Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!
HPI: 20 year old female with no significant past medical history who presents to the ED with one week of severe, diffuse abdominal pain. She’s never had this pain before. It waxes and wanes. Nothing makes it better or worse. It is associated with nausea, intermittent joint pain and swelling, and a non-pruritic rash on her lower extremities. She states she had a head cold about three weeks ago, but has been otherwise well. She denies fevers, chills, headache, shortness of breath, chest pain, nausea, vomiting, diarrhea, or urinary symptoms. Of note, she was seen at an urgent care when her symptoms started and put on doxycycline for presumed Lyme, although she denies any tick bites.
Vitals: BP 126/81, HR 73, T 98.7 °F, RR 18, SpO2 100 % on RA
Notable physical exam findings: Mild, diffuse abdominal tenderness, but no rebound or guarding. She has scattered, raised, purpuric lesions on her bilateral lower extremities. They are non-painful and non-blanchable (see below).
Notable laboratory workup: Trace, microscopic hematuria and a mildly elevated creatinine (1.24).
What’s the diagnosis?
Henoch-Schönlein Purpura (IgA Vasculitis)
Here are some quick facts:
- Although primarily a pediatric diagnosis, up to 10% of Henoch-Schönlein Purpura (HSP) cases are seen in adults.
- The cause of HSP is unknown, although about half the cases are typically preceded by an upper respiratory tract infection.
- The cardinal features are as follows:
- It is a clinical diagnosis, although can be more difficult to diagnosis in “incomplete presentations”, in which one or more of the above features are not present, especially if skin manifestations have not yet appeared.
- If there is diagnostic uncertainty, a platelet count and coagulation studies should be obtained, as abnormal results effectively rule out the diagnosis of HSP.
- The rash typically begins as urticarial wheals that coalesce into palpable purpura, typically in the lower extremities and buttocks.
- The arthritis is typically transient, migratory, and oligoarticular, affecting primarily joints of the lower extremities.
- Intussusception is a more common complication in children versus adults. It is more often small bowel in origin, versus classic intussusception (ileocolic).
- Adults are at an increased risk of developing acute renal failure up to and including end stage renal disease.
How is this managed:
- The mainstay of treatment is fluids, rest, and NSAIDs (symptomatic management).
- For patients with severe abdominal pain that interferes with oral intake or failure of supportive care, oral steroids are the next line therapy.
- For patients requiring IV fluids or those with severe symptoms (GI bleeding, severe abdominal pain, GI bleeding, significant arthralgias impairing ambulation, altered mental status, or significant renal dysfunction), hospitalization is indicated.
Patient was able to tolerate oral intake, and was discharged home on oral prednisone with PCP follow up to monitor her renal function.
Shout out to Dr. Jay Diamond and Dr. John Foggle for this case!
The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only. The patient consented to the use of these images.
See you next week!