory factors and IgA vasculitis: a bidirectional Mendelian randomization study

Background

IgA vasculitis (IgAV) is an immune-associated vasculitis, yet its exact etiology remains unclear. Here, we explore the interaction between IgAV and inflammatory factors using bidirectional Mendelian randomization (MR).

Methods

We conducted a bidirectional summary-level MR analysis to delineate the causality of C-reactive protein (CRP), procalcitonin (PCT), and 41 circulating inflammatory regulators with IgAV. Data on genetic variants related to inflammation were obtained from three genome-wide association studies (GWASs) on CRP, PCT, and human cytokines, whereas data on IgAV was from large meta-analyses of GWAS among 216 569 FinnGen Biobank participants. The primary MR analysis was performed using the inverse-variance weighted (IVW) approach, and the sensitivity analyses were carried out using MR-Egger, weighted median, weighted mode, and MR-pleiotropy residual sum and outlier.

Results

This study revealed the association of CRP higher levels with increased risk of IgAV through IVW method (Estimate odds ratio [OR] = 1.41, 95% confidence interval [CI]: 1.01-1.98, P = 0.04), MR-Egger (OR = 1.87, CI: 1.15-3.02, P = 0.01), weighted median (OR = 2.00, CI: 1.21-3.30, P = 0.01) and weighted mode (OR = 1.74, CI: 1.13-2.68, P = 0.02). Furthermore, elevated IL-8 was strongly implicated with a higher risk of IgAV (IVW OR = 1.42, CI: 1.05-1.92; P = 0.02). Conversely, genetically predicted IgAV was associated with decreased levels of TNF-β (IVW estimate β = -0.093, CI: -0.178 - -0.007; P = 0.033). Additionally, no such significant statistical differences for other inflammatory factors were found.

Conclusion

Our current study using bidirectional MR analysis provides compelling evidence for a causal effect of CRP, PCT, and circulating inflammatory regulators on IgAV. These findings contribute to a better understanding of the pathogenesis of IgAV and emphasize the potential of targeting inflammatory factors for therapeutic interventions.

Pharmacological importance of Kunxian Capsule in clinical applications and its adverse effects: A review

Kunxian Capsule (KX) is a popular Chinese patent medicine for the treatment of rheumatoid arthritis, nephrotic syndrome, systemic lupus erythematosus, Henoch-Schönlein purpura, ankylosing spondylitis, psoriatic arthritis and eczema. However, there is scarcity of comprehensive information on the significance of KX in the clinical application and its side effects. Hence, it is aimed to provide a review of the significance of KX, with a focus on the pharmacological effects, clinical applications, and its adverse reactions. This review was based on the published literatures in PubMed, China National Knowledge Infrastructure and WanFang database. The articles were collected by two independent authors with no time limits applied until November 30, 2022. The search term includes Kunxian Capsule and/or clinical effect, pharmacology, disease, therapy, adverse effects and quality control. KX has been shown to be effective in the treatment of autoimmune arthritis by inhibiting inflammatory responses and inducing apoptosis. Many studies suggest that KX has anti-inflammatory and analgesic properties that aid in the improvement of joint functions. KX dispels wind, removes dampness, invigorates the kidneys, and promotes blood circulation, thereby curing various diseases. However, studies also suggest KX-related adverse reactions in multiple systems. Overall, this review highlights the scientific basis of KX in curing or preventing various diseases and provides novel insights for further research and clinical applications.

SARS-CoV-2 Infection as a Possible Trigger for IgA-Associated Vasculitis: A Case Report

BACKGROUND

IgA-associated vasculitis (IgAV), formerly known as Henoch-Schönlein purpura (HSP) disease, is the most common type of systemic vasculitis observed during developmental age. Available published studies associate the outbreak of the disease with streptococci, adenovirus, parvovirus, mycoplasma, respiratory syncytial virus (RSV), and influenza infection in approximately 50% of patients with HSP, while some emerging reports have described a few cases of COVID-19 infection being associated with HSP in both adults and children.

