A 10‐year‐old girl presented with acute‐onset, severe abdominal pain and vomiting. She was initially treated at an outside hospital for three days with non‐steroidal anti‐inflammatory drugs (NSAIDs) for symptomatic relief of presumed gastroenteritis. She was re‐admitted with persistent nausea and abdominal pain. Her medical history included ulcerative colitis status‐post total colectomy with ileostomy after failing infliximab and steroid therapies. She was afebrile and had diffuse abdominal tenderness without peritoneal signs. ESR and CRP were 34 mm/hr and 7.35 mg/dL, respectively. CT abdomen/pelvis revealed jejunal bowel wall thickening and inflammatory changes. Esophagogastroduodenoscopy (EGD) revealed 2 small duodenal ulcers and gastritis attributed to NSAIDs taken prior to admission. A diagnosis of Crohn’s disease was considered; however, EGD biopsy specimens were negative. Small bowel capsule endoscopy was unremarkable. Severe, unexplained abdominal pain persisted throughout this evaluation. One week after admission, the patient developed polyarthralgias and non‐pitting edema of the hands and feet. She subsequently developed petechiae and palpable purpura on the lower extremities, buttocks, and arms (Figure 1). Urinalysis revealed microscopic hematuria, and a 24‐hour urine collection yielded 1.7 gm protein. Based on this constellation of findings, a diagnosis of Henoch‐Schonlein Purpura (HSP) was made.
While HSP is rare, it is the most common pediatric vasculitis and is often a diagnostic consideration for pediatric patients hospitalized with abdominal pain and rash. 25% of affected patients do not present with classic “palpable purpura;” in fact, this classic rash may not develop until 10‐14 days after the onset of abdominal pain. Delayed development of palpable purpura may impede the diagnosis, lead to unnecessary testing, and prolong hospitalization. Hospitalists should recognize that typical symptoms of HSP can be temporally distant and maintain a high index of suspicion for this diagnosis. In atypical presentations of HSP, evaluation for nephritis and complications such as intussusception may support the diagnosis.
HSP classically presents with the tetrad of abdominal pain, arthralgias, purpuric rash, and nephritis. Skin findings can be a late manifestation following the onset of abdominal pain. Early diagnosis is challenging in the absence of classic purpura; therefore, clinicians should consider HSP in pediatric patients with acute, persistent, unexplained abdominal pain.
To cite this abstract:Mouser B, McShane D, Tcheung W, Ming D. A “Palpable” Conundrum: Delayed Manifestation of Classic Findings. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 272. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/a-palpable-conundrum-delayed-manifestation-of-classic-findings/. Accessed July 22, 2019.