CR HSP

With all due respect to :
____________________________________
_
th
To be presented on : May 24 , 2021
CASE REPORT
HENOCH-SCHONLEIN PURPURA AND

MILD MALNUTRITION IN A CHILD
By :
Beatrice Koesmarsono
Supervisor :
dr. Raynald O. Takumansang, Sp.A(K)
Department of Child Health

Medical Faculty of Sam Ratulangi University
Prof. Dr. R. D. Kandou General Hospital Manado
2021
TIMELINE
April 27th 2021 April 28th 2021 May 4th 2021 May 24th 2021
Initial Final
Patient was Reporting
Observation Observation
admitted to
tertiary referral
hospital Observation
started
1
PATIENT’S RECORD
I. IDENTITY
1.1. PATIENT IDENTITY
Medical record : 00.73.98.XX
Name : K.Z.M
th
Date of birth : May 26 , 2011
Age : 9 years 11 months
Place of birth : Manado
Gender : Female
Nationality : Indonesian
Tribe : Minahasanese
th
Date of admission : April 27 , 2021
Address : Koka Jaga V
Health insurance : Patient use government insurance class II
1.2. PARENTS IDENTITY

FATHER MOTHER
Name : YK JS
Age : 39 years old 34 years old
Job : Employee Housewife
Education : Senior High school Senior high school
Tribe : Minahasanese Minahasanese
II. HISTORY
th
(Alloanamnesis from the mother and medical record, April 27 2021 in
pediatric ward)
- Chief complaint : reddish spot on both legs and thighs since 7 days
before admission
2
- Additional complaints : stools mixed with fresh blood since 1 day ago,
pain on ankle joints since 7 days before admission, abdominal pain since 3 days
before admission
2.1. HISTORY OF PRESENT ILLNESS

Patient was admitted to Prof. R.D Kandou hospital with chief
complain of reddish spots, located on both legs and some on the thighs
since 7 days before admission. The reddish palpable painless spots were
initially few and small, but increased in number and became bigger. The
spots are not itchy. Patient had experienced reddish spots like this since
2019, but it disappears by itself and never went to a doctor.
Patient had bloody defecation since 1 day ago. Patient also
complaints of pain on both ankle joints since 7 days before admission
and also difficulty moving her leg because of the pain. She never had
experienced any joint pain before. Joint stiffness in the morning was
not experienced by the patient.
Patient also felt abdominal pain, but without nausea and vomiting,
since three days before admission. Abdominal pain was not
accompanied by pain when urinating and not relieve even after eating.
Urination was normal with yellow-colored urine. Patient also had history
of fever, cold and cough two weeks before admission, but recover
spontaneously. He had no other complaints and no history of bleeding
before.
2.2 HISTORY OF PREVIOUS ILLNESS

- Patient had experienced reddish palpable spots like this since 2019, but it
disappears by itself.
- History of allergy to food and drugs was denied.
- History of vaccination was denied.
3
2.3 HISTORY OF ILLNESS IN THE FAMILY
There are no other family members suffering from the same illness.
FAMILY TREE
STRUCTURE OF FAMILY MEMBERS

No Name Relationship Sex Age Information
1. YK Father M 39 y.o. Healthy

2. JS Mother F 34 y.o. Healthy
3. KM Child F 18 y.o. 3 m.o Healthy
4. KZM Child F 9 y.o 11 m.o Patient
5. KJ Child M 2 y.o 1 m.o Healthy
2.4. PERSONAL / SOCIAL HISTORY

A. History of antenatal, labor, and postnatal
During pregnancy, patient’s mother did a regular doctor visit,
about 9 times, for routine antenatal care. She got two times
antenatal TT vaccines. She claimed to be healthy, never
consumed drug, alcohol, or smoke during pregnancy. She was
4
taking iron, folic acid, and also calsium supplementation during
pregnancy. She also never experienced fever during pregnancy
or before birth.
Patient was born spontaneously, full term at primary
health care, with birth weight of 3300 grams and birth length of
48 cm, cried immediately after birth, helped by midwife. The
patient had never experienced cyanotic or yellowish skin
discoloration.
B. History of Feeding
Patient was breastfed for 24 months since she was born.
Formula milk was given since 6 months until now. Milk porridge
was given since 6 months, then changed to strained porridge at
12 months. Patients began to eat soft rice at 12 months old and
eat family meals at 2 years old until now with feeding frequency
of three times a day, one portion of meal consist of rice with
fish, chicken, beef or egg, vegetables and fruits.
C. Developmental Milestones
The patient was routinely carried out to Public Health Care to

