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CASE CONFERENCE

CASE CONFERENCE. July 18, 2012. 15 year old male with a rash. HISTORY. Developed a red rash on the palms and soles Intensely itchy Discomfort while walking. 4 days PTC. (+) Mild throat discomfort (+) Low grade fever Sought consult at the ED: Impression – Coxsackie Virus infection

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CASE CONFERENCE

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  1. CASE CONFERENCE July 18, 2012

  2. 15 year old male with a rash

  3. HISTORY Developed a red rash on the palms and soles Intensely itchy Discomfort while walking 4 days PTC (+) Mild throat discomfort (+) Low grade fever Sought consult at the ED: Impression – Coxsackie Virus infection Tx: Diphenhydramine 2 days PTC No relief from Diphenhydramine Worsening of the rash Difficulty in walking because of b/l ankle pain Day of Admission Emergency Room

  4. History

  5. Physical Examination

  6. Physical Examination

  7. 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

  8. Laboratory Tests CBC Chemistries

  9. Laboratory Tests CHEMISTRIES OTHERS

  10. Laboratory Tests Urinalysis

  11. Henoch Schonlein Purpura Vincent Patrick Tiu Uy, MDPGY-2

  12. History

  13. 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

  14. Pathogenesis

  15. Possible Etiologies • Upper Respiratory Tract Infections (~75%) • Streptococcal infections • Other infections • Vaccinations • Medications • Insect Bites

  16. Clinical Manifestations

  17. Rash of HSP

  18. 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

  19. 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

  20. 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

  21. Nephritic vs Nephrotic Syndrome Nephritic Syndrome Nephrotic Syndrome 24 hour urine protein >50 mg/kg/day Low serum albumin Hypertension Hyperlipidemia • Hematuria • Hypertension • Azotemia • Oliguria

  22. Other Presentations • Scrotal Pain • Central Nervous System • Peripheral Nervous System • Respiratory Tract • Eyes

  23. Differential Diagnosis

  24. Reasons Behind Ancillary Procedures

  25. 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

  26. Criteria for Hospitalization • Inability to maintain adequate hydration orally • Severe anemia requiring transfusion • Severe abdominal pain • Significant GI bleeding • Changes in mental status • Severe joint involvement limiting ability to move • Renal insufficiency, hypertension and nephrotic syndrome

  27. 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

  28. Follow-up Weekly or bi-weekly BP + UA for blood Monthly BP + UA for blood Bi -monthly BP + UA for blood Recovery 2 months ~ 6 months 12 months Obtain SERUM CREATININE anytime if (+) abnormalities

  29. HSP of the BRAIN leading to CONFUSION! As the expert in Pediatric Henoch-SchonleinPurpura in St. Barnabas Hospital, you are called to see a 10 year old female who presented with palpable purpuraof 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? • Complete Blood Count and Coagulation studies • CBC and Urinalysis • Urine Dipstick • Abdominal Ultrasound • Anti-Nuclear Antibodies

  30. 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 hemoglobin level of 12.0 mg/dL with nosebleed for 1 minute • Rash involving the face, upper trunk and groin in addition to the typical leg and buttock rash • Patient was not responding to acetaminophen • Blood pressure of 140/80 with no proteinuria on dipstick • Fever of 101.2F and positive Guaiac test

  31. 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

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