Case Study 1. Rash on a Child's Legs

[unseennude]

One week ago, the mother of this 4-year-old girl noted small red dots on the child's legs, which the primary pediatrician diagnosed as bug bites. The lesions became larger, and a schoolteacher confronted the mother about what she thought were bruises on the child's legs. Concerned, the mother brought the child to a dermatologist, and biopsy was performed; however, the mother states that no diagnosis was made.



Now, nearly hysterical, the mother brings her daughter to the emergency department and complains that the rash looks worse and that the child refuses to walk. The girl is afebrile, appears well, and she is able to ambulate. What is the diagnosis?


Hint :Children with this idiopathic syndrome often complain of abdominal pain. In some, intussusception or renal dysfunction may even develop. When pressure is placed on the skin lesions, they are palpable but do not blanch.

[Oak]

Classical symtopms of Henoch-Schonlein purpura.

[demon_dissector]

i say HSP too.

[unseennude]

Absolutely!
The correct diagnosis is Henoch-Schonlein purpura (HSP)

Henoch-Schonlein purpura (HSP), anaphylactoid purpura:
The classic syndrome of HSP consists of a purpuric rash, arthritis, gastrointestinal symptoms, and renal involvement. Skin lesions are required for the diagnosis and often appear as small wheals or erythematous macules that progress to purpura. Angioedema of the face, hands, feet, and perineum is also common. Two thirds of the patients have arthritis in the large joints, and more than half have gastrointestinal symptoms. Colicky abdominal pain and vomiting are typical. Hemoccult results may be positive, or the stool can be grossly bloody.

The failure to recognize HSP can result in unnecessary laparotomy; however, intussusception or small-bowel obstruction rarely complicates HSP. Approximately 25-50% of the patients have renal involvement. Hematuria and proteinuria are the most common findings, but patients can have hypertension, azotemia, oliguria, or nephrotic syndrome as well. Central nervous system involvement is extremely rare.

Most patients have a benign course and require only nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief. Relapses may occur. Patients with intussusception, small-bowel obstruction, or nephrotic syndrome are given prednisone 1-2 mg/kg/d and require hospitalization.

For detail informations please refer to any standard text book of Pediatrics.

[JNUS]

classical HSP, sometimes with haematuria too.

[autowreckers]

How do we follow up a child with HSP?

Any one with good answer?

[CSF]

Originally Posted by autowreckers

How do we follow up a child with HSP?

Any one with good answer?

autowreckers its a very good discussion, follow up for the HSP needed to rule out the renal impairment.

Lets get back to its Pathophysiology: HSP is a small-vessel vasculitis characterized by immunoglobulin A (IgA), C3, and immune complex deposition in arterioles, capillaries, and venules. HSP and IgA nephropathy are related disorders. Both illnesses have elevated serum IgA levels and identical findings on renal biopsy; however, IgA nephropathy almost exclusively involves young adults and predominantly affects the kidneys only. HSP affects mostly children and involves the skin and connective tissues, gastrointestinal tract, joints, and scrotum as well as the kidneys.

Prognosis:

• HSP is generally a benign disease with an excellent prognosis.
• More than 80% of patients have a single isolated episode lasting a few weeks.
• Approximately 10-20% of patients have recurrences.
• Fewer than 5% of patients develop chronic HSP.
• Abdominal pain resolves spontaneously within 72 hours in most patients.

Therefore the duration of follow up to assess the risk of long term renal impairment in Henoch-Schonlein purpura (HSP) without nephritic or nephrotic syndrome or renal failure on diagnosis remains undetermined.

HSP should have urinalysis and blood pressure measurements at diagnosis and with each recurrence. If hematuria and/or proteinuria are discovered, serum urea and creatinine levels should be followed for up to 6 months after diagnosis. Follow-up beyond 6 months is required for those with continued isolated hematuria or proteinuria. If nephrotic syndrome or nephritis appears, immediate pediatric nephrology consultation is warranted, and continued long-term follow-up is appropriate.

[kenneth masamaro]

Just one minute guys,
What are the possible differentials that can confuse the clinician, even though these spectrum of symptoms are classic?

[Alpine]

In the presence of an atypical rash other vasculitic conditions should be considered. Microscopic polyarteritis, Wegener's granulomatosis, and systemic lupus erythematosus (SLE) may all be accompanied by a crescentic nephritis. The associated clinical features with the presence of ANCA or ANA (antinuclear antibody) can help to differentiate these conditions. Cytoplasmic ANCA (C-ANCA) is more commonly associated with Wegener's granulomatosis while perinuclear ANCA (P-ANCA) is more often associated with microscopic polyarteritis. Serology is also a distinguishing feature in SLE, although ANA positive HSP has been described.


Sepsis may cause a purpuric rash as may clotting disorders or thrombocytopenia. The clinical picture, particularly the distribution of the rash, with haematological investigations should identify these patients.

or if you just want to go through the differential diagnosis of HSP:

• Arthritis, Rheumatoid
• Disseminated Intravascular Coagulation
• Glomerulonephritis, Acute
• Idiopathic Thrombocytopenic Purpura
• Inflammatory Bowel Disease
• Meningitis
• Mononucleosis
• Orchitis
• Pediatrics, Chicken Pox or Varicella
• Pediatrics, Child Abuse
• Pediatrics, Gastroenteritis
• Pediatrics, Gastrointestinal Bleeding
• Pediatrics, Hand-Foot-and-Mouth Disease
• Pediatrics, Intussusception
• Pediatrics, Kawasaki Disease
• Pediatrics, Meningitis and Encephalitis
• Renal Failure, Acute
• Shock, Septic
• Systemic Lupus Erythematosus
• Testicular Torsion
• Thrombocytopenic Purpura
• Tick-Borne Diseases, Rocky Mountain Spotted Fever