CASE PRESENTATION

a 7-year-old girl was diagnosed with HSP, fulfilling the four required clinical criteria (palpable purpura and abdominal pain, arthralgia and edema, and periodic renal involvement). Infection with SARS-CoV-2 was confirmed via the presence of IgM and IgG antibodies. The disclosure of the Henoch-Schönlein purpura (HSP) disease was preceded by a mild, symptomatically treated infection of the upper respiratory tract. High levels of inflammatory markers were observed during hospitalization, including leukocytosis, an increased neutrophil count and a high neutrophil-to-lymphocyte ratio (NLR). All of these markers are associated with IgAV gastrointestinal bleeding, which was also associated with rotavirus diarrhea observed in the patient.

CONCLUSIONS

This case presented by us and similar cases presented by other authors indicate the possible role of SARS-CoV-2 in the development of HSP, but this assumption requires further research and evidence-based verification.

Viral Infections May Be Associated with Henoch-Schönlein Purpura

Henoch-Schönlein purpura or IgA vasculitis is the most common type of pediatric vasculitis that may affect adults as well. It is classified as a type of small-vessel vasculitis. It can cause cutaneous and systemic symptoms with a minority of patients developing kidney failure. Little is known about the specific pathophysiology of this disorder, except that it is believed to occur in individuals with abnormally glycosylated IgA1. Serum aberrant IgA1 may form large antigen-antibody complexes which, due to a defective clearance, are able to deposit in the small vessels of the skin, kidney, gut, and joints. A variety of factors, including infectious agents, drugs, and vaccines, have been identified as potential triggers. The majority of cases are preceded by upper respiratory tract infections, and seasonal variations suggest a link with many pathogens. The etiologic agent most frequently associated with IgA vasculitis historically have been group A β-hemolytic streptococcus and common respiratory tract viruses. However, during the current coronavirus pandemic, SARS-CoV-2 infection was identified as a main trigger factor. In addition, IgA vasculitis has been observed following COVID-19 immunization. This review provides insights into the state of the art on the relationship between viral infections, viral vaccines, and Henoch-Schönlein purpura.

Epidemiology and Clinical Characteristics of Henoch-Schönlein Purpura Associated with Streptococcal Infection in 217 Children in Hubei Province, China

Objectives The objectives of present study were to analyze the association of the streptococcal infection with childhood Henoch-Schönlein purpura (HSP) in China. Methods: We performed a case-control study over a period of five years to evaluate the epidemiology and clinical characteristics of group A β-hemolytic streptococcal (GABHS) triggered HSP. Results: 1. The frequency of GABHS-triggered HSP was 15.1%, while that of GABHS infection developing HSP in children was 4.7%. 2.The epidemiological characteristics of HSP with streptococcal infection were similar to those of HSP alone. 3. The GABHS-triggered HSP cases had a significantly higher frequency of renal involvement than the noninfectious group. 4. IgA and IgG were significantly increased in the streptococcal infection group than in the noninfectious group, while the levels of C3 and C4 decreased significantly. Conclusions: GABHS infection is the most frequent agent in HSP children, and may aggravate the immune dysfunction and prolong the course of HSP.

IgA vasculitis update: Epidemiology, pathogenesis, and biomarkers

Immunoglobulin A vasculitis (IgAV), formerly known as Henoch-Schönlein purpura, is the most common systemic vasculitis in children, characterized by diverse clinical manifestations with a wide spectrum ranging from isolated cutaneous vasculitis to systemic involvement. The incidence of IgAV is geographically and ethnically variable, with a prevalence in autumn and winter, suggesting a driving role that genetic and environmental factors play in the disease. Although IgAV has a certain degree of natural remission, it varies widely among individuals. Some patients can suffer from severe renal involvement and even progress to end-stage renal disease. Its pathogenesis is complex and has not been fully elucidated. The formation of galactose-deficient IgA1 (Gd-IgA1) and related immune complexes plays a vital role in promoting the occurrence and development of IgAV nephritis. In addition, neutrophil activation is stimulated through the binding of IgA to the Fc alpha receptor I expressed on its surface, resulting in systemic vascular inflammation and tissue damage. Starting from the epidemiological characteristics, this article will review the role of immunological factors such as Gd-IgA1, autoantibodies, circulating immune complexes, complement system, cellular immunization, and the contributions of environmental and genetic factors in the pathogenesis of IgAV, and conclude with the major biomarkers for IgAV.

