A biopsy of skin lesions at an outside hospital shows leukoclastic vasculitis. All his other laboratory results are normal, including ESR, CRP, UA, CBC, CMP.
He received Celecoxib (Celebrex) 200 mg po daily started 5 days ago.Past medical history was Negative.
Physical examination:
Afebrile,well-developed and well-nourished
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, +BS.
Extremities: edema of hands and feet , purpura of lower extremities.
Edema of hands and feet
Purpura and edema of lower extremitiesCBC, CMP, UA, ESR, CRP are all normal.
X-rays of hands are normal.
the likely diagnosis:Henoch-Schönlein Purpura
test to help confirm the diagnosis:
IgA
ASO
Throat culture
GC/Chlamydia probe
Stool guaiac
Results:
IgA level was elevated: IgA 516 mg/dL (lower limit 78, upper limit 391). ASO was elevated but the the throat culture was negative. The rest of the tests were normal.
Rheumatology and ID consults confirmed the diagnosis of Henoch-Schönlein purpura.
On hospital day 2, the purpura and swelling started to resolve. The patient felt much better and was discharged home with Celecoxib (Celebrex) 200 mg po qd and follow-up with rheumatology in 3-4 weeks. He was scheduled to have UA and BMP at that time to monitor for development of HSP-related renal disease.
What did we learn from this case?
Henoch-Schönlein purpura (HSP) is a self-limited systemic vasculitis. It is characterized by 4 clinical syndromes:
1. Palpable purpura in the absence of thrombocytopenia or coagulopathy. Develops in 100% of patients.
2. Arthritis/arthralgia in 45-75% of patients. Second most common manifestation of HSP.
3. Abdominal pain in 50%, GI bleeding (often occult) in 20-30% of patients.
4. Renal disease in 20-50%.
