Massive Gastrointestinal Bleeding and Diffuse Bowel Wall Thickening

Abstract

Purpose: Henoch-Schönlein purpura (HSP) is a systemic vasculitis characterized by immune complex deposition, usually in the skin and kidney, rarely in the gastrointestinal (GI) tract. It occurs mainly in young children. While the triad of purpura, arthritis, and abdominal pain is the classic presentation of HSP, the manifestation of GI involvement in adults is less defined. Methods: We report a rare case of massive GI bleeding and diffuse bowel wall thickening caused by mesenteric small vessel vasculitis due to HSP post-MRSA infection. Results: Patient is a 24 year old male with a medical history of multiple left arm MRSA-abscesses in the past. The patient now presents with severe left lower quadrant abdominal pain, hematemesis, and melena. Computed tomography of the abdomen and pelvis revealed diffuse small bowel wall thickening. Subsequent esophagogastroduodenoscopy (EGD) and push enteroscopy showed acute gastritis and “punched-out” ulcers in the proximal jejunum. The patient developed a diffuse palpable, pruritic, coalescing rash throughout his bilateral lower extremities 6 days after the initial symptoms. Skin biopsy of the rash showed vasculitis consistent with HSP. Plasmapheresis and immunosuppressive therapy with oral prednisone were begun. However, the patient developed recurrent hematemesis and melena. Repeat EGD showed an ulcerated esophageal mucosa with severe inflammation; biopsy demonstrated a neutrophilic vasculitis. Small bowel biopsy showed granulation tissue with a neutrophilic vasculitis with fibrinoid necrosis. The patient was kept on bowel rest with parenteral nutrition and given intravenous methylprednisolone. The hospital course was complicated by alveolar hemorrhage and acute renal failure likely from HSP vasculitis, requiring intubation and hemodialysis. Subsequent kidney biopsy showed vasculitis with acute post infectious glomerular nephritis. Eventually, the patient improved clinically with the resolution of the rash and improvement of pulmonary and renal function to baseline. The patient was tapered off steroids, tolerated oral feeds and was finally discharged home on hospital day 21. Conclusion: HSP vasculitis with diffuse GI involvement causing massive GI bleeding is rare, but carries a high mortality. This case presentation is that of adult onset HSP developed after MRSA infection in a patient that presented with massive GI bleeding prior to the appearance of typical palpable purpura In an era when MRSA is omnipresent, it should be considered as an important risk factor for developing HSP. Furthermore, early endoscopic intervention and biopsies are vital to diagnosing this rare entity in order to initiate early systemic steroid therapy, especially when the GI hemorrhage is the only initial presentation.