Navigating the initial diagnosis and management of adult IgA vasculitis: A review

Background

IgA vasculitis in adults has not been thoroughly studied. This has left a practice gap related to the management and follow-up of a population that is at an increased risk of comorbidities and potentially poor outcomes. For this reason, it is important to synthesize evidence from the current literature because this can help direct the movement for more robust studies to clarify best practice recommendations.

Objective

We sought to create a narrative review for the practicing dermatologist when diagnosing and leading the care of IgA vasculitis in adult patients.

Methods

A broad literature search was performed with a focus on articles that were published after the introduction of the most updated European Alliance of Associations for Rheumatology/Pediatric Rheumatology International Trials Organization/Pediatric Rheumatology European Society criteria.

Results

The characteristics and management guidelines for IgA vasculitis in adults have been refined, although more rigorous studies are needed to develop best practice recommendations.

Limitations

Because of the lack of sufficient randomized controlled trials on IgA vasculitis in adults, this narrative review is composed of mostly observational, descriptive studies.

Conclusion

Adults with IgA vasculitis are at an increased risk of complicated disease course, necessitating formal diagnostic assessment and clear-cut follow-up recommendations to manage and prevent poor health outcomes related to various comorbidities.

Infections or Vaccines Associated with Finkelstein-Seidlmayer Vasculitis: Systematic Review

Finkelstein-Seidlmayer vasculitis, also referred to as acute hemorrhagic edema of young children, is a rare small-vessel leukocytoclastic vasculitis. This condition is skin-limited, mainly affects infants up to 2 years of age and spontaneously remits. It has been suggested that an infection or a vaccine precede (by ≤ 14 days) this vasculitis. To better understand the interplay between infections or vaccines and Finkelstein-Seidlmayer vasculitis, we utilized the data contained in the Acute Hemorrhagic Edema BIbliographic Database AHEBID. The database, initiated in 2019, is being regularly updated, encompasses the entire original literature on Finkelstein-Seidlmayer vasculitis published after the original description and is attainable on request. The possible existence of an infectious or a vaccine precursor was addressed in 447 cases. Most cases were preceded by an infection (N = 384; 86%), by a vaccination (N = 20; 4.4%), or both an infection and a vaccination (N = 17; 3.8%). No precursor was reported in the remaining cases (N = 26; 5.8%). Two distinct infections preceded the onset of the vasculitis in 11 of the 381 cases with infection-associated Finkelstein-Seidlmayer vasculitis. The following infectious precursors were reported: upper respiratory tract infection (N = 292); acute gastroenteritis (N = 40); a benign febrile infection (N = 36); lower respiratory tract infection (N = 22); further infections (N = 8). The temporal relationship between the infectious precursor and the onset of the skin eruption was detailed in 336 cases: 54 cases developed before resolution and 282 after resolution of the infection. In conclusion, most cases of Finkelstein-Seidlmayer vasculitis are preceded by an infection. In a minority of cases, this skin vasculitis develops before resolution of the infection. In most cases, however, this vasculitis develops after resolution of the infection. More rarely, this vasculitis is preceded by a vaccination.

COVID-19 Vasculitis and vasculopathy-Distinct immunopathology emerging from the close juxtaposition of Type II Pneumocytes and Pulmonary Endothelial Cells

