Henoch-Schonlein purpura is an immunoglobulin A (IgA)-immune complex mediated leukocytoclastic vasculitis that classically manifests with palpable purpura, abdominal pain, arthritis, and hematuria or proteinuria. The condition is much more predominant in children (90% of cases) and commonly follows an upper respiratory infection. We present a case of recurrent Henoch-Schonlein purpura (HSP) complicated by nephritis in an adult female initially categorized as IgA nephropathy (IgAN). We review the pathophysiologic basis of HSP nephritis as the variant of HSP accompanied by renal involvement and its pathogenetic commonality with IgA nephropathy.

Background

Children with Henoch-Schonlein purpura nephritis are frequently burdened with psychological problems besides disease treatment and adherence. Currently, there is a shortage of appropriate and effective educational materials to facilitate physical and psychological recovery.

Objectives

To examine a picture book for the effectiveness of disease-related knowledge, coping strategies, resilience, quality of life and depressive symptoms in children with Henoch-Schonlein purpura nephritis in China.

Design

A quasi-experimental design with repeated measures was adopted. The control group received standard care. The intervention group received the standard care plus a free picture book. This disease-specific picture book narrated the story of two rabbits diagnosed with Henoch-Schonlein purpura nephritis who underwent a series of examinations, faced difficulties taking medication, and eventually recovered.

Participants

The study recruited 60 children diagnosed with Henoch-Schonlein purpura nephritis.

Measurements

Disease-related knowledge, resilience, coping strategies, depression and paediatric quality of life were measured at baseline, the third day, the first month and the third month after recruitment. The acceptability of the picture book was evaluated at the last data-collection point.

Results

The data showed that children in the intervention group demonstrated higher levels of knowledge (p < 0.001), less usage of emotional coping strategies (p = 0.003), reduced depressive symptoms (p = 0.003), improved psychological resilience (p < 0.001), and better quality of life (p < 0.046) than those in the control group in the third month. Most children (83.3%) in the intervention group were satisfied with the picture book.

Conclusions

The targeted picture book is an effective educational tool for improving clinical outcomes and was highly accepted by children.

Trifluridine/tipiracil has been approved for the treatment of refractory metastatic colorectal cancer. Adverse effects of this drug combination include leukopenia, neutropenia, fatigue, diarrhea, and vomiting. We present a case of trifluridine/tipiracil-induced leukocytoclastic vasculitis (LCV) with late-onset Henoch-Schönlein purpura (HSP) in a 42-year-old man with metastatic appendiceal cancer. The patient's biopsy-proven LCV developed one month after he began trifluridine/tipiracil treatment and resolved after discontinuation of the drug. He presented to the emergency department two months after the appearance of his LCV with shortness of breath, elevated blood pressure, elevated creatinine, hematuria, and proteinuria. A kidney biopsy was performed and the presence of IgA deposits and cellular crescents indicated rapidly progressive glomerulonephritis secondary to Henoch-Schönlein purpura (HSP). Neither LCV nor HSP have been reported as adverse effects of trifluridine/tipiracil treatment. Malignancy as a cause of our patient's HSP is another possibility. The delay between our patient's skin findings and acute renal failure indicates that suspected HSP should be monitored by urinalysis for a period of time owing to the risk of life-threatening renal disease.

Henoch-Schönlein purpura (HSP) is a small vessel vasculitis characterized by the presence of vascular immunoglobulin A deposition that usually presents as non-thrombocytopenic palpable purpura. It primarily affects children and is less common in adults. The incidence of hemorrhagic necrotic skin lesions increases with age, similarly to renal involvement. Warfarin is a widely used oral anticoagulant drug that has rarely been associated with leukocytoclastic vasculitis and allergic interstitial nephritis. We report a patient with HSP who presented with cutaneous ulcerative plaques and proteinuria in the setting of warfarin therapy. We would like to raise the awareness of this potential adverse effect of warfarin for prompt diagnosis.

We report the first case of direct immunoflourescence-proven immunoglobulin A (IgA) vasculitis associated with influenza infection in an adult patient. IgA vasculitis, which was previously known as Henoch-Schönlein purpura, is the most common systemic vasculitis in children but rarely occurs in adults. Disease onset often occurs after upper respiratory tract infections that are caused by adenovirus or enterovirus. The American College of Rheumatology defines IgA vasculitis by the presence of any two of the following four criteria: age ≤ 20 years at disease onset, palpable purpura, acute abdominal pain, and a biopsy specimen that shows granulocytes in the walls of small arterioles or venules. Purpura, abdominal pain, and arthralgia comprise the classic triad. Renal involvement may be severe, especially in adults. Treatment is most often supportive but glucocorticoids and/or immunosuppressive agents are recommended in severe or refractory cases.

BACKGROUND Henoch-Schönlein purpura (HSP), a small vessel vasculitis mediated by deposition of immune-complexes containing IgA in the skin, gut, and glomeruli, often presents with abdominal pain, purpuric rash in the lower extremities and buttocks, joint pain, and hematuria. The disease most commonly targets children but can affect adults who tend to have a worse prognosis. CASE REPORT We discuss a case of HSP in an elderly Chinese male who presented with severe proximal bowel inflammation, vasculitic rash, and proteinuria; he was found to have positive stool rotavirus and giardia. He improved significantly with high dose steroids. We believe rotavirus may have been a triggering event in this patient. A brief review of the literature is also presented. CONCLUSIONS This is the first case report describing a classic presentation of HSP in an adult following a rotavirus infection. HSP can cause significant morbidity and mortality in adult patients predominantly from progressive renal failure; therefore careful management and monitoring is important. GI infections seem to be a common trigger for HSP and this case report suggests that rotavirus may be part of the spectrum.