be weighed until 2 years old and it was reported that her growth
was normal. According to the mother, the growth of the patient
appears to be the same as her peer.
The patient was able to sit at 6 months old, crawling at 7

months old and walk at 12 months old. She was able to
pronounce “mother” and “father” at 11 months old. At 5 years
old, patient already can dress/undress by herself. At
elementary school age, patient actively socialized with her
peers, had curiosity and learnt well. According to the mother,
the development of the patient is comparable to her peer.
5
Conclusion : patient growth and developmental milestones are
normal according to her age.
D. History of Vaccination
Patient received Bacille Calmette Guerin (BCG) vaccine with
scar on right arm, five times polio vaccines, four times DPT
vaccine, once Td, four Hepatitis B vaccine, and twice measles
vaccinee.
Conclusion: patient received basic immunization and booster
according to age.
E. History of Basic Needs Physic-biomedic

Patient received adequate primary needs (food, clothes, and
shelter). Patient eats three times daily.
Emotional Need
Patient received sufficient affection from both parents and other
family members. Parents accepted patient’s medical condition,
care and give adequate affection for patient’s recovery.
Mental Stimulation
Patient learn and play like her peers. Patient has many friends
and easily socialize with new friend. Currently, patient in fourth
grade of elementary school and can follow the lessons taught
in school very well.
Conclusion: Patient received adequate affection, care, and
attention from her family.
F. Socio-economic and Environement Conditions

Patient lives in a permanent house with tin roof, concrete wall,
and tile floor. There are three rooms occupied by 5 people, 2
adults and 3 children. Bathroom/restroom is located inside the
6
house. Water source come from public water company.
Electricity source used also come from state electricity company.
Garbage handled by dumping.
III. PATIENT’S HOSPITAL ADMISSION SUMMARY BEFORE

th
ACCEPTED AS A CASE (April 27 , 2021)
Patient was admitted to Prof. R.D Kandou hospital on April
th
27 , 2021 with chief complaints of reddish spots, located on both legs
and some on thighs since 7 days ago. She had experienced this
reddish spots since 2019, but it disappear by itself at that time, so she
never went to a doctor. She also had bloody defecation since 1 day
ago and felt pain on both ankle joints since 7 days ago and difficulty to
move. Patient also felt abdominal pain since three days ago, but
without nausea and vomiting. Abdominal pain was not accompanied by
pain when urinating. She had history of fever, cold and cough two
weeks before admission, but she has no fever now.
From physical examination when admitted to hospital, her weight
was 30 kg and her height was 144 cm (mild malnutrition according to CDC
2000 stature for age and weight for age curve for girl). Patient looked ill,
but fully alert. The vital signs were: blood pressure 90/60 mmHg, pulse 80
bpm (regular, full pulses), respiration rate 24 cycles per minute, and body
temperature 36.6°C. On head examination, there was no anemic
conjunctiva. On chest examination, the heart and lungs were within normal
limit. The abdomen was flat and soft on palpation, with normal bowel
sounds. The extremities were warm, with no deformity, no paresis, CRT
≤2 seconds, no cyanosis, and tenderness on ankle joints. There were
multiple painless palpable purpura of various size, with well defined
borders on both femoralis and cruris regions.
th
The laboratory results on admission (April 27 , 2021) were
6
haemoglobin 13.6 g/dL, hematocrit 43.5%, erythrocyte 5.51 x 10 /µL,
leukocyte 15,200/µL, platelet 357,000/µL, MCV 78.9 fL, MCH 24.7 pg,
7
MCHC 31.2 g/dL, Differential Count 3/5/0/65/22/5, ALC 3,344, NLR 2.95,
ureum 30 mg/dL, creatinine 0.5 mg/dL, AST 29 U/L, ALT 12 U/L, ASTO
200 IU/mL, Erythrocytes Sedimentation Rate (ESR) 30 mm, C3 133.49
mg/dL, sodium 134 mEq/L, potassium 4.85 mEq/L, chloride 97.9 mEq/L,
calcium 9.04 mg/dL, C-reactive protein (CRP) <6 mg/dL, albumin 4.46
g/dL, PT 13.5” (control: 13.6”), aPTT 32.5” (control: 32.8”), INR 1.16”
(control: 1.01”). Urinalysis found that urine was clear yellow, SG 1.015, pH
7, erythrocytes 40-50 cells/hpf (+5), leucocytes 0-1 cells/hpf, protein (-),
nitrite (-), ketone (-), glucose (-), bilirubin (-), and urobilin (-). Stool analysis
showed soft consistency, brown color, erythrocytes 10-15, epithel 1-2,
bacteria (+), protozoa (-), fungi (-), benzidine test (+). From chest x-ray
cor and pulmo was within normal limit. From abdominal x-ray in three
views, there was no ileus and pneumoperitoneum.
The patient was diagnosed with Henoch Schonlein Purpura (HSP)
and mild malnutrition and has been receiving methylprednisolone 30 mg
IV injection two times a day and omeprazole 20 mg IV injection two times
a day and paracetamol 375 mg tablet if needed.
IV. PHYSICAL EXAMINATION WHEN ACCEPTED AS A CASE