The SARS-CoV-2 virus ACE-2 receptor utilization for cellular entry and the defined ACE-2 receptor role in cardiovascular medicine hinted at dysregulated endothelial function or even direct viral endotheliitis as the key driver of severe COVID-19 vascular immunopathology including reports of vasculitis. In this article, we critically review COVID-19 immunopathology from the vasculitis perspective and highlight the non-infectious nature of vascular endothelial involvement in severe COVID-19. Whilst COVID-19 lung disease pathological changes included juxta-capillary and vascular macrophage and lymphocytic infiltration typical of vasculitis, we review the evidence reflecting that such “vasculitis” reflects an extension of pneumonic inflammatory pathology to encompass these thin-walled vessels. Definitive, extrapulmonary clinically discernible vasculitis including cutaneous and cardiac vasculitis also emerged- namely a dysregulated interferon expression or “COVID toes” and an ill-defined systemic Kawasaki-like disease. These two latter genuine vasculitis pathologies were not associated with severe COVID-19 pneumonia. This was distinct from cutaneous vasculitis in severe COVID-19 that demonstrated pauci-immune infiltrates and prominent immunothrombosis that appears to represent a novel immunothrombotic vasculitis mimic contributed to by RNAaemia or potentially diffuse pulmonary venous tree thrombosis with systemic embolization with small arteriolar territory occlusion, although the latter remains unproven. Herein, we also performed a systematic literature review of COVID-19 vasculitis and reports of post-SARS-CoV-2 vaccination related vasculitis with respect to the commonly classified pre-COVID vasculitis groupings. Across the vasculitis spectrum, we noted that Goodpasture’s syndrome was rarely linked to natural SARS-CoV-2 infection but not vaccines. Both the genuine vasculitis in the COVID-19 era and the proposed vasculitis mimic should advance the understanding of both pulmonary and systemic vascular immunopathology.

Analysis of children with Henoch-Schonlein purpura secondary to infection

OBJECTIVES

Henoch-Schonlein purpura (HSP) is the most common childhood vasculitis, infection is the most essential inducement. We hypothesized that infection could impact the blood routine characteristics and/or outcome of vasculitis. Thus, we aim to find the most common infectious agent in HSP patients and identify convenient indicators to predict renal involvement in HSP patients with infection.

METHOD

We conducted a retrospective study of 208 HSP children and 98 healthy children. Clinical parameters were compared in those cases.

RESULTS

A total of 68.75% of patients were infected with various pathogens. The mean platelet volume (MPV) (P < 0.02) was lower in HSP patients with infection than patients without infection. Mycoplasma pneumoniae (MP) infection accounted for the largest proportion (45.77%). MPV in HSP nephritis (HSPN) group was lower than in HSP patients (excluded renal involvement) in patients with MP infection. Logistic regression analysis found that age and MPV were risk factors for the occurrence of MP-infected HSPN. The receiver operating characteristic curve (ROC) analysis showed that the combination of MPV with the onset age at the optimal cut-off point had 81% sensitivity in predicting whether HSP patients with MP infection would develop into HSPN.

CONCLUSIONS

Our research revealed that MP was the most commonly infected pathogen of children's HSP. MPV was an essential predictor of nephritis in HSP patients with MP infection. This discovery can prompt clinical treatments as well as reduce costs. Key Points • Mycoplasma pneumoniae (MP) accounts for the largest proportion in HSP children with infection. • MPV can be used as a predictor for the development of MP-triggered HSP to HSPN.

The occurrence of infection-related systemic diseases in Korean children and adolescents has decreased after the spread of the COVID-19 pandemic: a multicenter retrospective study

BACKGROUND

The occurrences of infection-related systematic diseases, such as Henoch-Schönlein Purpura (HSP), intussusception, and mucocutaneous lymph node syndrome (MCLS) may have decreased, similarly to the decreased occurrence of infectious diseases following the Coronavirus disease 2019 (COVID-19) pandemic. We aimed to investigate whether there was a change in the occurrence of these diseases in South Korea after the spread of the COVID-19 pandemic.

METHODS

In this multicenter, retrospective study conducted in 16 medical centers in South Korea patients diagnosed with HSP, intussusception, and MCLS at the age of <18 years between January 2016 and December 2020 were included. New occurrences of these three diseases were investigated monthly and annually, while to compare between the pre- and post-COVID-19 era cases, new occurrences between 2017-2019 and 2020 were compared. Additionally, the total annual occurrence rate was calculated by dividing each center's occurrence into the annual population per 100,000 of the population <18 years in each region that the center covers.

