Case study - A transient purpuric rash with vomiting

After treatment for suspected tonsillitis, Mr R developed abdominal pain and a purpuric rash.

The patient developed a purpuric rash over his ankles and buttocks (Photograph: SPL)

Mr R is a 30-year-old male who presented with a three-day history of a sore throat and a transient maculopapular rash on his trunk and limbs. There was no history of joint swelling or pain. He had otherwise been well.

Mr R was born in Austria.

He occasionally drinks alcohol and smokes cigarettes. He takes no regular prescription medications and has no known allergies. There is no past medical or family history of note.

On examination he was afebrile. His BP was 115/69mm Hg and his pulse rate was 80 bpm, in sinus rhythm. His chest was clear, and his cardiovascular and abdominal examinations were unremarkable.

His ear drums and nasal mucosa were both inflamed, as was his throat. There was evidence of a left-sided tonsillar exudate. There was no cervical lymphadenopathy.

His FBC showed a mildly raised WCC, which was predominantly a neutrophilia. The ESR was 8mm/hr and the CRP 39mg/dL. His LFTs and renal function tests were within normal limits, as was a clotting screen.

The diagnosis at this stage was one of acute tonsillitis.

Following discussion of treatment options a short course of a penicillin antibiotic and analgesia were prescribed. These treatments led to resolution of his symptoms.

Two days later he developed severe colicky central abdominal pain, together with distension and vomiting. In addition, a purpuric rash developed over his ankles and buttocks. By the time of attendance the symptoms had settled and apart from the rash, clinical examination was unremarkable. Urinalysis and BP were normal.

The diagnosis was Henoch-Schonlein purpura (HSP). At review four weeks later the patient was well and asymptomatic.

Small-vessel vasculitis
HSP is a small-vessel vasculitis characterised by purpura, arthritis, abdominal pain and haematuria. The illness is named after the two German physicians who first described the condition.

Approximately 14 cases of HSP occur per 100,000 school-aged children. HSP also occurs in adults, as in this case, but less commonly than in children. In general, HSP is a benign self-limiting disorder. The male-to-female ratio is about 2:1.

The aetiology of HSP is unknown, though about 50 per cent of patients have a preceding URTI. Certain drugs, foods and insect bites may also trigger HSP.

It is a clinical diagnosis. The most common symptoms of HSP include palpable purpura, particularly on the buttocks and legs (95-100 per cent), abdominal pain and vomiting (85 per cent), joint pain (60-80 per cent), especially involving the knees and ankles, subcutaneous oedema (20-50 per cent) and blood in the stool.

The differential diagnosis includes disseminated intravascular coagulation, meningitis, endocarditis, pancreatitis and thrombocytopenic purpura.

Treatment of HSP is mostly supportive and includes adequate hydration and monitoring for abdominal and renal complications.

Key points
  • HSP is a small-vessel vasculitis.
  • HSP also occurs in adults, although less commonly than in children.
  • About 50 per cent of patients have a preceding URTI.
  • Diagnosis of HSP is clinical and not based on laboratory evaluation.
  • HSP is a self-limiting disease and its treatment is mostly supportive.
  • Dr Rashidy is a sessional GP in Mayfair, London

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