Henoch Schonlein Purpura.

1. WELCOME TO
Clinical Meeting
Dr Rumi Myedull Hossain
FCPS Student
BSMMU

2. Particulars of the patient:
• Name : Shrsbonti Das
• Age : 3 years
• Sex : Female
• Address : Barishal
• Date of admission : 5th August, 2015
• Date of examination: 5th August, 2015
• Informant : Mother

3. Chief Complaints:
Vomiting for 12 days.
Rash over whole body for 10 days.
Multiple joint pain for the same duration.
Abdominal pain for 6 days.

4. History of present illness:
• According to the statement of the informant mother, Shrabonti
was reasonably well 12 days back . Then she developed
vomiting, occurring several times a day in the first 2 days.
Vomiting was not projectile, vomitus contained undigested food
particles and was not mixed with blood or bile.
• She had developed rash for 10 days which first appeared over
dorsum of the foot then gradually distributed over both legs,
arms, buttock and back. Rash were pruritic in nature.

5. Cont..
She had also developed pain and swelling over multiple
joints for the same duration. Pain involved ankle joints and
small joints of the feet which was non migratory in nature.
She also had diffuse abdominal pain for the last 6 days
which was moderate to severe in nature not associated
with fever.
She has no history of cough or cold, loose motion, urinary
problems or insect bite.

6. Cont.
• For this illness she was admitted in Barishal Medical College
Hospital for 6 days and treated with I/V antibiotics, anti ulcerants,
anti emetics and oral steroid. As there was not significant
improvement, she admitted in BSMMU for further management.

7. Birth history :
Antenatal : uneventful
Natal : Delivered at term in hospital by LUCS.
Post natal : uneventful
Developmental History :
Age appropriate.
History of past illness:
Nothing significant

8. Immunization History:
Completed as per EPI schedule
Feeding history :
Exclusive breast feeding for 3 months. Then she was started
formula feeding. At 6 months complimentary feeding started
.She is now on family diet and formula feeding.
Family History:
She is the single issue of her non consanguineous parents.
Her other family members are healthy.

9. Socio Economic condition :
She belongs to middle socio economic background. Father
is a businessman & mother is a housewife. They lives in
paka house, drinks tubewell water and use sanitary
latrine.
Treatment History :
Nothing significant.

10. General Examination:
• Appearance : Well,alert
• Anaemia : mild
• Jaundice : absent
• Cyanosis : absent
• Clubbing : absent
• Edema : absent
• Koilonychia : absent
• Leukonychia : absent

11. Cont…
• Throat : normal
• Lymph nodes : not palpable
• Thyroid Gland : not enlarged
• JVP : not raised
• Skin survey : Extensive palpable reddish spots of
variable sizes over extensor and flexor surfaces of lower limbs,
buttock, back and extensor surface of upper limbs. The spots did
not blanch on pressure. BCG mark present.
• Bony tenderness : absent
• Signs of meningeal irritation : absent.
• Bed side urine albumin : nil

13. Vital parameters:
H.R - 92 beats/min(regular in rhythm,
normal in volume, symmetrical)
B.P - 80/50 mm Hg
(both - b/w 5th & 10th centile)
R.R - 26 breaths/min
Temp - 98 ͦ F

14. • Weight : 13 kg
• WA : Between 50th and 75th centile
• Height : 93 cm
• HA : Between 50th & 25th centile

15. Systemic Examination

16. •Alimentary system :
Mouth & Oral Cavity : Healthy
 Abdomen proper :
Inspection :
Abdomen normal in shape, Umbilicus centrally placed
& inverted.

17. cont…
Palpation:-
 Abdomen soft, diffusely tender.
 No Organomegaly
Auscultation:-
 Bowel sound : present

18. Locomotor System:
• Look: Swelling in both ankle joints. No redness or
deformity.
• Feel: Tenderness grade 3/4
• Movement could not be elicited.

19. Genitourinary System:
• Inspection
Abdomen : normal in shape & flanks are not full.
Umbilicus : centrally placed & inverted.
Genitalia : normal.

20. Genitourinary System cont…
• Palpation
Abdomen- soft, tender
Kindeys- not bimanually palpable
Urinary Bladder- not palpable
Fluid thrill- absent
Renal angle tenderness-absent
Hernial orifice- intact
• Percussion
Shifting dullness – absent
• Auscultation
Bowel sound present

21. Cardiovascular System:
• Pulse :92/min
• B.P :80/50 mm of Hg
• JVP : not raised
•Precordium:
--No visible apical impulse
--Apex beat: Left 5th ICS, medial to MCL.
--S1& S2- audible.
--No added sounds

22. RESPIRATORY SYSTEM
Inspection
• Shape of the chest : normal
• R/R : 26 breaths/min
• Movement of chest – normal
• Subcostal & intercostal recession -absent
Palpation
• Trachea : centrally placed
• Apex beat : left 5th ICS, medial to midclavicular line