RESULTS

A total 6,857 patients were included in this study. From 2017 to 2020, the number of patients diagnosed with HSP, intussusception, MCLS at the age of <18 years were 1,301, 1,693, and 3,863 patients, respectively. The average number of patients during the three years before the COVID-19 pandemic were each 379.7, 505.3, and 1,112.0 for HSP, intussusception, MCLS, respectively, which each decreased by 57.3%, 65.0%, 52.6% to 162, 177, 527 in 2020, respectively. Furthermore, the total annual occurrence rate showed a significant decrease in 2020 compared to 2017 to 2019 in all three diseases (2017-2020; HSP: 11.85, 12.96, 10.52, and 5.48; intussusception: 13.94, 16.97, 16.31, and 5.98; MCLS: 33.89, 35.11, 34.69, and 17.82, respectively).

CONCLUSIONS

We revealed that the occurrence of HSP, intussusception, and MCLS, which are representative of infection-related systemic diseases in the pediatric population, decreased significantly after the spread of the COVID-19 pandemic.

SARS-CoV-2-associated Henoch-Schönlein purpura in a 13-year-old girl

In the context of the current coronavirus disease 2019 (COVID-19) pandemic, cutaneous lesions are being described. Here, we report on a 13-year-old girl with SARS-CoV-2-associated Henoch–Schönlein purpura and Epstein–Barr virus (EBV) infection. She presented without any respiratory symptoms, only a purpuric skin rash, abdominal pain, low-grade fever, and pharyngitis. Virology tests by polymerase chain reaction (PCR) were positive for SARS-CoV-2 and EBV. The potential association of Henoch–Schönlein purpura and SARS-CoV-2 should be kept in mind in order to reduce the spread of the virus, particularly in children with few respiratory symptoms.

Streptococcal infection in childhood Henoch-Schönlein purpura: a 5-year retrospective study from a single tertiary medical center in China, 2015-2019

BACKGROUND

The present study focuses on the associations of streptococcal infection with the clinical phenotypes, relapse/recurrence and renal involvement in Henoch-Schönlein purpura (HSP) children.

METHODS

Two thousand seventy-four Chinese children with HSP were recruited from January 2015 to December 2019. Patients' histories associated with HSP onset were obtained by interviews and questionnaires. Laboratory data of urine tests, blood sample and infectious agents were collected. Renal biopsy was performed by the percutaneous technique.

RESULTS

(1) Streptococcal infection was identified in 393 (18.9%) HSP patients, and served as the most frequent infectious trigger. (2) Among the 393 cases with streptococcal infection, 43.0% of them had arthritis/arthralgia, 32.1% had abdominal pain and 29.3% had renal involvement. (3) 26.1% of HSP patients relapsed or recurred more than 1 time within a 5-year observational period, and the relapse/recurrence rate in streptococcal infectious group was subjected to a 0.4-fold decrease as compared with the non-infectious group. (4) No significant differences in renal pathological damage were identified among the streptococcal infectious group, the other infectious group and the non-infectious group.

CONCLUSIONS

Streptococcal infection is the most frequent trigger for childhood HSP and does not aggravate renal pathological damage; the possible elimination of streptococcal infection helps relieve the relapse/recurrence of HSP.

Morbidity and mortality in adult-onset IgA vasculitis: a long-term population-based cohort study

OBJECTIVES

With sparse data available, we investigated mortality and risk factors in adults with IgAV.

METHODS

Observational population-based cohort study using state-wide linked longitudinal health data for hospitalised adults with IgAV (n = 267) and matched comparators (n = 1080) between 1980-2015. Charlson comorbidity index (CCI) and serious infections (SI) were recorded over an extensive lookback period prior to diagnosis. Date and causes of death were extracted from WA Death Registry. Mortality rate (deaths/1000 person-years) ratios (MRR) and hazard ratio (HR) for survival were assessed.

