Gastrointestinal Manifestations of Henoch-Schoenlein Purpura

Abstract

A 43-year-old Hispanic male was admitted to the hospital with a 2-week history of epigastric pain, hematochezia, rash, and joint pain in his elbows and knees. The pain was non-radiating, without nausea, vomiting, or exacerbating or alleviating factors. Two weeks prior to the onset of these symptoms he had developed flu-like symptoms that resolved without treatment. His past medical history was significant for hypertension; however, he had no personal or family history of gastrointestinal, hematological, or autoimmune disease. He had been taking hydrochlorothiazide and irbesartan for his hypertension. He did not smoke or drink alcohol. On admission, he was afebrile without any abnormalities in his vital signs or cardiopulmonary examination. Physical examination was notable for palpable petechial and purpuric lesions on his legs, arms, and periumbilical region; epigastric tenderness was elicited upon deep palpation, and his elbows and knees were tender to touch (Fig. 1). Stool occult blood was positive. Laboratory investigations revealed leukocytosis and positive inflammatory markers but without evidence of bacterial, infectious, or autoimmune process. Urine analysis did not reveal hematuria or proteinuria. A skin biopsy was reported as leukocytoclastic vasculitis. Computed tomography, performed at the referring outside hospital, revealed focal thickening of the third and fourth portions of the duodenum and proximal jejunum without signs of intussusception or pancreatic inflammation. An upper endoscopy revealed acute, moderately severe, patchy inflammation, as well as ulcerations and friability of the distal duodenum and jejunum. Duodenal and jejunal biopsies revealed benign small bowel mucosa with acute and chronic inflammation, ulceration and fragments of ulcer bed. Fungal Grocott methenamine silver staining was negative; no granulomas or viral changes were noted. A chest radiograph was normal. Colonoscopy revealed small non-bleeding vasculitic lesions and red erythematous plaques throughout the colon and the terminal ileum (Fig. 2). A small bowel capsule endoscopy, performed to evaluate the extent of gastrointestinal tract involvement, demonstrated scattered areas of erythematous ulcerated mucosa extending from the duodenum to the ileum (Fig. 3). His symptoms began to resolve within 2 days after admission without further treatment. His rash, diarrhea, abdominal pain, and joint pain steadily improved during his hospitalization. At follow-up 2 months later, he remained symptom-free; his urine screen for hematuria remained negative.