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Revenge of Henoch and Schönlein: a case of diffuse peritonitis in an adult with IgA vasculitis.Marcin Strzałka1 Introduction IgA vasculitis, formerly known as Henoch-Schönlein purpura, is an IgA-mediated autoimmune vasculitis usually of children. Adult onset of IgA vasculitis is rare [1]. It often presents with symptoms including purpuric rash, abdominal pain, renal involvement or arthritis. The clinical manifestations are due to deposition of IgA immune complexes in the intima of small blood vessels, leading to complement activation, leukocyte recruitment and subsequent destruction of endothelial cells. Abdominal symptoms in IgA vasculitis are caused by haemorrhage and oedema within the bowel wall and mesentery [2]. In terms of digestive system involvement, 10% to 20% of patients in general present with abdominal complaints, and 85% have an abdominal complaint along with other symptoms [3]. The most common gastrointestinal symptoms are abdominal pain (86%), massive GI bleeding (20%), occult blood loss (66%), vomiting (40%) and diarrhoea (20%) [4]. Abdominal symptoms in IgA vasculitis are usually benign and show a good response to corticosteroid therapy in most cases. However, severe complications such as intussusception, massive gastrointestinal bleeding, and intestinal perforation can occur. Peritonitis associated with IgA vasculitis is a rare, but life-threatening complication and requires emergency surgical intervention [5]. Nowadays many of acute abdomen cases can be treated laparoscopically [6, 7]. Patient description A 34-year-old male patient was admitted to the University Hospital in Cracow with a 5-day history of upper respiratory tract infection symptoms, high fever (up to 39.8C) and purpuric rash localized on the skin of the lower and upper extremities, abdomen and thorax (Fig. 1). At the beginning he was admitted to the University Department of Infectious Diseases because of the suspicion of sepsis. The abdominal symptoms started two days later. It was a diffuse, constant abdominal pain localized over the whole abdominal cavity, aggravating during body movements and meals. The abdominal pain was accompanied by nausea, vomiting, high fever, watery stools, oedema and numbness of the lower extremities, mild myalgia and arthralgia.  Figure 1. Skin lesions on the shin of the patient with IgA vasculitis. [please click on the image to enlarge] The laboratory tests revealed elevated WBC (23 000/μl), CRP (92 mg/l), D-dimers (24 μg/ml) and ferritin, proteinuria, normal levels of procalcitonin, decreased levels of albumin and total proteins. On physical examination the patient presented with diffused tenderness of the abdomen on palpation, muscle guarding and positive Blumberg sign. The peristaltic sounds were silent and rare on auscultation. The abdominal ultrasound examination revealed dilated intestinal loops with the presence of free fluid in the peritoneal cavity. Because of the symptoms and signs of diffuse peritonitis he was admitted to the Department of General Surgery, Orthopaedics and Polytrauma after the surgical consultation. Treatment The patient was operated on laparoscopically. The operation revealed the presence of serous fluid in the abdominal cavity, oedema and dilation of the small intestine with purpura of its walls (Fig. 2). The mesentery was also oedematous with enlarged lymph nodes. No other pathologies were discovered inside the abdominal cavity. The laparoscopic lavage of the peritoneal cavity with saline and drainage were performed. The patient was treated with antibiotics, corticosteroids, proton pump inhibitor and analgesics. His recovery was uneventful. |
 Generate PDF/or right-click and save as.../  Figure 2. Dilated small intestinal loops with purpura and oedema in the patient with IgA vasculitis (laparoscopic picture). [please click on the image to enlarge] References [1] Hsu HL, Hsiao CH, Liu KL. Henoch-Schonlein purpura. Clin Gastroenterol Hepatol 2010; 8:e83-4. [2] Kaswala D, Chodos A, Ahlawat S. Henoch-Schonlein Purpura With Gastrointestinal Involvement in an Adult Patient. Gastroenterol Hepatol 2016; 12:321-3. [3] Sharma A, Wanchu A, Kalra N et al. Successful treatment of severe gastrointestinal involvement in adult-onset Henoch-Schonlein purpura. Singapore Med J 2007; 48:1047-50. [4] Tancrede-Bohin E, Ochonisky S, Vignon-Pennamen MD et al. Schonlein-Henoch purpura in adult patients. Predictive factors for IgA glomerulonephritis in a retrospective study of 57 cases. Arch Dermatol 1997; 133:438-42. [5] Lerkvaleekul B, Treepongkaruna S, Saisawat P et al. Henoch-Schönlein purpura from vasculitis to intestinal perforation: A case report and literature review. World J Gastroenterol 2016; 22:6089-94. [6] Strzałka M, Bobrzyński A. Laparoscopy in the treatment of acute abdominal diseases. Videosurg Other Miniinv Tech 2008; 3: 1-9. [7] Strzałka M, Bobrzyński A, Budzyński A, Gwóźdź A. Open or laparoscopic appendectomy? Videosurg Other Miniinv Tech 2009; 4:110-4. Conflict of interest: none declared Author's affiliation: 1Jagiellonian University Medical College in Cracow, Poland 2nd Chair of General Surgery, Department of General Surgery, Orthopaedics and Polytrauma Head: Prof. Kazimierz Rembiasz, MD, PhD Corresponding author: Marcin Strzałka MD, PhD Department of General Surgery, Orthopaedics and Polytrauma, 2nd Chair of General Surgery, Jagiellonian University Medical College ul. Kopernika 21, 31-501 Kraków, Poland e-mail: marcin.strzalka@interia.pl ph. +48 12 351 66 63 To cite this article: Strzałka M. Revenge of Henoch and Schönlein: a case of diffuse peritonitis in an adult with IgA vasculitis. World J Med Images Videos Cases 2017; 3:e1-4. Submitted for publication: 06 December 2016 Accepted for publication: 28 December 2016 Published on: 13 January 2017 |
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