Girl With Palpable Purpura and Ecchymoses

September 14, 2005
Donald J. Kovacs, MD

Ten days after ballet practice, a 9-year-old girl noticed a nonpruritic, petechial rash on her lower legs. Swelling of the ankles and knees was also apparent. The patient was afebrile, otherwise healthy, and had no abdominal pain. There was no family history of blood dyscrasias. The patient was taking no medications.

Ten days after ballet practice, a 9-year-old girl noticed a nonpruritic, petechial rash on her lower legs. Swelling of the ankles and knees was also apparent. The patient was afebrile, otherwise healthy, and had no abdominal pain. There was no family history of blood dyscrasias. The patient was taking no medications.

Palpable purpura and ecchymoses were present on the legs bilaterally. A complete blood cell (CBC) count, urinalysis results, and erythrocyte sedimentation rate were normal. Dr Donald J. Kovacs of Boiling Springs, Pa, made the clinical diagnosis of Henoch-Schnlein purpura; the patient was told to rest and to avoid aspirin.

One week later, the patient reported fatigue and mild nausea. She had no abdominal pain, and the rash was clearing. The petechiae were less prominent; the joints were less swollen.

After trying to resume ballet 2 weeks later, the patient reported new petechiae and swollen joints. The petechiae were obvious; joint findings were minimal. After another 3 weeks, the patient was dancing again with no untoward effects.

Two weeks later-2 months after the illness first began-the patient developed cold symptoms with a temperature of 38.6°C (101.4°F), and the rash and ankle and knee swelling recurred. The results of a second urinalysis were normal.

The petechiae and knee pain flared 2 months later and were associated with some bleeding from the gums. To rule out leukemia, another CBC count with careful evaluation of the peripheral smear was performed and roentgenographic studies of the more symptomatic knee were obtained; all findings were normal. The patient was told to avoid further vigorous activity, including ballet, for 6 more weeks. There were no further episodes.

Dr Kovacs comments that Henoch-Schnlein purpura is a vasculitis of small vessels that typically lasts from 4 to 6 weeks but may recur. Possible causes include various infectious agents, drugs, and toxins. The disease occurs in 14 per 100,000 children in the 2- to 14-year-old age group; males are affected twice as often as females. It is seen more commonly in winter.1 Skin lesions-typically petechiae or purpura-occur in all affected patients. Associated arthritis develops in two thirds of patients; knees and ankles are the most commonly involved joints. GI symptoms, including colicky abdominal pain, gross or occult blood in the stool and, rarely, intussusception, affect half of patients with Henoch-Schnlein purpura. Renal involvement, usually hematuria, is less common. There are no definitive diagnostic laboratory studies; the diagnosis is based on the clinical findings.

REFERENCE:1. Griffith HW. Griffith's 5 Minute Clinical Consult. Baltimore: Williams & Wilkins; 1996.