23. Cont…
Percussion
Resonant
Auscultation
 Breath sound : Vesicular with no added
sound .

24. Nervous System:
• Higher Psychic functions- normal
• Cranial nerves- intact
• Motor functions-
Bulk -Normal
Tone - Normal
Power – 5/5
Reflexes- Normal as far could be examined
Plantar - Flexor
• Sensory functions- Intact

25. Salient Features:
Sharabonti, 3 years old girl, single issue of non consanguineous
parents, hailing from Barishal, immunized as per EPI schedule
presented with the complaints of vomiting for 12 days, which was
several times a day, non projectile, non bilious or not mixed with
blood and vomitus was undigested food particles. After two days she
developed multiple erythematous palpable rashes all over the body
which 1st appeared in dorsum of the foot. Rashes were pruritic in
nature.
At the same time she developed pain swelling of ankle joints and
small joints of leg which was non migratory in nature. Pain was so
severe that she cannot move the joints.

26. Cont..
She also developed diffuse abdominal pain for the last 6 days
which was moderate to severe in nature and not associated
with fever. She could not pin point the site of pain or
describe the characteristics of pain.
She has no history of cough or cold, lose motion, urinary
problems or insect bite.

27. Cont..
For these complaints she was admitted in Barishal Medical
College hospital and was treated with antibiotics, antiulcerants,
antiemetics and oral steroids.
On examination, she was afebrile, conscious, mildly pale, no
lymphadenopathy or bony tenderness. Skin survey revealed
Extensive palpable reddish spots of variable sizes over extensor
and flexor surfaces of lower limbs and extensor surface of upper
limbs, buttock and back. The spots did not blanch on pressure.

28. Cont..
Bed side urine albumin was nil. Vitals were normal.
Abdomen was soft and diffusely tender, no organomegaly
or ascites present. Locomotor system examination
revealed ankle joint swollen and tenderness present
grading ¾.
Other systemic examination revealed no abnormality.

29. Provisional Diagnosis

30. Provisional Diagnosis
HENOCH SCHÖNLEIN PURPURA

31. Differential Diagnosis
Idiopathic Thrombocytopenic Purpura
Systemic Lupus Erythematosus

32. HENOCH SCHÖNLEIN PURPURA
Points in Favour Points against
H/O
• Multiple erythematous rash in
lower limbs followed by buttock,
back and upper limbs.
•Vomiting.
•Abdominal pain.
•Joint pain.
O/E
Multiple palpable rash present in
the upper & lower limbs, back and
buttock which do not blanch on
pressure.

33. ITP
Points in Favour Points against
H/O
• Multiple erythematous rash in
lower limbs, buttock and back.
No H/O epistaxis, gum bleeding,
bleeding from other site.
Abdominal pain.
Vomiting.
Joint pain.
O/E
Multiple palpable rash present in
the upper & lower limbs, back and
buttock which do not blanch on
pressure.

34. SLE
Points in Favour Points against
•Female patient
• Multiple erythematous rash in
lower limb, buttock and back.
• Joint pain.
No H/O photosensitivity, oral
ulceration, malar rash, headache,
Weight loss.

35. Investigation
• CBC:
Hb: 11.1 gm/dl
TC: 12,000/cmm
N-70%, L-26%, M- 02%, E- 01%
PLT: 3,53,000/cmm
ESR: 40 mm in 1st hour

36. Investigation
• Urine R/E :
Protien :nil
Epithelial cell : 0-1/ HPF
Pus cell : 0-2/ HPF
RBC : Nil
Cast : absent

37. Investigation cont..
• S. Electrolytes: Sodium: 130 mmol/L
Pottasium: 4.3 mmol/L
Chloride: 95 mmol/L
• ANA : Negative
• C3 : 1.36 g/L (N)
• C4 : 0.235 g/L (N)
• 24 hours UTP: 0.04g/day

38. Final diagnosis
HENOCH SCHÖNLEIN PURPURA

39. Management
• Counselling
• Supportive management.
• Inf. 5% dextrose in 0.5N saline.
• Inj. Dexamethasone later Tab. Prednisolone.
• Inj. Ranitidine
• Syp. Naproxane Sodium.

40. Follow Up
Date -2 Subjective Objective Assessme
nt
Plan
7/8/15
At 9.30 am
No new
complain
Erythematous rashes
reduced.
Temp: N
Vitals within normal
limit.
Abdominal tenderness
diminished.
Pain and swelling over
ankle joint present.
Tenderness : 2/4
Improving Diet: Liquid>
semi solid>
Normal.

41. Follow Up
Date - 5 Subjective Objective Assessme
nt
Plan
10/8/15
At 9.30 am
No new
complaints
Few rahes over legs
only.
Temp: N
Vitals within normal
limit.
No abdominal
tenderness.
Ankle joint not
swollen.
Mildly tender.
Improvin
g
Plan for
discharge with
oral
Prednisolone.

42. THANK YOU