Intraoperative Microvascular Thrombosis Secondary to Henoch-Schönlein Purpura of Hidden Onset

Abstract

Henoch-Schonlein purpura (HSP) is a systemic small-vessel vasculitis. Here, we report a case of recurrent microvascular thrombosis during microsurgery that initially presented as insidiously developing HSP. A 17-year-old male adolescent underwent latissimus dorsi myocutaneous free tissue transfer for an exposed tibia bone following a motorcycle accident. During microsurgery, gross clots rapidly formed in the artery and vein after anastomoses; Doppler sounds and the flap pallor indicated intravascular thrombosis. Multiple re-anastomoses and salvage interventions failed eventually; the flap was removed for an unknown reason. The patient developed nausea and vomiting, diarrhea, digestive tract hemorrhaging, and abdominal angina refractory to an opioid injection following the flap removal. A palpable petechial rash developed over the entirety of his extremities, bilaterally. Urinalysis revealed severe glomerular injury with microscopic hematuria and nephrotic-range proteinuria. After the 2-month-long consultation, the patient was eventually diagnosed with HSP-induced by preoperative vancomycin therapy. Renal biopsies indicated immunofluorescent deposition of IgA on the glomeruli, confirming grade III–V Henoch-Schonlein nephritis. Clinical and wound problems were corrected following daily bolus injections of 30 mg intravenous methylprednisolone for 7 days. The patient returned to our outpatient clinic 19 months postoperatively with an acceptable esthetic appearance and unrestricted ambulation and physical activity. HSP is rare; however, it is extremely challenging to overcome recurrent and refractory thrombosis during microsurgery in patients with insidiously developing vascular disease. Vancomycin, a commonly used antibiotic, can trigger HSP and is a possible culprit in patients who develop recurrent and unexplained thrombosis during microsurgery.