1. PER case presentation 家醫科 R1 曾客樺

2. Chart No.: 7169850 Sex: F Birthday: 2003/4/29 2008/11/4 11:32 檢傷 3 級 T 36.4 P 108 R 22 BP 124/75 BW 17 E4V5M6 C.C: bilateral knee pain and mild fever for 1 week

3. Present illness ER at 2008/10/29 This 5.5 y/o girl denied any disease before. She had cough with sputum, fever and mild chillness for 7 days. Her R ’ t ear was discomfortable too. PE showed injected throat, but no eardrum; BS was clear; abd was mild tenderness; no skin rash; Ext was free movable.

4. Present illness Her diagnosis was fever. She took Ibuprofen, Lactobacillus, Guaifenesin, Diclofenac and Augmentin and went home. 2008/11/4 morning the little girl had went to LMD due to bilateral knee pain and unable to walk; but no fever, erythema, skin rash, local heat nor swelling was found.

5. Present illness So she was transferred to our ER. At ER she told she had fever off and on, cough with yellowish sputum, RN with mild yellowish discharge, sorethroat and abd pain for 1 week. No diarrhea, constipation or N/V was told.

6. Present illness PE: Throat: injected(+), tonsil: no enlarge, exudate nor ulcer Eardrum: R ’ t ear with a lot of purulent discharge Abd: normal active BS with mild tenderness Ext: ROM limitation at bilateral knee Skin: no rash Neck, chest and heart were no positive finding

7. order CBC/DC, CRP, ALT Knee A-P+lateral view Both Consult ENT

8. ENT Imp: AOM, R ’ t ear, with possible small rupture Suggestion: 1.s/p local Rx 2.Augmentin PO

9. lab ALT:70 CRP:105.23 CBC/DC: WBC: 9200 Platelet:551000 Seg: 61%

10. order X-ray showed no specific bony finding Suspect septic knee=>consult ortho Admitted to ward B/C, ESR, AST, Alk-p, bilirubin, Cr

11. ortho Imp: bilateral knee swelling r/o reactive arthritis r/o septic arthritis Suggestion: Echo guide aspiration and culture for knee to r/o septic arthritis

12. lab ESR:104 CR:0.35 Bilirubin:0.6 AST:27 Alk-p:168

13. Clinical course At ER before admission on 2008/11/4 afternoon, she had multiple erythematous rash over extensor surface of bilateral ankle. There was also a few petechia found. The impression was Henoch- Schonlein purpura and admitted for further Rx.

15. Clinical course After admission Ampicillin and hydrocortisone were used for HSP and AOM. Her bilateral knee pain improved and could walk on the next day. The amount of purpura progressed on 11/5 and it regressed on 11/6. No more abd pain or ear discomfortable she was discharged on 11/7.

16. D/D of purpura Non-palpable purpura Palpable purpura

17. Non-palpable purpura Platelate disorder: --Thrombocytopenia (ITP) --Platelate dysfunction (vWF disease) Thromboemboli: --DIC --TTP

18. Palpable purpura Vasculitis: --HSP --Churg-Strauss syndrome Infetious emboli: --Meningococcemia

19. D/D of arthritis

20. D/D by synovial fluid

21. Septic Arthritis (Infectious Arthritis) What is septic arthritis? Infection of one or more joints by microorganisms. Microbes are identifiable in an affected joint fluid.

22. Septic Arthritis (Infectious Arthritis) Septic arthritis affects a single joint, but occasionally more joints are involved. The most common causes of septic arthritis are bacteria, including staphylococcus arues and Haemophilous influenzae.

23. Septic Arthritis (Infectious Arthritis) predisposing risk factors ? E.coli and Pseudomonas spp. in intravenous drug abusers and the elderly Neisseria gonorrhoeae in sexually active young adults Salmonella spp. in young children or in people with sickle cell disease taking medications that suppress the immune system, intravenous drug abuser, past joint disease, injury, or surgery, and underlying medical illnesses including diabetes, alocoholism, sickel cell disease, rheumatic diseases, and immune deficiency disorders.

24. Septic Arthritis (Infectious Arthritis) What are symptoms and signs of septic arthritis? Fever Chills joint pain, swelling, redness, stiffness, and warmth Joints most commonly involved are large joints, such as the knees, ankles, hips, and elbows.

25. Hemorrhagic Arthritis what is hemorrhagic arthritis bleeding within a joint leading to joint inflammation, or arthritis

26. Hemorrhagic Arthritis predisposing risk factors ? trauma. In the absence of trauma, ~ bleeding diathesis (e.g., hemophilia) ~ coagulopathy (e.g., warfarin). ~ joint neoplasm

27. Hemorrhagic arthritis What are symptoms and signs of hemorrhagic arthritis? The knee is most commonly affected, followed by the elbow and the ankle, but any large joint may be involved. blood to accumulate within the joint causing swelling and pain

28. Conclusion Septic arthritisHemorrhagic arthritis definition Microbes in joint fluid Blood in joint fluid etiology infectionTrauma or coagulopathy Symptoms and sign Fever, chillness, local heat, tender and local swelling Petechia, echymosis, tender and local swelling characteristicSingle jointMore often on knee Synovial effusionTurbid fluid content Bloody fluid content

29. discussion Henoch-Schonlein purpura

30. background Most common vasculitis in childhood Arterioles, venules, capillary Skin, joint, kidney and GI system

31. pathogenesis URI 40%~50% ASO↑(antitreptolysin O) Serum IgA↑ IgA+C3 immune complex (Bx in skin or kidney) Granulocytic infiltration

32. epidemiology 9-18:100000 in childhood spring and winter <5 y/o(50%) <10y/o(75%) M:F=1.5:1

33. Clinical manifestation Skin: 1.Palpable purpura 2.No thrombocytopenia 3.Ecchymosis at the site of pressure Exm: leg, buttock and arm

34. petechia

35. petechia

36. Ecchymosis

37. purpura

38. Clinical manifestation Joint: 1.Arthralgia(65-84%), most common sites are knee and ankle 2.Arthritis(30%)

39. Clinical manifestation GI: 1.UGI or LGI bleeding(63-76%) 2.Abd. Pain 3.Nausea/vomiting 4.Diarrhea/constipation

40. Severe gastrointestinal vasculitis in a child with Henoch-Sch ö nlein purpura. The small intestinal loops are edematous, inflamed, and hemorrhagic.

41. Clinical manifestation Kidney: 1.Nephritis(20-50%), with hematuria, about 80% p ’ t in one month 2.HTN 3.RPGN(rapid progressive glomerulo-nephritis): rare

42. RBC cast crescent formation mesangial proliferation and IgA deposits

43. Clinical manifestation Others: 1.Headache 2.Seizure 3.Scrotum swelling and tenderness 4.Testicular torsion

44. diagnosis American college of rheumatology 1.<20 y/o 2.Palpable purpura 3.Bowel angina 4.Granulocytic infiltration in arterioles and venules of skin and kidney

45. Routine examination CBC/DC BP Stool OB U/A BUN Cr

46. management Steroid U/A(1 time 1 week at least 3-6 months, then 1 time 1 month at least 3 years) Prophylactic antibiotics(amoxicillin) about 1 year because of 50% recurrent rate and suspect streptococcus related

47. prognosis Mortality: rare Morbidity: 1.Long term complication was nephritis 2.5-15% ESRD children were related with HSP

48. Thank you for attention