th nd
(Examination was done at pediatric ward on April 28 , 2021, 2 day of
hospitalization)
General conditions : Looked ill
Consciousness : compos mentis
Vital sign : Blood pressure : 100/60 mmHg
Pulse rate : 88 times/minute
Respiratory rate : 20 cycles/minute
Body temperature : 36.80C
Nutrition Status and Anthropometric

Anthropometric status based on CDC 2000 stature for age and weight for
age, girls, 2-20 years:
8
Body weight : 30 kg
Body height : 144 cm
Nutritional status : Body weight / age = 30/32 x 100% = 93.7%
Body height / age = 144/137 x 100% = 105.1%
Body weight / Body height = 30/37 x100% = 81%
➔ Mild Malnutrition status (CDC 2000)
Skin : Light brown colored, BCG scar on right upper arm,

thin subcutaneous fat, no jaundice. There were
multiple painless palpable purpura of various size,
with well-defined borders on both femoral and cruris
region.
Head : Normocephaly, closed fontanelle, hair colou
black and not easily pluckable, no nuchal rigidity
Eye : Conjunctivae was not anemic, anicteric scle
clear lenses, corneal reflexes +/+, round
isochoric pupils diameter 3-3 mm, direct light refle
+/+, indirect light reflexes +/+, centered eye
normal eye movement, no strabismus, no nistagm
Nose : No deformity, no secretion, no nasal flaring.
Ear : No deformity, no secretion, intact tymp
membranes.
Mouth : Moist buccal mucosa and lips, no atrophy of ton
papillae, no cyanosis, trismus (-).
Throat : Tonsils T1/T1 not hyperemic, pharynx
hyperemic.
Neck : Centered trachea, there was no lymph n
enlargement
Chest : Symmetrical respiratory movements, there wa
retractions
9
Heart :
- Inspection : ictus cordis not visible, no precordial bulging
- Palpation : ictus cordis palpable in intercostal space
(ICS) V, in midclavicular line sinistra
- Percussion : right border at right parasternal line, left border
rd
at left midclavicular line, upper border at 3
intercostal space
- Auscultation : Heart rate beats 88 x/min, regular, no murmur
Lungs :
- Inspection : symmetrical respiration movement on the both
- Palpation : vocal fremitus right = left
- Percussion : sonor percussion right = left
- Auscultation : bronchovesicular breath sound, rales -/-,
Wheezing -/-
Abdomen :
- Inspection : Flat, no venectation
- Palpation : soft, no distention, spleen and liver not
palpable
- Percussion : tympanic, no ascites
- Auscultation : normal bowel sounds
Vertebrae : deformity (-)

Genitalia : female, no deformity
Rectal Touche : Sphincter was tight, ampulla felt empty and
smooth mucosa, there was no mass
Gloves : blood (-), mucus (-), feces (-)
Puberty scale : female Tanner stage II
Extremities : Warm, no cyanosis, CRT less than 2 seconds,
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no spasticity, tenderness on ankle joints, no
deformity
Reflex : Normal physiological reflexes, no
pathological reflexes
Sensory : Normal
Motoric : Strength of four extremities
5555 5555
5555 5555
Cranial nerves examination