RESULTS

During 9.9 (±9.8) years lookback patients with IgAV accrued higher CCI scores (2.60 vs1.50 p < 0.001) and had higher risk of SI (OR 8.4, p < 0.001), not fully explained by CCI scores. During 19 years follow-up, the rate of death in Patients with IgAV (n = 137) was higher than in comparators (n = 397) (MRR 2.06, CI 1.70-2.50, p < 0.01) and the general population (SMRR 5.64, CI 4.25, 7.53, p < 0.001). Survival in IgAV was reduced at five (72.7 vs. 89.7%) and twenty years (45.2% vs. 65.6%) (both p < 0.05). CCI (HR1.88, CI:1.25 - 2.73, p = 0.001), renal failure (HR 1.48, CI: 1.04 - 2.22, p = 0.03) and prior SI (HR 1.48, CI:1.01 - 2.16, p = 0.04) were independent risk factors. Death from infections (5.8 vs 1.8%, p = 0.02) was significantly more frequent in patients with IgAV.

CONCLUSIONS

Premorbid comorbidity accrual appears increased in hospitalized patients with IgAV and predicts premature death. As comorbidity does not fully explain the increased risk of premorbid infections or the increased mortality due to infections in IgAV, prospective studies are needed.

Atypical Bacterial Pathogens and Small-Vessel Leukocytoclastic Vasculitis of the Skin in Children: Systematic Literature Review

Leukocytoclastic small-vessel vasculitis of the skin (with or without systemic involvement) is often preceded by infections such as common cold, tonsillopharyngitis, or otitis media. Our purpose was to document pediatric (≤18 years) cases preceded by a symptomatic disease caused by an atypical bacterial pathogen. We performed a literature search following the Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. We retained 19 reports including 22 cases (13 females and 9 males, 1.0 to 17, median 6.3 years of age) associated with a Mycoplasma pneumoniae infection. We did not find any case linked to Chlamydophila pneumoniae, Chlamydophila psittaci, Coxiella burnetii, Francisella tularensis, or Legionella pneumophila. Patients with a systemic vasculitis (N = 14) and with a skin-limited (N = 8) vasculitis did not significantly differ with respect to gender and age. The time to recovery was ≤12 weeks in all patients with this information. In conclusion, a cutaneous small-vessel vasculitis with or without systemic involvement may occur in childhood after an infection caused by the atypical bacterial pathogen Mycoplasma pneumoniae. The clinical picture and the course of cases preceded by recognized triggers and by this atypical pathogen are indistinguishable.

Childhood Immunoglobulin A Vasculitis Associated with COVID-19: A Case Report

Primary immunoglobulin A vasculitis (IgAV) is one the most common childhood vasculitis. A 5-year and 10-month-old girl child patient presented with confluent palpable purple red rash, mainly over both ankles. This was associated with edematous, tender ankles, limited range of movement, and inability to walk. A concomitant coronavirus disease 2019 (COVID-19) was documented by nasopharyngeal swab. This case suggested that COVID-19 can trigger IgAV in children. Hence, awareness of COVID-19 infection in IgAV should be present, and it may be useful to investigate COVID-19 as one of the causes of IgAV, especially in the presence of an epidemic.

Myositis and acute kidney injury in bacterial atypical pneumonia: Systematic literature review

BACKGROUND

Bacterial community-acquired atypical pneumonia is sometimes complicated by a myositis or by a renal parenchymal disease. Available reviews do not mention the concurrent occurrence of both myositis and acute kidney injury.

METHODS

In order to characterize the link between bacterial community-acquired atypical pneumonia and both myositis and a renal parenchymal disease, we reviewed the literature (United States National Library of Medicine and Excerpta Medica databases).

RESULTS

We identified 42 previously healthy subjects (35 males and 7 females aged from 2 to 76, median 42 years) with a bacterial atypical pneumonia associated both with myositis (muscle pain and creatine kinase ≥5 times the upper limit of normal) and acute kidney injury (increase in creatinine to ≥1.5 times baseline or increase by ≥27 μmol/L above the upper limit of normal). Thirty-six cases were caused by Legionella species (N = 27) and by Mycoplasma pneumoniae (N = 9). Further germs accounted for the remaining 6 cases. The vast majority of cases (N = 36) presented a diffuse myalgia. Only a minority of cases (N = 3) were affected by a calf myositis. The diagnosis of rhabdomyolysis-associated kidney injury was retained in 37 and that of acute interstitial nephritis in the remaining 5 cases.

