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NOORUL AMEEN
DR.R.PANDICHELVAN
M6
No h/o vomiting
No h/o fever
No h/o diarrhoea
No h/o jaundice
No h/o cough
No h/o dysuria
On examination pt Conscious
Oriented
Afebrile
Ao /Jo/Cy o/Cl
CVS S1S2
RS NVBS
fossa
clinically diagnosed as
Acute appendicitis and treated with
NPO
IVF DNS and NS
INJ Ciprofloxin 200mg iv bd
INJ Metronidazole 500mg iv tds
INJ Ranitidine 50 mg iv bd
Planned for surgery
General examination:
Pt
Conscious
Oriented
Afebrile
I * P * CY * CL * LNE *
Purpura both lower legs upto thigh
and in both upper limbs -palpable ;confluent
Bp 110/80 mmHg
PR 86/min
CVS S1S2
RS NVBS
CNS NFND
PICTURE
P/A
Not distended
Moves with respiration
Flanks free
No distended veins
No visible peristalis
Soft
Tender
No organomegaly
No free fluid
BS heard
Provisional diagnosis
A/C abdominal pain with
purpura for evaluation
Pt managed with
IVF DNS 2 pints
Inj.Ciprofloxin 200 mg iv bd
Inj.Metronidazole 500 mg iv tds
Inj.Ranitidine 50 mg iv bd
Tab.Paracetamol 500mg tds
Urine
Albumintrace
Sugar
- nil
Deposit- 1-2pc/hpf
CBC
HB- 12.2GM/DL
TC-6400
DC P 65; L 32; E 3
ESR -8/12
PLC 345000
MCV 82.2
MCH 24.5
MCHC 31.2
PCV 38 %
RFT :
Urea -14
Creatine- 0.6
RBS 87
Na -132
K-3.7
Cl -94
Bicarbonate-18
ECG : Normal
CXR : Normal
SP 3 09.02.11
CBC
Platelet count
TC
RBC
DC
PCV
MCV
MCH
MCHC
HB
ESR
Prothrombin time
APTT
INR
-424000
-12800 cells/ cumm
-5.51million/ul
P78; L12; E10
-45.7%
-32.9
- 26.9
-32.4
-14.8
-30mm/hr
14 sec
26 sec
1.0
BIOCHEMISTRY
Sugar
-87
Urea
21.8
Creatine 0.74
LIVER FUNCTION TEST
Total bilirubin
Direct bilirubin
AST
ALT
GGT
SAP
Total protein
Albumin
Globulin
-0.52
-0.20
-25 u/l
-17u/l
17u/l
- 160u/l
-7g/dl
4g/dl
-2.9 g/dl
ELECTROLYTES:
Na
-141
K
- 4.89
Cl
-103.4
SEROLOGY
HBSAG
Negative
ANTIHCV- Negative
HIV Negative
URINE MICROSCOPY
Leucocytes -3-4/hpf
Ep cells
- occassional
RBc
-2-3/hpf
SERUM LDH
219 u/l
IMMUNOLOGY
Histopathology report
Specimen:purpura right forearm biopsy
Microscopic description:stratified squamous
epithelium with hyperkeratosis ,
subepithelium shows congested blood vessels
infiltrated with lymphocytes
Impression : cutaneous small vessel vasculitis
DIAGNOSIS
HENOCH SCHONLEIN PURPURA
Patient treated with Tab. Prednisolone 1mg/kg
Tab.Ranitidine 150 mg bd
Tab.BCT tds
purpura
Arthralgia or arthritis
Gastrointestinal and renal involvement
Rarely involvement of lungs ,
cns,genitourinary tract
Cutaneous involvement is most common
presentation
Also called anaphylactoid purpura
EPIDEMIOLOGY
90% of cases reported in children
Peak in children aged 4-7
Male:Female (1.5:1)
50% follow a URI
Renal disease is more severe in adults
Seasonal variation ; peak incidence in spring
PATHOGENESIS
Likely mechanism thought to be an immunecomplex mediated disease with deposits in
the glomerular capillaries, dermal capillaries
and GI tract.