NI = no olfactory problem
N II = round, isochoric pupils, positive direct and
indirect light reflexes
N III,IV,VI = normal movements of the eyeballs, normal
accomodation, light reflexes (+/+)
NV = normal motoric and sensory
N VII = symmetrical nasolabialis sulci, no
lagophtalmus
N VIII = no hearing or balance problem
NIX,X = center uvula, symettrical pharinx movement
N XI = shoulders shrugged symmetrically
N XII = no tongue deviation
Conclusion: cranial nerves within normal limit
SUMMARY
Patient, a girl, 9 and 11 month years old, admitted to hospital on April

th
27 , 2021 with chief complaint of reddish spots, located on both legs and
some on thighs since 7 days ago. She had experienced this reddish spots on
2019, but it disappear by itself. She also had bloody defecation since 1 day
ago and pain on ankle joints since 7 days ago and difficulty to move.
11
Patient also complaint of abdominal pain, but without nausea and vomiting.
Abdominal pain was not accompanied by pain when urinating. She also
had history of fever, cold and cough around 2 weeks before admission, but
now she has no fever.
On physical examination when admitted to hospital, body weight was
30 kg, body height was 144 cm. She is in mild malnutrition status according to
CDC 2000 stature for age and weight for age, girls, 2-20 years. General
condition when examined was looked ill, consciousness E4M6V5. Vital signs,
blood pressure 90/60 mmHg, pulse rate 80 bpm (regular, adequate content),
respiration rate 24 cpm, and 36,6°C body temperature. Head and chest
examinations were within normal limit. The abdomen was flat, soft on
palpation, liver was not palpable, spleen not palpable, with normal bowel
sounds. The extremities were warm on palpation, no deformity, CRT < 2
seconds, no cyanosis, tenderness on ankle joints. There were multiple
painless palpable purpura of various size, with well-defined borders on both
femoralis and cruris regions. There was no abnormality on genital.
th
From laboratory finding on April 27 2021, haemoglobin 13.6 g/dL,
hematocrit 43.5%, leukocyte 15,200/µL, platelet 357,000/µL, ALC 3,344,
NLR 2.95, ureum 30 mg/dL, creatinine 0.5 mg/dL, AST 29 U/L, ALT 12
U/L, sodium 134 mEq/L, potassium 4.85 mEq/L, chloride 97.9 mEq/L,
calcium 9.04 mg/dL, C-reactive protein (CRP) <6 mg/dL, albumin 4.46
g/dL, ASTO 200 IU/mL, Erythrocytes Sedimentation Rate (ESR) 30 mm,
C3 133.49 mg/dL, PT 13.5” (control: 13.6”), aPTT 32.5” (control: 32.8”),
INR 1.16” (control: 1.01”). Urinalysis found that urine was clear yellow, SG
1.015, pH 7, erythrocytes 40-50 cells/hpf (+5). Stool analysis showed soft
consistency, brown color, erythrocytes 10-15, bacteria (+), benzidine test
(+). Chest and abdominal x-ray was normal.
th
Upon examination on April 28 , 2021, when observed as a case,
the patient had complaints of reddish spots and abdominal pain, but
tenderness on both ankle joints had decreased. There was no complaints
on urination and defecation. Patient looked ill, fully alert. The vital signs
12
were: blood pressure 100/60 mmHg, pulse 88 bpm (regular, full pulses),
respiration rate 20 cpm, body temperature 36.8°C. Head and chest
examinations were within normal limit. The abdomen was flat and soft on
palpation, with normal bowel sounds. The extremities were warm, with no
deformity, CRT <2 seconds, no cyanosis, no deformity and slight
tenderness on ankle joints. There were multiple painless palpable purpura
of various sizes, with well-defined borders on both femoralis and cruris
region. Rectal touche was within normal limit.
Patient was diagnosed with Henoch Schonlein Purpura and mild
malnutrition and was given methylprednisolone 30 mg IV injection two
times a day and omeprazole 20 mg IV injection two times a day and
paracetamol 375 mg tablet if needed.
V. DIAGNOSIS
Henoch Schonlein Purpura (D69.0)
Mild Malnutrition (E44.1)
VI. PROBLEMS
a. Diagnostic problem
In Henoch Schonlein Purpura, a skin biopsy should be performed to
find IgA deposition, but this can not be done.
b. Observation problem
Clinical improvement has been achieved in this case. Another
problem is the need to monitor the complications of Henoch-
Schonlein Purpura that can occur, as well as to educate on the
possibility of relapse.
VII. MANAGEMENT PLAN

a. Diagnostics plans Skin biopsy
Abdominal ultrasonography
13
Feces culture
Consult Gastroentero-hepatology division
Consult Ear Nose Throat division and Dental division
b. Medication treatment plan :