CONCLUSION

Bacterial atypical pneumonia may occasionally induce myositis and secondary kidney damage.

Clostridioides difficile infection in a patient with immunoglobulin A vasculitis: a triggering factor or a rare complication of the disease? A case-based review

IgA vasculitis, formerly known as Henoch-Schonlein purpura (HSP), is the most common form of systemic vasculitis in children and is characterized by inflammation of the small vessels with typical deposition of IgA immune complexes. It is a leukocytoclastic type of vasculitis and is characterized by a tetrad of clinical manifestations: non-thrombocytopenia or coagulopathy-induced palpable purpura, arthritis, or arthralgia, gastrointestinal, and renal involvement. The exact cause of IgA vasculitis is not known yet, although infections, vaccinations and insect bites have been implicated in the appearance of the disease. The main risk factors for Clostridioides difficile infection (CDI) are previous CDI, age > 65 years old, pharmacologic agents (antibiotics, PPIs, histamine-2 receptor antagonists, glucocorticoids, and chemotherapy), prior hospitalization, the presence of co-morbidities, especially inflammatory bowel diseases and chronic kidney disease (CKD) and immunosuppression. Oral vancomycin or fidaxomicin are the gold standard of the therapy, with metronidazole being an alternative choice. The purpose of this study was to describe a case of IgA vasculitis and Clostridioides difficile infection to see whether there is any association between the two distinct clinical entities. Herein, we describe a 17-year old patient with IgA vasculitis and bloody diarrhea due to Clostridioides difficile infection and we discuss the co-existence of these two pathological conditions. The patient presented to the hospital with diffuse abdominal pain, nausea, vomiting, and two episodes of bloody diarrhea. Stools tested positive for Clostridioides difficile toxins, while he remained afebrile with hs-CRP = 1.5 mg/dL (normal range < 0.5 mg/dL). Direct immunofluorescence from the extremities' purplish eruption showed leukocytoclastic vasculitis with IgA deposition. Whether co-existence of the two above-mentioned distinct clinical entities is just a co-incidence or CDI is a triggering factor for IgA vasculitis remains to be elucidated in future large-scale studies.

Expression of miRNA-223 and NLRP3 gene in IgA patients and intervention of traditional Chinese medicine

Objective

The purpose of this study was to investigate the expression of miRNA-223 and NLRP3 in IgA patients and the intervention of traditional Chinese medicine (TCM), so as to realize the basic pathological changes of IgA patients, the expression of miRNA-223 and NLRP3 in IgA patients and the changes of patients' body indexes before and after the treatment of TCM.

Methods

Firstly, according to the clinical data, patients with IgA nephropathy were divided into different groups according to their pathological changes. After that, the chemical sections and staining steps of the immune kidney were carried out. Immunohistochemical pv-9000 two-step method was used to stain it. By this method, miRNA-223 and NLRP3 genes in kidney were determined. After that, the image analysis method was used for semi quantitative experiment. Finally, the intervention of TCM was used to study the changes of indicators before and after treatment.

Results

miRNA-223 and NLRP3 genes could be found mainly in the cytoplasm of renal tubular epithelial cells and the interstitium of monocyte in renal tissue, and there were significant differences between miRNA-223 and NLRP3 genes in the expression levels of proteinuria alone, hematuria albuminuria alone and hematuria alone. There was a positive correlation between miRNA-223 and NLRP3 expression and 24-hour urinary protein in IgA nephropathy. In addition, it also had positive correlation with MCP-1 and IL-18.

Conclusion

This study could provide some direction and guidance for clinical diagnosis and treatment of IgA nephropathy.

A Case of Adult-onset Henoch-Schönlein Purpura Triggered by Fire Ants

Adult-onset IgA vasculitis, also known as Henoch-Schönlein purpura (HSP), is a rare disease that often presents with a non-blanchable, purpuric rash and can simultaneously affect the gastrointestinal, renal and musculoskeletal systems. The etiology of HSP is unknown. It can be triggered by any entity that creates an immunological insult, including medications, infections and vaccines. We describe a unique case of an adult woman who presented with HSP after experiencing multiple insect bites from fire ants and mosquitos while traveling overseas.