Lesion starts at bilateral ankles,
then progressing up to thigh. It is raised and palpable, red in color, no unity
in shape and size and tender. Both of the legs also edematous but otherwise no
sign and symptom of compartment syndrome or deep venous thrombosis. There were
no involvements of upper trunks.
She otherwise denies abdominal
pain, vomiting, headache, joint pain and anorexia.
On examination, patient is fully
conscious and well oriented, tachycardic, and feverish. Otherwise, other
systemic examinations are uneventful
Discussion
Henoch Schonlein Purpura is an IgA
mediated small vessel vasculitis which classically occurs in pediatric
population and in association with arthritis, abdominal pain and hematuria.
Apart from IgA, C3 and immune complex may as well deposit in the arterioles,
capillaries and venules hence triggering the vasculitis.
HSP is usually appears after the
prodrome symptoms of headache, anorexia and fever. The rash develops with
abdominal pain, peripheral edema, vomiting, joint pain, bloody stools or
scrotal edema. However, atypical HSP may not have these sign and symptoms.
In contrast to younger children
population which the rash develops on the buttock and upper thigh, it appears
on the feet, ankles and lower legs of older child and adults. Compared to
pediatric population, bullae and ulcers are more common and cutaneous
exacerbation can be seen for 6 months and longer. Furthermore, it is uncommon
to see involvement of face, palms and soles.
The lesions are usually symmetrical
that start with erythematous macular or urticarial lesion and progress to
blanching papules and later to palpable purpura. It may also accompanied by
bullae, vesicles, petichiae, ecchymosed, necrotic, ulcerative and target
lesion. The lesion’s color usually progress from red to purple and then rusty
or brown before fading which took place over several days.
While the diagnosis is clinical,
other investigation are mainly done to exclude the differentials of HSP like Disseminated
intravascular coagulation, Endocarditis, Pancreatitis, Meningococcal meningitis
and Thrombocytopenic purpura. Serum IgA level and skin biopsy can be considered
for confirmatory diagnosis.
After excluding the more serious
differential diagnosis, patient can be managed conservatively and monitored for
renal and abdominal complication. Choices of treatment include analgesia like
NSAIDs, and anti inflammation like steroids.
Reference
1)
Andrew D Montemarano, "Dermatologic Manifestations of Henoch-Schonlein
Purpura. http://emedicine.medscape.com/article/1083588
2)
Philip Bossart,"Henoch-Schonlein Purpura in Emergency Medicine
Medication", http://emedicine.medscape.com/article/780452
* Verbal permission has been
obtained from patient for the pictures publication.
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