Henoch-Schönlein purpura

The clinical implications of adult-onset henoch-schonelin purpura

Henoch-Schonlein 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. Pathologically, it can be considered a form of immune complex-mediated leukocytoclastic vasculitis (LCV) involving the skin and other organs. Though it primarily affects children (over 90% of cases), the occurrence in adults has been rarely reported. Management often involves the use of immunomodulatory or immune-suppressive regimens.

Henoch-Schölein purpura and polysaccharide meningococcal vaccine

BACKGROUND

We describe here a case of Henoch-Schönlein purpura (HSP) that occurred 10 days after administration of the meningococcal polysaccharide vaccine and came to the attention of a Vaccine Safety Datalink (VSD) investigator (but did not occur in the VSD cohort). Periodic case reports have linked vaccines to HSP.

OBJECTIVE

To better understand the potential risk for HSP after immunization with the meningococcal polysaccharide vaccine.

PATIENTS AND METHODS

We studied the VSD cohort to estimate the 42-day postvaccination incidence rate of HSP in the VSD population 16 to 20 years of age. Electronic data from all 8 VSD sites were gathered. All subjects aged 16 to 20 years who received a meningococcal polysaccharide vaccine were followed for 42 days after that vaccination for evidence of HSP. Background rates were determined by examining all the nonexposed time of the same cohort.

RESULTS

No cases of HSP were seen in the 42 days after 49,027 doses of meningococcal polysaccharide vaccine among the entire VSD adolescent and young adult population. The background incidence rate was 4.2 per 100,000 person-years.

CONCLUSION

These data provide the strongest evidence so far that HSP is not associated with receipt of meningococcal polysaccharide vaccine in the 16- to 20-year age group.

Significance of antineutrophil cytoplasmic antibody in adult patients with Henoch-Schönlein purpura presenting mainly with gastrointestinal symptoms

AIM: To test the clinical significance of antineutrophil cytoplasmic antibody (ANCA) in evaluation of adult Henoch-Schönlein purpura (HSP) patients presenting mainly with abdominal symptoms.

METHODS: Twenty-eight consecutive HSP patients who presented predominantly with abdominal symptoms were enrolled in this study. Control subjects included 27 age- and sex-matched patients with peptic ulcer disease, colon cancer, acute gastroenteritis, irritable bowel syndrome and colonic polyps. ANCA was measured by indirect immunofluorescence (IIF) in all patients, and follow-up ELISA was performed in patients with positive IIF tests.

RESULTS: ANCA was detected in 9 HSP patients by IIF (2 were positive for c-ANCA and 7 were positive for p-ANCA). No ANCA was found in the control group. The sensitivity and specificity of a positive ANCA test (either c- or p-ANCA) were 32.1% and 100% respectively. Only one out of the 9 patients with positive ANCA by IIF had positive ANCA by ELISA and the antigen was myeloperoxidase (MPO). The patients positive for ANCA had higher HSP clinical scores, and were more likely to have renal function impairment. Patients with late purpura development were also associated with more severe clinical manifestations.

CONCLUSION: A positive ANCA test is associated with more severe symptoms in HSP. After inflammatory bowel disease is excluded, a positive ANCA test provides a clue to the diagnosis of HSP presenting predominantly with abdominal symptoms.

Development of acute Henoch-Schönlein purpura subsequent to endodontic treatment

BACKGROUND

Henoch-Schönlein purpura (HSP) is an inflammatory disorder of unknown origin that is characterized by IgA-dominant immune complexes in smaller blood vessels. It results in a triad of symptoms, including a purpuric rash on the lower extremities, abdominal pain or renal involvement, and arthritis. Any of the triad may be absent, however, which often leads to confusion in diagnosing the condition. Cases of acute HSP developing subsequent to dental treatment have not been previously reported in the dental literature.

CASE REPORT

This study reports the unusual case of a 14-year-old female who developed acute HSP following endodontic treatment.

CONCLUSION

Treatment for this condition is supportive and children affected by this disorder need close follow-up of their renal status.

Recurrent gastrointestinal Henoch-Schönlein purpura

A 7-year-old boy was seen for severe abdominal pain, vomiting, and a 2.0-kg weight loss of 2 weeks duration. Stools were Hemoccult positive. Upper gastrointestinal (UGI) endoscopy showed multiple, raised red lesions in the duodenal bulb and descending duodenum. Although the patient did not have the typical cutaneous eruption, other findings such as acute onset of abdominal pain in a previously healthy boy, absence of infectious or surgical lesions, and more importantly endoscopic changes seen typically in the descending duodenum, led to the likely diagnosis of Henoch-Schönlein purpura (HSP). The patient was treated with prednisone and the duodenal lesions resolved. The diagnosis of HSP was confirmed 24 weeks after the initial symptom when he developed a palpable purpuric rash over both legs. Thirteen months following the initial symptoms and 6 months after the onset of rash, severe abdominal pain with epigastric tenderness recurred and stools were Hemoccult positive. UGI endoscopy showed multiple, raised red lesions in the descending duodenum as seen earlier. The patient was diagnosed with recurrent HSP. This presentation is atypical because of the abnormally long interval between the onset of abdominal pain and the appearance of the skin rash, and unique because of the endoscopically demonstrated recurrent gastrointestinal lesions.

Intra-abdominal manifestations of Henoch-Schönlein purpura

Gastrointestinal involvement occurs in approximately two thirds of children with Henoch-Schönlein Purpura (HSP) and usually is manifested by abdominal pain. Abdominal symptoms precede the typical purpuric rash of HSP in 14-36%; the symptoms may mimic an acute surgical abdomen and result in unnecessary laparotomy. Major complications of abdominal involvement develop in 4.6% (range 1.3-13.6%), of which intussusception is by far the most common. The intussusceptum is confined to the small bowel in 58%; its frequent inaccessibility to demonstration by contrast enema means that ultrasonography is the investigation of choice. Ultrasonography complements serial clinical assessment, clarifies the nature of the gastrointestinal involvement and reduces the likelihood of unnecessary surgery. Bowel ischaemia and infarction, intestinal perforation, fistula formation, late ileal stricture, acute appendicitis, massive upper gastrointestinal haemorrhage, pancreatitis, hydrops of the gallbladder and pseudomembranous colitis are seen infrequently. Earlier diagnosis and prompt treatment of intra-abdominal complications has reduced the mortality from 40% to almost zero.

The value of colour Doppler ultrasonography for small bowel involvement of adult Henoch-Schönlein purpura

Three patients presented with a non-thrombocytopenic purpuric rash on their upper and lower limbs, abdominal pain, diarrhoea, and arthralgia. Grey scale ultrasound showed abnormally thickened walls of the small bowel. Colour Doppler showed blood flow signals in the diseased bowel wall in all patients. Subsequent barium and endoscopic studies showed oedematous bowel loops with petechial lesions. Biopsy from the purpuric rash of the skin demonstrated vasculitis of subdermal small vessels. The clinical diagnosis of Henoch-Schönlein purpura was made in each case. This paper describes the efficacy of grey scale and colour Doppler ultrasonography in the assessment of the small bowel involvement of Henoch-Schönlein purpura.

The Yale-Affiliated Gastroenterology Program. A personal note

The Yale-Affiliated Gastroenterology Program provides an effective combination of tutorial and group dynamics and may be the model for need-based training of subspecialists in communities. If the present university centers work in partnership with quality community programs, the consequent university program may offer more pertinent education and proceed in a more appropriate direction for the field of gastroenterology than that of the currently accepted agenda.