Small intestinal abnormalities in anaphylactoid purpura; report of two cases.

Abstract

Purpura is a manifestation of pathological bleeding which may occur as the result of various underlying diseases or mechanisms. In general, the bleeding is due either to a deficiency in the clotting mechanism or to an increase in vascular permeability. The purpura which may result from an allergic or anaphylactoid reaction is commonly classified as attributable to an abnormal capillary response (1, 2). The name “Henoch's purpura” has been given to the type associated with gastro-intestinal symptoms, presumably due to an allergic serosanguineous involvement of the intestinal wall. However, other sites, particularly the skin and joints, are frequently involved. Thus, the terms Schonlein-Henoch's syndrome and anaphylactoid purpura are assigned to the exanthem found associated at different times with gastro-intestinal symptoms, joint symptoms, edema of the face and extremities, and nephritis. Gairdner (3) reviewed 12 cases of “anaphylactoid purpura.” He found a “rash” in all, gastro-intestinal symptoms in all but one, and articular symptoms in 10 of the 12. Eight patients passed blood in the stools. The disease is predominantly, but not exclusively, one of childhood and more frequently involves males. Since the gastro-intestinal symptoms are variable and frequently precede the skin eruption, many of the cases are confused with such conditions as appendicitis, ileitis, and intussusception, with frequent resort to unnecessary surgery (4). Abnormalities in the radiographic appearance of the small intestine occurring in a case of Henoch's purpura were described in 1946 by Whitmore and Peterson (5). Kraemer (1947) also reported small intestinal changes in a case of Henoch's purpura (6). These cases displayed two common features. First, the radiographic changes were demonstrable before the appearance of purpura on the skin. Second, the small intestine reverted to a normal pattern after the subsidence of symptoms. The two cases of anaphylactoid or Henoch's purpura reported here also demonstrate “pre-exanthematous” abnormal and reversible changes in the small intestine. This report may serve to emphasize the diagnostic importance of small intestinal abnormalities in cases of acute abdominal pain of uncertain etiology. Case Reports Case I: R. C., Italian male, age 6, was admitted to Danbury Hospital on July 9, 1948, because of generalized abdominal pain, associated with nausea and vomiting, as well as a mild diarrhea. Gross blood had been noted in the stools on the day of admission. During the four preceding days the child had complained of anorexia and occasional abdominal pain of no definite localization. About nine months previously, he had experienced similar abdominal pain of short duration but without melena. Physical examination on admission was entirely negative. No skin eruptions were noted.