Post on 03-Jan-2016
CASE CONFERENCEJuly 18, 2012
15 year old male with a rash
HISTORY
4 days PTC
Developed a red rash on the palms and solesIntensely itchyDiscomfort while walking
2 days PTC
(+) Mild throat discomfort(+) Low grade feverSought consult at the ED:Impression – Coxsackie Virus infectionTx: Diphenhydramine
Day of Admission
No relief from DiphenhydramineWorsening of the rashDifficulty in walking because of b/l ankle pain
History
Review of Systems
Denies vomiting, abdominal pain, changes in bowel habits, and changes in urine output
Past Medical History
Nodular acne; has been on Doxycycline 100 mg daily x 5 months
Family History Denies any medical/surgical problems among immediate family members
Social History Child lives in an apartment with parents and siblings. (+) Pets at home. No recent travel. HEAADDSS history non-contributory to the case
Physical ExaminationGeneral Appearance Alert and awake, not in distress.
Cooperative
Vital Signs Afebrile, 100/60, HR80; RR 20
Head, Eyes, Ears, Nose Throat, Neck
NCAT, pinkish conjunctivae, anicteric sclerae, nasal septum midline, TM’s intact, dry oral mucosa, non-hyperemic OP, supple neck, no CLAD
Chest and Cardiovascular CTAB, no wheezes, +S1/S2, no murmurs
Abdominal Exam Flat abdomen, normoactive bowel sounds, no tenderness to palpations, no CVA tenderness
Extremities No edema, no cyanosis, brisk capillary refill; No limitation in ROM
Neurologic Exam No focal neurologic findings; Gait difficulties
Physical Examination
ED Management
Concerns for vasculitis – Basic labs sent, which included coagulation panels
Strep infection partially ruled out with RST
Urinalysis
RPR, Rickettsial antibodies
ANA, RF
Patient booked for admission for observation
Laboratory Tests
CBCParameter Result
sNormal
WBC count 6.1 4.5-13.5
Hemoglobin
13.8 13-14.5
Hematocrit 41.1 36-43
Platelets 306 150-350
N 42
L 41
M 10
ChemistriesParameter
Results
Normal
Na+ 136 133-146
K+ 4.1 3.4-4.7
Cl- 106 98-107
Bicarb 28 20-28
BUN 7 5-18
Crea 0.6 0.5-1
Glucose 97 60-100
Calcium 9.3 8.6-10
Laboratory Tests
CHEMISTRIES OTHERS
Parameter Results
Normal
ALT 16 10-40
AST 20 15-45
Bilirubin 0.5 0.3-1.2
Albumin 3.8 3.2-5.1
Total Protein
7.3 6.0-7.9
Parameter Results
C3 126
C4 32
RPR Non-reactive
Rickettsial Negative
ANA Negative
RF Negative
Laboratory Tests
UrinalysisParameter Results
Color Yellow
Clarity Clear
SPG 1.029
pH 5.5
Proteins TR
Glucose Negative
Blood Negative
WBC 3/hpf
RBC 1/hpf
Sq Cells < 1/hpf
Henoch Schonlein PurpuraVincent Patrick Tiu Uy, MDPGY-2
History
Epidemiology
Peak age of onset: 3-15 years old
Exceedingly rare in the adult population
Males>Females
Very common during the cooler months and rare during the summer
Pathogenesis
Possible Etiologies
Upper Respiratory Tract Infections (~75%)
Streptococcal infections
Other infections
Vaccinations
Medications
Insect Bites
Clinical Manifestations
Rash of HSP
Arthritis and Arthralgias
Typically presents in 84% of patients with HSP, and is the presenting manifestation in 15% of the cases.
Oligoarticular (1-4 joints); Migratory; Mild
> Ankles/Knees
Usually no joint effusion and no swelling will be seen
Toddlers and younger children will refuse to ambulate
Does not cause permanent joint deformities
Gastrointestinal Symptoms
Can range from mild symptoms of nausea/vomiting and pain to significant events like bowel angina and GI bleeding.
Colicky pain
Massive GI hemorrhage is rare
Submucosal hemorrhage and bleeding Mesenteric vasculitis
Intussusception
Renal Disease
20-54% of cases; usually in patients with persistent rashes
Long-term outcome determined by extent of kidney involvement.
Most common presentation is nephritic syndrome with hematuria and mild/absence of proteinuria.
