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Serosal surface small vessel vasculitis in Henoch-Schonlein purpura

Open AccessPublished:February 07, 2020DOI:https://doi.org/10.1016/j.pedneo.2020.01.002
      A previously healthy 8-year-old girl complained of painful bilateral swelling of the ankles and elbows followed by recurrent vomiting and severe abdominal pain the following day. Physical examination on admission at day 4 of illness showed that the girl was in pain. Clinically she was febrile, with a body temperature of 38.0 °C and her abdomen was tender. Petechial rashes were noted over the dorsum of both feet and buttocks.
      Laboratory investigations showed total white blood cells 21 × 109/L, neutrophils 81%, and platelets 541 × 109/L. Abdominal ultrasound was equivocal and acute appendicitis could not be excluded. Laparoscopic examination showed multiple petechial hemorrhagic lesions over the serosal surface of the terminal ileum (Figure 1, Figure 2), similar to the skin of patients with Henoch–Schonlein purpura (HSP). A closer view (Fig. 1) shows hemorrhagic lesions arranged in linear, packed fashion and were not raised, unlike the palpable purpura characteristic of cutaneous HSP. The appendix was normal and HSP diagnosis was made. The abdominal pain subsided a few days after a short course of prednisolone.
      Figure 1
      Figure 1Laparoscopic image of the terminal ileum showing multiple hemorrhagic lesions.
      Figure 2
      Figure 2Multiple hemorrhagic lesions on the surface of ileum on laparoscopy.
      HSP, a systemic vasculitis characterized by the deposition of immunoglobulin A-containing immune complexes in the walls of small vessels,
      • Trnka P.
      Henoch-Schönlein purpura in children.
      may present as abdominal pain, diarrhea, and hematochezia in approximately two-thirds of affected children.
      • Trnka P.
      Henoch-Schönlein purpura in children.
      Abdominal pain is caused by vasculitis of the intestine leading to submucosal hemorrhage and edema of the bowel wall.
      • Trnka P.
      Henoch-Schönlein purpura in children.
      It may be severe enough to mimic acute abdomen caused by surgical conditions, occasionally leading to laparotomy.
      • Moore S.
      • Bowden A.
      • Afify S.
      Henoch-Schönlein purpura.
      ,
      • Davies M.
      • Kumar M.N.
      • Shetty V.
      • Mitchell P.
      Henoch-Schönlein purpura as a rare cause of an acute abdomen.
      Purpuric small vessel vasculitis lesions of the intestinal serosal surface have previously been reported in adult patients with HSP who had laparotomy for acute abdomen
      • Moore S.
      • Bowden A.
      • Afify S.
      Henoch-Schönlein purpura.
      ,
      • Davies M.
      • Kumar M.N.
      • Shetty V.
      • Mitchell P.
      Henoch-Schönlein purpura as a rare cause of an acute abdomen.
      but have not been reported in children. Mucosal swelling, erosions, hemorrhage, and ulcers in the duodenum and terminal ileum have also been observed in an adolescent with active HSP presented with abdominal pain. However, simultaneous observations of serosal purpuric lesions and intestinal mucosal manifestations in the same patient have not been reported previously.
      Hemorrhagic lesions on the serosal surface reported in this case are similar to those described in literature for adult patients. Laparoscopic examination may occasionally be necessary to exclude acute appendicitis in a child with acute abdominal pain complicating acute HSP. Demonstration of typical serosal hemorrhagic lesions observed in this patient will help to confirm HSP.

      Declaration of Competing Interest

      We have no conflict of interest to declare for this case report.

      Acknowledgements

      The authors declare that no funding was received for the preparation of this work.

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