Immunological Cause of Abdominal Pain in the Adult

Abstract

Purpose: Henoch Schonlein purpura (HSP) is the most common vasculitis syndrome of children affecting skin, joints, and the gastrointestinal tract. There are only a few cases in the literature describing gastrointestinal manifestations and bleeding in the adult population. We present a 25 year old woman with abdominal pain, vomiting, skin rash and joint pain.One month prior to presentation she took amoxicillin-clavulanate for a sore throat accompanied with fevers and chills.Two weeks after began with non pruritic rash located over both thighs with spread to upper and lower extremities. She then developed mid abdominal pain, diffuse joint pain and swelling of both ankles, knees and elbows. Also had heme streaked emesis. She denies taking NSAIDS. She is a non-smoker with occasional alcohol and marijuana use. Her physical exam is remarkable for pinpoint to 7mm purpuric, non blanching, non palpable red macular rash involving the buttocks, lower back bilaterally, thighs and legs, dorsal surface of feet and posterior elbows (spares upper arms and hands). Her abdominal exam reveals mild epigastric tenderness. Labs reveal normal hemoglobin, kidney function and complement levels. Upper endoscopy findings are shown in Figure 1. The pathology showed mild superficial chronic gastritis, focal mild acute inflammatory activity and no evidence of H. pylori in the antrum. Duodenal fragments showed acute inflammatory exudates consistent with ulcer, unremarkable mucosa. With dermatologic consultation and the above clinical and upper endoscopy findings, the patient was diagnosed with HSP. Prednisone was initiated with symptom resolution after three days. This is a case of HSP in an adult patient with classic skin lesions that correlate to endoscopic findings located in the stomach and duodenum. The confirmatory histologic findings include neutrophilic and eosinophilic infiltrates with leukocytoclastic vasculitis. However, as in this case, endoscopic biopsies often miss the submucosal vessels and only reveal nonspecific inflammation. Therefore, a complete clinical presentation with endoscopic findings must be accounted for to diagnose and subsequently treat the gastrointestinal symptoms of HSP.Figure: [960]