Injection Methylprednisolone 2 x 30 mg IV
Injection Omeprazole 2 x 20 mg IV
Paracetamol 375 mg tablet (if needed), orally
c. Nutritional care
a. Nutritional assessment : Mild Malnutrition
b. Nutritional requirement :
Protein needed : 1 gr/kgBW/day = 37 gr/day

Fluid needed : 70-85 mL/kgBW/day = 2590 - 3145 mL/day
Fat : 30% x 2590 kcal/day = 777 kcal/day = 86 gr/day
c. Adminitration route : oral
d. Type of food : polymeric
In the form of:
Solid food three times a day (@ 550 kcal, 20 g of proteins, 16
g of fats) :
• 1 cup of rice 130 g (50 g carbohydrate, 5 g protein, 230 kcal)
• 1 medium cut of chicken with skin 40 g (13 g fat, 7 g protein,
150 kcal)
• 2 pieces of tempe 50 g (5 g protein, 3 g fat, 7 g
carbohydrate, 75 kcal)
• 1 portion spinach 100 g (10 g carbohydrate, 3 g protein, 50
kcal)
• 1 piece apple 100 g (12 g carbohydrate, 50 kcal)
14
Snacks three times a day (@ 300 kcal) :
• Pieces of biscuit (40 g) = 4 g protein, 40 g carbohydrate, 180
kcal
• 1 glass of milk 200 mL (10 g carbohydrate, 7 g protein, 125
kcal)
Mineral water : 2590 - 3145 mL/day
e. Monitoring and evaluation:

Monitoring of acceptability, food tolerance, adverse reactions
and body weight monitoring
d. Monitoring Plan
1. Monitor the general state and vital signs
2. Monitor medication dose adjustment
3. Hygiene monitoring for parents/caregiver, nurse and medical
personal
4. Monitor daily nutritional, fluid and calorie intake
5. Monitoring therapy, evaluation of treatment response, therapeutic
side effects
6. Mental supports for parents
e. Education Plan
1. Describes the illnesses: causes, treatment, prognosis,
complications and treatment plans
2. Motivate parents to routinely follow-up for medication adherence
and any side effects of medication.
3. Educate to maintain oral hygiene and environment
4. Educate about further evaluation after patient’s discharged
(routine follow-up)
15
f. Nursing Plan
1. Vital sign monitoring
2. Nutritional, growth and development care
3. Personal hygiene of patient
4. Hygiene monitoring of parents/care giver, nurse, and medical
personal
16
FOLLOW UP
th st nd
April 28 , 2021 (1 observation day, 2 day care)
S Ankle joint pain (+), redness spots (+), abdominal pain (+) decreased,
bloody defecation (-)
O General conditions : Looked ill, compos mentis
Vital sign : Blood pressure : 100/60mmHg
Pulse : 88 times/minutes,regularly
Respiratory rate : 20 cycles/minutes
0
Temperature : 36,8 C
Physical examination
Head : no anemic conjunctiva, anicteric sclera
Chest : Symmetrical respiratory movements, retractions (-)
Heart : Heart margin was normal
Lungs : bronchovesicular breath sound, rales -/-, wheezing -/-
Abdomen : Flat, soft, with normal bowel sound, liver and spleen were not
palpable
Extremities : Warm, CRT ≤2 seconds, tenderness on ankle joints, no
deformity
There were multiple painless palpable purpura of various
size, with well-defined borders on both femoral and cruris
region.
Rectal touche :
Sphincter was tight, ampulla felt empty and smooth mucosa, there was no
mass
Gloves : blood (-), mucus (-), feces (-)
A Henoch Schonlein Purpura (D69.0)
P Pharmacology :
Injection Methylprednisolone 2 x 30 mg IV (2)
Injection Omeprazole 2 x 20 mg IV
Nutritional support:
Solid food three times a day (@ 550 kcal, 20 g of proteins, 16 g of fats) :
- 1 cup of rice 130 g, ½ sausages, 1 tofu, 1 portion banana leaves, 1
slice papaya
•Pieces of biscuit (40 g)
•1 glass of milk 200 mL
Nursing support : Same as before
Waiting Result : feces culture
Plan : Abdominal ultrasonography, consult gastroentero-hepatology
division, consult ENT division and dental division
17
th nd
April 29 , 2021 (2 observation day, 3rd day care )
S Ankle joint pain (+) decreased, redness spots (+), abdominal pain (-),
Respiratory rate : 16 times/minutes
0
palpable
Extremities : Warm, CRT ≤2 seconds, no deformity, tenderness on ankle
joint decreased
size, with well-defined borders on both femoral and cruris
region.
Gastroentero-hepatology consult results : feces culture, no additional

