P094 Henoch–Schonlein purpura and inflammatory bowel disease

Abstract

BACKGROUND: Approximately 7.5% of children with inflammatory bowel disease (IBD) develop cutaneous extra-intestinal manifestations, with erythema nodosum, pyoderma gangrenosum, and psoriasis being the most common. Although rare, cases of cutaneous small-vessel vasculitis in children with IBD have been reported. CASE: An 8 Y/M with ileo-colonic Crohn disease presented with 3 days of bilateral lower extremity swelling and 1 day of tender palpable rash on the right arm, chest and dorsal surface of the right foot. Crohn disease was diagnosed at age 5 years and was on mesalamine for treatment at the time of presentation. A year ago he had been on infliximab infusions, but had to stop the treatment after a severe infusion reaction. On exam, patient was uncomfortable, unable to bear weight, afebrile, and without abdominal pain or tenderness to palpation. He had limited range of motion of right foot secondary to pain. No joint swelling was noted. He had a palpable purpuric rash on his right arm, chest and dorsal surface of the right foot. Urinalysis was positive for trace protein and ketones. His ANA titers were positive and rheumatoid factor was negative. A clinical diagnosis of Henoch-Schonlein purpura (HSP) was made based on the typical rash and urinalysis. He was treated symptomatically with acetaminophen and did well subsequently DISCUSSION: HSP occurs in approximately 10–22 persons/100,000 each year. More than 90% of patients are children younger than 10 years, with a peak incidence at 6 years of age. HSP is the most common vasculitis in children and has a slight predominance in males. The clinical features of HSP are a consequence of widespread leukocytoclastic vasculitis owing to immunoglobulin A deposition in vessel walls. In 15% to 20% of patients, the gastrointestinal symptoms precede the diagnostic rash by a number of days. In such patients, IBD is a diagnostic consideration, even though the coexistence of HSP and IBD is quite uncommon. In this report, we describe a child with Crohn disease who developed HSP 3 years after diagnosis. HSP can be seen as a complication of infliximab or adalimumab therapy, but our patient was not on biologic therapy at the time HSP diagnosis.