Henoch-Schönlein purpura from vasculitis to intestinal perforation: A case report and literature review

Table 1 Summaries of clinical data, investigations, and treatment in this case report

Category	D1-3	D5	D6	D7	D12	D14	D17	D31
	8-10/1/15	12/1/15	13/1/15	14/1/15	19/1/15	21/1/15	24/1/15	7/2/15
	Private hospital			This hospital
Symptoms	Intermittent abdominal pain, purpuric rash	Abdominal pain progressed	Seizure	Regained consciousness, abdominal pain improved, purpura faded away	Abdominal pain progressed	Persistent abdominal pain with hematochezia	Low grade fever, severe abdominal pain	No abdominal pain, normal appetite
Abdominal signs	Soft, mild tenderness	Generalized voluntary guarding		Soft, not tender	Localized guarding and tenderness at RLQ	Localized guarding and tenderness at RLQ	Distend, generalized guarding	Soft, not tender
Investigations		US - no intussuscep-tion	Hyponatremia MRI/MRA - no vasculitis, CSF fluid - normal	Normal EEG	US - Diffuse small bowel wall thickening, minimal ascites, no intussuscep-tion	Radiograph - no free air, CT - bowel wall thickening, normal homogeneous enhancement	Radiograph - intraperitoneal free air
IVMP (mg/kg/d)	2	1	30	2	2	2	2	Switch to oral prednisolone
Treatment		Nexium, sucralfate	ET tube, 3% NaCl, Keppra, Refer	Extubation, off Keppra	NPO, IVIG 2 gm/kg/dose	NPO	NPO, ATB, exploratory laparotomy

RLQ: Right lower quadrant; US: Ultrasonography; CT: Computerized tomography; EEG: Electroencephalogram; IVIG: Intravenous immunoglobulin; IVMP: Intravenous methylprednisolone; NPO: Nothing by mouth; ATB: Antibiotic; ET: Endotrachial; NaCl: Sodium chloride.

Table 2 The characteristics and outcome in pediatric patients with Henoch-Schönlein purpura associated-intestinal perforation

Ref.	Age (yr)	Sex	Interval between the onset of symptoms and perforation	Location of the perforation	Associated findings	Treatment before perforation	Symptoms before perforation	Reason for surgery	Outcome
Choong et al[1]	5.0	M	16 d	Ileum	Intussusception (ileocolic)	Prednisolone	Fever	Peritonitis Subphrenic free air	Survive
Shiohama et al[6]	7.0	M	15 d	Distal ileum	No	Prednisolone	Melena	Abdominal rigidity	Survive
								Free air below the right diaphragm
	11.0	M	11 d	Jejunum and ileum	No	Prednisolone	Melena, hematemesis	Free air in peritoneal cavity	Death
Başaran et al[9]	4.5	M	> 15 d	Ileum	Intussusception (ileoileal)	NA	NA	Generalized peritonitis	Death
	8.5	M	> 10 d	Distal ileum	Small bowel adhesions	Prednisolone	NA	Peritonitis	Death
Blachar et al[10]	5.0	M	28 d	Distal ileum	Intussusception (jejunojejunal)	Hydrocortisone	Hematochezia, hematemesis, fever	Peritonitis	Survive
Reginelli et al[11]	4.0	F	19 d	Ileum	Bowel necrosis	Cortisol hemisuccinate	Melena, fever	Peritonitis	Survive
Rodriguez-Erdmann et al[12]	5.0	M	> 12 d	Proximal ileum	Intussusception (ileocolic)	Prednisolone	Fever	Abdominal rigidity Pneumoperitoneum	Survive
Law et al[13]	3.0	M	4 wk	Ileum	Ileal stricture	Prednisolone	Fever	Peritonitis	Survive
Yigiter et al[14]	13.0	M	7 d	Ileum	Ileal necrosis	Prednisolone	Bile-stained vomiting, bloody stools	Abdominal rigidity Pneumoperitoneum	Death
Wang et al[15]	5.0	F	22 d	Terminal ileum	Intestinal necrosis, and adhesion	Broad spectrum antibiotics	Abdominal bulge	Peritonitis Subphrenic free air	Death
This case	4.0	M	21 d	Ileum	Intestinal ischemia, necrosis	IVMP	Hematochezia, RLQ pain and guarding	Peritonitis Subphrenic free air	Survive
						IVIG

NA: Not available; IVMP: Intravenous methylprednisolone; IVIG: Intravenous immunoglobulin; RLQ: Right lower quadrant.