Mesangial deposits of IgA are the same as those
seen in IgA nephropathy
PRECIPITATING ANTIGENS
INFECTIONS
URI
Measles
Rubella
Parvovirus B19
Mycoplasma
Coxsackie virus
Toxocara
Amebiasis
Salmonella
C.difficile
H.pylori
Adenovirus
Legionella
Tuberculosis
Mumps
Streptococcus
Morganella morganii
PRECIPITATING ANTIGENS
Drugs
Vancomycin
Streptokinase
Ranitidine
Cefuroxime
Diclofenac
Enalapril
Captopril
PRECIPITATING ANTIGENS
Other:
Food hypersensitivity
Cold exposure
Autosomal recessive Chronic granulomatous
disease
Myelodysplastic syndrome
Small cell lung cancer
Breast cancer
CLINICAL FEATURES
PALPABLE PURPURA: most commonly seen on
Gastrointestinal manifestations
One third with HSP have GI features
Colicky pain, nausea, vomiting, GI bleed
50% have occult bleeding
Major GI bleed in 5%
Intussusception 2%
Abdominal pain: sub-mucosal and intramural
extravasation of fluid and blood
Endoscopy: Erosive duodenitis
Renal manifestations
CHILDREN
ADULTS
Knees, ankles,
elbows, shoulders
Wrists, MCP,
PIP, MTP
Edema
Absent
Purpura
Limbs (usually
dependent areas)
Limbs, torso
Present
Present
Uncommon
Common
Course
Benign
More
fulminant
Familial
Rare
Absent
Arthritis/
Arthralgia
Abdominal pain
Renal
involvement
DIAGNOSTIC EVALUATION
May have mild leukocytosis
Normal platelet count
Occasionally eosinophilia
Normal serum complement levels
Elevated IgA in 50% cases
DIAGNOSIS
Generally a clinical diagnosis
Skin Biopsy: can be helpful and used to confirm
IgA and C3 deposits and leukocytoclastic
vasculitis.
Renal Biopsy: not usually needed for diagnosis.
Will show mesangial IgA deposits and
segmental glomerulonephritis
DIAGNOSTIC CRITERIA
ACR criteria-1990
three or more of the following cricteria
1.age 20 yrs or less at disease onset
2.palpable purpura
3.a/c abdominal pain with git bleeding
4.biopsy show granulocytes in the walls
of small arterioles and venules in superficial
layers of skin
Medications
Indication
Acetaminophen,
NSAIDs
Severe rash,
cutaneous edema,
severe colicky
abdominal pain,
scrotal and
testicular
involvement
IV steroids (1-2
mg/Kg)
Same as oral
Same as oral
steroids, should
steroids
be given if patient
is not able to
tolerate oral
medications
Comments
These cannot
prevent
development of
systemic
involvement but
can be helpful for
symptomatic
treatment.
High-dose IV
pulse steroids
Nephrotic range
proteinuria
High-dose IV
pulse steroids
plus
immunosuppressi
on
Rapidly
progressive
glomerulonephriti
s (RPGN),
hemorrhagic
involvement of
lungs, brain
Plasmapheresis
and/or IV
immunoglobulin
therapy
Refractory HSP to
combination
therapy (steroids
and
immunosuppressi
on), massive
hemorrhage in
gastrointestinal or
other organs
Decreases ESRD
progression (in
some case series
and reports)
Grade D
recommendation,
but evidence is
growing with
multiple case
series and
reports. This is
used as the last
resort to treat
refractory HSP.
MANAGEMENT
Usually self-limiting (1-6 weeks)
Steroids:
may decrease tissue edema, may aid in
arthralgias and some abdominal pain
Has not been shown to be beneficial in kidney
disease or dermal manifestations
Does not lessen chance of recurrence
Does not shorten duration of disease
Ref:Harrison 17 e
Cmdt 2011
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