A 17‐year‐old boy was in his usual state of health until 3 weeks prior to admission, when he developed intermittent abdominal pain, vomiting, arthralgia, and skin rash. He started with localized, sharp, continuous abdominal pain on the left half of the abdomen associated with 2 episodes of nonbloody, nonbilious forceful vomiting, A nonpruritic skin rash started on the legs, ascending up the thighs and arms. His exam was unremarkable except for a documented BP of 153/78, and the abdominal exam was benign without focal or rebound tenderness and palpable purpura on legs and arms. Laboratory studies were sent and were remarkable for moderate blood in the urine, increased lipase, and guaiac‐positive stools. C3 level and CBC, chem 8, and LFTs were all normal. The patient had a CT evaluation of abdomen secondary to persistent severe abdominal pain and vomiting, which showed pneumomediastinum with small dots of air anterior to the esophagus consistent with esophageal perforation. The patient was admitted with a diagnosis of esophageal perforation with skin rash and was kept NPO for 1 week was started on fluconazole, ampicillin, and sulbactam and pain medication for the abdominal pain. The patient was also receiving Zofran, Protonix, and TPN. A dermatologist performed a skin biopsy, which showed leukocytoclastic vasculitis but was negative for IgA deposits. The patient was started on IV solumedrol on day 4 of hospitalization because of suspected Henoch‐Schönlein purpura and was tapered over 2 days to PO prednisone. The patient had a gastrograffin study to check for esophageal perforation. The examination was negative, and he was started on a clear liquid diet. The patient was discharged on prednisone, Protonix, and Zofran after 1 week.
Henoch‐Schönlein purpura is a clinical diagnosis, and this patient presented with the abdominal pain, arthralgia, and palpable purpura, with a platelet count of 349. This patient had an atypical presentation, including later age of onset and forceful vomiting episode leading to esophageal perforation. The patient's symptoms, including palpable purpura, abdominal pain, arthralgia. increased lipase, and large to moderate blood on UA, were correlated with HSP. Steroids are indicated in HSP if a patient has severe abdominal pain, Gl bleeding, and associated nephritis.
In 2005 pediatric criteria were developed by the European League against Rheumatism (EULAR) and the Pediatric Rheumatology European Society (PReS), The criteria included palpable purpura without thrombocytopenia and coagulopathy as a mandatory finding and 1 or more of the following: diffuse abdominal pain, arthritis or arthralgia, and biopsy with predominant IgA deposition, The patient presented with esophageal perforation, which was a part of his Gl manifestation. Extreme Gl findings are Gl hemorrhage, bowel ischemia and necrosis, intussuception, and bowel perforation.
R. Kamat, none; D. Patel, none,
To cite this abstract:Patel D, Kamat R. Henoch‐Schönlein Purpura: An Atypical Presentation with Esophageal Perforation. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 183. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/henochschnlein-purpura-an-atypical-presentation-with-esophageal-perforation/. Accessed November 11, 2019.