Nephrotic range proteinuria and altered kidney function tests predict a more progressive kidney disease
Watch out for high blood pressure – this may be a clue!
Refer to Renal
Findings on kidney punch biopsy = IgA nephropathy
Nephritic vs Nephrotic Syndrome
Nephritic Syndrome
Hematuria
Hypertension
Azotemia
Oliguria
Nephrotic Syndrome
24 hour urine protein >50 mg/kg/day
Low serum albumin
Hypertension
Hyperlipidemia
Other Presentations
Scrotal Pain
Central Nervous System
Peripheral Nervous System
Respiratory Tract
Eyes
Differential Diagnosis
Condition Presentation
AHEI 4 mos – 2 years; (+) Fever, purpura, ecchymosis and edema; Resolves spontaneously
Hypersensitivity Vasculitis
After drug exposure; Fever, urticaria, lymphadenopathy & arthralgias; Skin biopsy has no IgA
Rocky Mountain Spotted Fever
Presents with fever and rashes on the palms and soles; caused by insect bite
SLE Must satisfy 4/11 criteria for SLE
Meningococcemia Patient appears more septic; may be unvaccinated; Larger purpura and ecchymosis
ITP/HUS Platelet abnormalities are present
Reasons Behind Ancillary Procedures
Test Reason
Complete Blood Count Check platelets; anemia/bleeding
Coagulation Studies Bleeding disorders/Coagulopathy
Urinalysis Check for hematuria/proteinuria
Serum Creatinine Should be obtained if urinalysis is abnormal; always obtain in older patients
Abdominal Ultrasound (+) Severe abdominal pain
Skin Biopsy Usually not necessary unless manifestations are unclear
SUPPORTIVE Treatment of HSP
Most patients may be treated on an outpatient basis
Advise patients to rest until symptoms wear off
Prognosis is generally good, especially if no renal involvement
STRICT Follow-up should be advised
Criteria for Hospitalization
1. Inability to maintain adequate hydration orally
2. Severe anemia requiring transfusion
3. Severe abdominal pain
4. Significant GI bleeding
5. Changes in mental status
6. Severe joint involvement limiting ability to move
7. Renal insufficiency, hypertension and nephrotic syndrome
SYMPTOMATIC Treatment of HSP
Pain control may be achieved with NSAIDS.
No studies that relate worsening of GI bleeding in patients given NSAIDS or cyclooxygenase inhibitors
May give Naproxen, Acetaminophen or Ibuprofen
Glucocorticoid use is controversial
May be considered in hospitalized patients, symptoms that are severe enough to prevent oral fluid intake or severe joint symptoms that prevent ambulation.
Not enough data to support that steroid provide rapid improvement
Follow-up
Weekly or bi-weekly
BP + UA for blood
Monthly BP + UA for
blood
2 monthsRecovery ~ 6 months
Bi -monthly BP + UA for
blood
12 months
Obtain SERUM CREATININE anytime if (+) abnormalities
HSP of the BRAIN leading to CONFUSION!As the expert in Pediatric Henoch-Schonlein Purpura in St. Barnabas Hospital, you are called to see a 10 year old female who presented with palpable purpura of the buttocks and legs with pain on both knees. The doctor was convinced that this is HSP – and she apparently sent for labs. Which of the following laboratory work-up will make the diagnosis of HSP stronger?
A.Complete Blood Count and Coagulation studies
B.CBC and Urinalysis
C.Urine Dipstick
D.Abdominal Ultrasound
E.Anti-Nuclear Antibodies
HSP of the BRAIN leading to BRAIN INFARCT!!!An otherwise healthy 15 year old male was seen in the ED for rashes, arthralgia and abdominal pain. A diagnosis of HSP was made and the ED attending booked him for admission. You are the admitting resident on the floor. Which of the following situation warrants admission?
A.A hemoglobin level of 12.0 mg/dL with nosebleed for 1 minute
B.Rash involving the face, upper trunk and groin in addition to the typical leg and buttock rash
C.Patient was not responding to acetaminophen
D.Blood pressure of 140/80 with no proteinuria on dipstick
E.Fever of 101.2F and positive Guaiac test
THANK YOU!
I would like to thank Dr. Pertubal and Dr. Bhopi for the H&P
& Dr. Shafaghi for her guidance while managing this case