Clinical Case 1

Landon Eggleston, M.D.

Janae Hohbein, D.O.

HPI

30 y/o F with PMHx of GERD, depression, anxiety, IBIDS, recent cholecystitis s/p cholecystectomy 2 weeks ago presents to the emergency department with nausea, vomiting, diarrhea and gradually worsening diffuse rash starting after leaving the hospital two weeks ago following cholecystectomy. Reports daily episodes of bilious vomiting and yellow-green diarrhea associated with left upper quadrant and epigastric abdominal pain that is crampy, constant and non-radiating in nature. Rash began two days post-op, initially in her upper and lower extremities including palms and soles and gradually spread to her entire body. She reports taking Norco for 2 days post-surgery but has not taken any other medication. Denies any new shampoos, soaps, detergents. Denies CP, SOB, fevers, chills, dysuria, headaches, vision changes, numbness/weakness.

Physical Exam

Vitals: HR 113, RR 18, BP 140/100, Temp 98.4, SPO2 98%

General: No acute distress, resting comfortably

HENT: Extraocular movements intact, head normocephalic/atraumatic

Lungs: Clear to auscultation bilaterally, breath sounds equal, non-labored respirations

Cardiac: Regular rate and rhythm, no murmurs, rubs, or gallops

Abd: Tenderness to palpation left upper quadrant, no rebound or guarding

Skin: diffuse nonblanchable palpable purpuric rash to trunk, arms, legs, face, neck including palms and soles, areas of excoriation and coalescing, no skin sloughing, no intact blister, no oral lesions

Neurologic: Alert and oriented x4, no motor/sensory deficits

Psych: appropriate mood/affect, cooperative

Labs

CBC

WBC 13.8^

RBC 4.74

HGB 13.9

HCT 40.7

MCV 85.9

MCH 29.3

MCHC 34.2

RDW-CV 13.5

RDW-SD 41.9

PLT 385

NRBC 0

Neutrophil, % 73

Lymphocytes, % 20

Monocytes, % 4

Eosinophils, % 2

Basophils, % 0

Immature Granulocytes 1

Absolute Neutrophils 10.1^

Absolute Lymphocytes 2.7

Absolute Monocytes 0.6

CMP

Na+: 137

K+: 3.9

Cl-: 99

CO2: 30

Anion Gap: 12

Glucose: 100^

BUN: 9

Cr: 0.64

GFR: >90

BUN/Cr Ratio: 14

Ca2+: 9.0

Bili, Total: 0.5

GOT/AST: 23

GPT/ALT: 32

Alk Phos: 98

Albumin: 2.8 (L)

Protein, total: 7.0

Globulin: 4.2 (H)

A/G Ratio: 0.7 (L)

Lipase

Lipase: 118

C-Reactive Protein

CRP: 9.9 (H)

PT, PTT

Prothrombin Time 12.4 (H)

INR 1.2

PTT 26

Procalcitonin

Procalcitonin 0.15 (H)

ESR

RBC Sedimentation Rate: 43 (H)

Beta HCG

HCG, Quant <2

Urinalysis

Color: Yellow

Appearance: Clear

Glucose: Negative

Bilirubin: Moderate (A)

Ketones: 40 (A)

Specific Gravity: 1.025

Occult Blood: Small (A)

pH: 6.0

Protein: 30 (A)

Urobilinogen: 0.2

Nitrite: Negative

WBC Esterase: Negative

CT Abdomen/Pelvis

Click for diagnosis and more

IgA Vasculitis

HPI

Distribution and progression of the skin lesions
Recent exposures (sick contacts, foreign travel, sexual history and vaccination status)

Red Flags:

Fever
Hypotension
Any new medications
Toxic appearance
Mucosal lesions
Severe pain
Very old or young age
Immunosuppressed

Causes of Petechiae/Purpura

Abnormal platelet count and/or coagulation

Septicemia
Idiopathic thrombocytopenic purpura (ITP)
Hemolytic uremic syndrome
Leukemia
Coagulopathies (e.g. hemophilia)
Acute hemorrhagic edema of infancy (AHEI)

Primary vasculitides

Wegener's
Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

Hypersensitivity Vasculitides

Secondary vasculitides

Henoch-Schonlein purpura
Scurvy
Connective tissue disorder

Systemic lupus erythematosus

Infectious disease

Hepatitis B
Hepatitis C

Trauma

IgA Vasculitis

Henoch-Schonlein Purpura

Triad: non-thrombocytopenic palpable purpura, abdominal pain, arthritis
Most common vasculitis in childhood (ages 2-11 yr)
- commonly white/asian males
- 5% of cases associated with intussusception (abdominal vasculitis)
- Most cases preceded by a URI
- 95% recover completely after 3-4wk
Progression to renal insufficiency in 5-15% of children
- Presentation in adults is 30-50% risk
- Adults may require more aggressive treatment with steroids +/- cyclophosphamide

Lab Abnormalities

Coag studies normal
CRP/ESR elevated
CBC- increased white count and platelet count
UA- hematuria and proteinuria
Guaiac positive stool
Abd US can show intussusception

Biopsy is definitive NOT labs

In our patient...

ESR- 43mm/hr (ref range 0-20-mm/hr)

CRP- 9.9 mg/dL (ref range <=1.0mg/dL)

WBC- 13.8K/mcL (ref range 4.2-11.0K/mcL)

Hgb- 13.9g/dL (ref range 12.0-15.5g/dL)

Plt- 385K/mcL (ref range 140-450K/mcL)

Creatinine- 0.64mg/dL (ref range 0.51-0.95mg/dL)

Procalcitonin- 0.15ng/mL (ref range <=0.09ng/mL)

Management

Supportive
NSAIDs may worsen renal or GI disease
Prednisone 1mg/kg/day
- Severe arthralgias, abdominal disease, or scrotal disease
IVIG to prevent or treat glomerulonephritis
Admission Criteria:
- Renal failure
- Significant GI Bleed
- Intussusception
Outpatient management appropriate for most cases with rheumatology and renal
Recurrence rate 33%

Our patient was started on 1mg/kg of Prednisone in the emergency department and admitted for further workup where she obtained EGD, colonoscopy and skin biopsy. She also received blood cultures, hepatitis, HIV, and antibody testing. The patient responded well to steroid therapy and was discharged home several days later. Her rash continued to improve and resolved within two weeks and her kidney function remained normal.

Take Home Points

Don't panic when you see a rash on the tracking board

Use your resources

Keep these red flags in mind

Take a thorough history