April 27, 2013

Henoch Schonlein Purpura in a 61 Years old Lady

61 years old lady with co morbid of hypertension and bronchial asthma presented with complaint of bilateral leg skin lesion and swelling for two days associated with 1 day history of fever.

Lesion starts at bilateral ankles, then progressing up to thigh. It is raised and palpable, red in color, no unity in shape and size and tender. Both of the legs also edematous but otherwise no sign and symptom of compartment syndrome or deep venous thrombosis. There were no involvements of upper trunks.

She otherwise denies abdominal pain, vomiting, headache, joint pain and anorexia.

On examination, patient is fully conscious and well oriented, tachycardic, and feverish. Otherwise, other systemic examinations are uneventful



Henoch Schonlein Purpura is an IgA mediated small vessel vasculitis which classically occurs in pediatric population and in association with arthritis, abdominal pain and hematuria. Apart from IgA, C3 and immune complex may as well deposit in the arterioles, capillaries and venules hence triggering the vasculitis.

HSP is usually appears after the prodrome symptoms of headache, anorexia and fever. The rash develops with abdominal pain, peripheral edema, vomiting, joint pain, bloody stools or scrotal edema. However, atypical HSP may not have these sign and symptoms.

In contrast to younger children population which the rash develops on the buttock and upper thigh, it appears on the feet, ankles and lower legs of older child and adults. Compared to pediatric population, bullae and ulcers are more common and cutaneous exacerbation can be seen for 6 months and longer. Furthermore, it is uncommon to see involvement of face, palms and soles.

The lesions are usually symmetrical that start with erythematous macular or urticarial lesion and progress to blanching papules and later to palpable purpura. It may also accompanied by bullae, vesicles, petichiae, ecchymosed, necrotic, ulcerative and target lesion. The lesion’s color usually progress from red to purple and then rusty or brown before fading which took place over several days.

While the diagnosis is clinical, other investigation are mainly done to exclude the differentials of HSP like Disseminated intravascular coagulation, Endocarditis, Pancreatitis, Meningococcal meningitis and Thrombocytopenic purpura. Serum IgA level and skin biopsy can be considered for confirmatory diagnosis.

After excluding the more serious differential diagnosis, patient can be managed conservatively and monitored for renal and abdominal complication. Choices of treatment include analgesia like NSAIDs, and anti inflammation like steroids.


1) Andrew D Montemarano, "Dermatologic Manifestations of Henoch-Schonlein Purpura. http://emedicine.medscape.com/article/1083588

2) Philip Bossart,"Henoch-Schonlein Purpura in Emergency Medicine Medication", http://emedicine.medscape.com/article/780452

* Verbal permission has been obtained from patient for the pictures publication.

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