Prepared by Danner T. Hodgson, MD, Resident, Department of Emergency Medicine, and Elena Kret-Sudjian, MD, Assistant Professor, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento
A 26-year-old previously healthy man presented to our emergency department with fever and rash of 5 days’ duration. He had initially noted small, erythematous, “red spots” on the soles of his feet, which had evolved into diffusely tender and coalescent blisters, with progressive involvement of both thighs. Self-treatment with antifungal cream had given no relief. Physical examination revealed numerous violaceous, palpable, nonblanching, and indurated purpuric lesions of differing sizes on the lower and upper extremities (Figure). All the lesions were tender to palpation. Urinalysis showed microscopic hematuria. Immunologic workup was negative, except for an antinuclear antibody titer of 1:40. Biopsy of the lesions showed granular dermal perivascular deposition of immunoglobulin (Ig) A containing immune complexes consistent with Henoch-Schönlein purpura (HSP)–associated leukocytoclastic vasculitis.
Points to remember: HSP is a systemic small-vessel vasculitis characterized by palpable purpura (usually on the lower extremities), hematuria (consequent to an IgA nephropathy), arthralgias, and abdominal pain. Palpable purpura is typically a major finding. HSP is primarily a disease of childhood, with 75% of patients presenting between ages 2 and 11. Confirmation of the diagnosis requires evidence by immunofluorescence microscopy of IgA tissue deposition in the skin or kidney. All the manifestations of active HSP usually resolve spontaneously, although recurrent episodes of purpura and glomerulonephritis may be seen.
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