HENACH SCHONLEIN PURPURA IN HEPATITIS A Dr (MAJOR) D RAVI SHANKAR MD CONSULTANT PHYSICIAN MANIPAL HOSP. SALEM

 Mr Kiran  17 yrs  C/o Fever -1 wk Nausea/vomiting Jaundice Red patches both dorsum of foot Burning both foot

 O/E Conscious, oriented, febrile Icteric Palpable purpuric patches over both dorsum of foot. Vitals PR – 120 BP - 90/60 SPo2 – 97% CVS-NAD RS-NAD CNS-NAD ABD-Mild tender hepatomegaly

LAB  Hemogram-N  USG ABD – mild HS megaly  LFT TB -3.2 DB-2.1 IDB-1.1 SGOT-1500 SGPT-1900 ALP-324 PROTEINS-N

LAB  INR -1.6  SEROLOGY HIV--ve HBsAG--ve Anti HCV--ve Hep E--ve Anti HAV-positive  Serum ANA – neg  CRP - +ve

LAB  PS study – N  24 hrs urinary protein – 534 Mg  RA factor - +ve  Lepto – Ig M –ve  Malarial Ag –ve  Renal – N  Sugars - N

Skin biopsy  Neutrophilic infiltration in dermis and perivascular region  DIAGNOSIS HENOCH SHONLEIN PURPURA

TREATMENT GIVEN  INJ SOLUMEDRAL 125mg IV BD 3DAYS  SUPPORTIVE MEASURES FOR HEPATITIS  PT RECOVERED  STEROIDS CONTINUED FOR 3 WKS

NAME BegamPalaniappanSuman AGE PRE-disposing Fever,diarrheaFeverURI wk before Purpura legs Symp Abd pain/ diarrhea - Burning feet +++ Co morbid DMDM/SHT- 24 hr pr CRP +VE(96)+ve(140)-VE ANA +VE(dsDNA –ve)-ve+VE (dsDNA -ve) RA -ve -VE Serology -veHBsAg +ve-ve TC ,7 Biopsy Perivascular inflammation with hemorrhage Leucocytoclastic vasculitis Leucocytoclastic Vas culitis (IgA IF sent) OTHER THREE PATIENTS

CAUSES  Viral and bacterial infections, such as strep throat and parvovirus infection — nearly half the children with Henoch- Schonlein purpura develop the disease after an upper respiratory infection  Certain medicines - antibiotics and antihistamines  Insect bites  HEPATITIS B & C  Some vaccinations - measles, typhoid, yellow fever and cholera, varicella, Hep B  Cold weather  Certain chemicals

SYMPTOMS  Rashes and bruising. 100% Legs, buttocks, Rarely, the rash may spread to the upper part of the body, but it is usually on the parts of the body that “hang down,” like the legs, buttocks, elbows, and even earlobes.  Abdominal pain. 80% two-thirds of people with HSP experience pain in the stomach that may cause vomiting or blood in the stool. Intussuseption in children  Arthritis. 80 percent have pain and swelling in the knees and ankles, less frequently in the elbows and wrists. NO residual effects  Kidney involvement. Hematuria & PROTEINURIA - 40 % Mostly no residual damage May progress to Ig A Nephropathy

Classical Purpura

Rare presentation  [Hepatitis A infection and Henoch-Schonlein purpura: a rare association].  [Article in French]  Chemli J, Zouari N, Belkadhi A, Abroug S, Harbi A. Chemli JZouari NBelkadhi AAbroug SHarbi A  Source  Service de pédiatrie, CHU Sahloul, Sousse 4054, Tunisie.  Abstract  OBSERVATION: A 10-year-old boy presented cholestatic hepatitis A virus infection confirmed by IGM anti-HAV antibody. Three days after admission, he presented a palpable purpuric rash on the declivous regions, arthralgia and abdominal pain. He met all criteria set by the American College of Rheumatology (ACR) for Henoch Schonlein purpura. The evolution was gradually favorable with no renal involvement (recoil of 3 years and half). CONCLUSION: Henoch Schonlein purpura is an exceptional extra-hepatic manifestation of hepatitis A infection.  PMID: [PubMed - indexed for MEDLINE]

CONCLUSION MOSTLY FOLLOWS URI/LRI OUR CASE FOLLOWED HEPATITIS A MOSTLY SELF LIMITING MAY HAVE LONG TERM EFFECTS ON KIDNEYS TREATMENT WITH STEROIDS WILL PREVENT THIS FOLLOW UP WITH URINE ANALYSIS UP TO 6 MONTHS