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Case 372

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Male patient, 14-years-old, comes to a primary care health center due to “red spots” on arms and legs for 5 days, which has been increasing in quantity, and aren’t accompanied by fever or other symptoms. The purpuric lesions initially appeared on both thighs, did not change in size, and were not preceded by flu-like episodes or drug use. On physical examination, there were the lesions in photos 1-3, predominant in the lower limbs, and which did not disappear on digital pressure. Routine urinalysis, blood count and coagulogram were requested. The next day, he returned complaining of diffuse abdominal pain and dysuria, but no fever or alterations of the skin lesions. The requested exams results had no alterations.

Analysing the images, laboratory tests and the clinical history, the most likely diagnosis is:

a) Henoch-Schonlein Purpura

25%

b) Idiopathic thrombocytopenic purpura

25%

c) Systemic lupus erythematosus

25%

d) Antiphospholipid Antibody Syndrome

25%
   

Image analysis

Image 1 - Analysis: Anterior view of the right arm. Presence of bruises (>1cm in diameter) pointed by red arrows and petechiae (some are highlighted by the blue circle).

 

Image 2 - Analysis: View of the inner side of the right tight. Presence of bruises (>1cm in diameter) pointed by red arrows and petechiae (some are highlighted by the blue circle).

 

Image 3 - Analysis: View of the inner side of the left arm. Presence of bruises (>1cm in diameter) pointed by red arrows and petechiae (some are highlighted by the blue circle).

 

Highlights

            - Henoch-Schonlein Purpura (HSP) is the most common form of vasculitis in childhood, predominating between the age of 3 and 6 years old (1,2-1,8:1)

            - Possible triggers are: infections of the upper airways by Streptococcus, exposure to cold, some medications and insect bites;

            - HSP is the cutaneous expression of IgA deposits on the wall of small vessels with granulocyte infiltration;

            - Its diagnosis is clinical, given by the presence of palpable purpura plus at least one of the following criteria: age of onset

            - HSP has an unknown etiology and its treatment is supportive. Its prognosis is favorable, unless when joint, kidney, gastro-intestinal changes are present and when it’s associated with chronic kidney disease in adulthood.

References

1 - Dedeoglu Fatma, Susan Kim. IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis. UpToDate [Internet] 2019. Available at https://www.uptodate.com/contents/iga-vasculitis-henoch-schonlein-purpura-clinical-manifestations-and-diagnosis

2 - Dedeoglu Fatma, Susan Kim. IgA vasculitis (Henoch-Schönlein purpura): Management. UpToDate [Internet] 2019. Available at https://www.uptodate.com/contents/iga-vasculitis-henoch-schonlein-purpura-management?topicRef=6406&source=see_link

3- Rajendra Bhimma, et. al. Henoch-Schonlein Purpura Treatment & Management. Medscape [Inthernet] 2019. Available at: https://emedicine.medscape.com/article/984105-treatment

Authors

Leandra Prates Diniz, 5th year medical school at Universidade Federal de Minas Gerais

E-mail: leandraprates[at]hotmail.com

Supervisors

Professor Aline Almeida Bentes, pediatric infectologist of the Department of Pediatrics at UFMG.

E-mail: alinebentes2000[at]gmail.com

Reviewers

Gustavo Vargas Borgongino Monteiro, Letícia de Melo Elias, Felipe Eduardo Fagundes Lopes, Maria Cecília Landim Nassif, Professor Viviane Parisotto.

Translated by

Leandra Prates Diniz, 5th year medical school at Universidade Federal de Minas Gerais

E-mail: leandraprates[at]hotmail.com

Test question

a)

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b)

25%

c)

25%

d)

25%

e)

25%
   

Commentics

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