Henoch-Schonlein Purpura with hematochezia in an adult patient

Manappallil, et al.: Henoch-Schonlein Purpura with hematochezia Asian Journal of Medical Sciences | Jul-Aug 2020 | Vol 11 | Issue 4 99 On examination, he was conscious and oriented, with stable vitals. His right elbow and ankle joints were swollen and tender, with local rise in temperature. He had purpuric lesions over his upper (Figure 1) and lower (Figure 2) limbs, and gluteal regions. His abdomen was mildly distended, with no tenderness on palpation. Other systemic examinations were normal. There were no signs of meningeal irritation. His throat examination was also normal. From his history and clinical presentation, the probable diagnosis of HSP was made. His blood invest igat ions showed leucocytosis (12200 cells/cumm with 74% neutrophils, 20% lymphocytes, eosinophils 6%), elevated erythrocyte sedimentation rate (30 mm/hour) and C-reactive protein (47 mg/L), and hypoalbuminemia (2.8 mg/dL). Antistreptolysin O (ASO) titers were elevated (440). His renal and liver functions, C3 and C4 complement levels and electrolytes were normal. Anti-nuclear antibody and anti-double stranded DNA were negative. Urine microscopy did not show any haematuria. Epstein-Barr viral capsid antigen IgM and IgG, cytomegalovirus IgM and IgG, HIV, hepatitis B virus surface antigen, anti-hepatitis C virus were negative. Blood cultures were sterile. Ultrasound abdomen showed mild to moderate ascites. Contrast enhanced computerized tomography (CT) of the abdomen revealed long segment symmetrical circumferential continuous wall thickening in the ileal loops with moderate luminal narrowing, and mild to moderate ascites (Figure 3). Multiple erosions were seen in the rectum, sigmoid, descending, transverse and ascending colon on colonoscopy (Figure 4). Upper gastrointestinal (GI) endoscopy was normal. Histopathologic examination of skin biopsy from the pretibial region showed leukocytoclastic vasculitis, and that from the ileal and colonic mucosa showed edema with mild lymphoplasmacytic infiltration and lymphoid aggregates. Echocardiography and chest Xray were also normal. He was given pulse doses of methylprednisolone (20 mg/kg/day) for 3 days, and was kept nil per oral (NPO) with adequate hydration and intravenous pantoprazole (40 mg twice daily). By day 2 of admission, his arthritis disappeared and purpuric lesions started subsiding. He was started on soft oral diet but had vomiting and abdominal Figure 1: Purpuric lesions over upper limb Figure 2: Purpuric lesions over lower limb Figure 3: Contrast enhanced CT of the abdomen showing long segment symmetrical circumferential continuous wall thickening in the ileal loops with moderate luminal narrowing and mild to moderate ascites Figure 4: Colonoscopy showing multiple erosions in the rectum, sigmoid, descending, transverse and ascending colon Manappallil, et al.: Henoch-Schonlein Purpura with hematochezia 100 Asian Journal of Medical Sciences | Jul-Aug 2020 | Vol 11 | Issue 4 pain. There were no further episodes of hematochezia. He was again kept NPO with adequate hydration. Intravenous methylprednisolone was continued at reduced dosage (0.8 mg/kg/day). By day 6 of admission, he was asymptomatic. Oral diet was started again, which he tolerated. He was discharged on day 7 on oral prednisolone (1 mg/kg/day), which was tapered and stopped over 1 month. He was also advised strict rest from physical activities for 10 days. He was reviewed every week for 1 month and then monthly for next 3 months; and continued to be asymptomatic.