therapy
ENT consult results : no abdnormalities on ENT
Dental consult results : necrosis pulp and gangrene radix (advice : dental
health education and control to outpatient dental clinic when discharge)
P Pharmacology :
Injection Methylprednisolone 2 x 30 mg IV (3)
Injection Omeprazole 2 x 20 mg IV (if needed)
- 1 cup of rice 130 g, 1 medium slice of pork, 2 slice of tempe, 1 portion
cassava leaves, 1 slice watermelon
Waiting results : feces culture
Plan : abdominal ultrasonography, change injection
methylprednisolone and omeprazole to oral
18
th th
April 30 , 2021 (3rd observation day, 4 day care )
S Ankle joint pain (-), redness spots (+) decreased, abdominal pain (-),
Temperature : 36,5 0C
palpable
Extremities : Warm, CRT ≤2 seconds
There were decreased multiple painless palpable purpura of
various size, with well-defined borders on both femoral and
cruris region
Abdominal ultrasonography :
Liver : not enlarged, regular and sharp border. Homogen echoic
parenchim, no mass appear, no vascular or bile duct
dilatation, no ascites
Gallbladder : size and shape normal, no thicken wall, regular mucosa, no
echoic stone or sludge
Pancreas : size and echoic parenchim within normal limit, no echoic mass,
no pancreatic ductal dilatation
Spleen : no enlargement, regular border, homogen echoic parenchim,
no vena dilatation
Kidney : both kidney size and echoic parenchim within normal limit, no
pelvicocalyceal system dilatation, no stone or mass
Urinary bladder : no thicken wall, regular mucosa, no stone or mass
Intestinal loops within normal limit.
Conclusion : abdominal ultrasonography is within normal limit

A Henoch Schonlein Purpura (D69.0) Mild Malnutrition (E44.1)
19
P Pharmacology :
Methylprednisolone 2 x 28 mg (4), orally
Omeprazole 2 x 20 mg, orally (if needed)
Paracetamol 375 mg tablet, orally (if needed)
- 1 cup of rice 130 g, 1 medium slice of chicken with skin, 1 tofu, 1
portion bean sprouts, 1 banana
• Pieces of biscuit (40 g)
• 1 glass of milk 200 mL
20
st th th
May 1 , 2021 (4 observation day, 5 day care )
S Ankle joint pain (-), redness spots (+) decreased, abdominal pain (-), bloody
defecation (-)
0
Temperature : 36.6 C
palpable
There were decreased in multiple painless palpable purpura
of various size, with well-defined borders on both femoral and
cruris region
P Pharmacology :
- 1 cup of rice 130 g, ½ sausages, 2 slice of tempe, 1 portion spinach,
1 slice melon
21
nd th th
May 2 , 2021 (5 observation day, 6 day care )
S Ankle joint pain (-), redness spots (+) only on cruris regio, abdominal pain
(-), bloody defecation (-)
0
palpable
There were decreased multiple painless palpable purpura
of various size, with well-defined borders on both cruris regio
Feces culture : Eschericia coli (normal flora)

P Pharmacology :
- 1 cup of rice 130 g, 1 medium slice of pork, 2 slice of tempe, 1 portion
banana leaves, 1 slice pineaple
Nursing support :
Same as before
Plan : urynalisis
22
th th
May 3th, 2021 (6 observation day, 7 day care)
S Ankle joint pain (-), redness spots (+) faded, abdominal pain (-), bloody
defecation (-)
0
Temperature : 36.8 C
palpable
size that is faded, with well-defined borders on both cruris
region
Urinalysis :
SG : 1,015 Leukocytes : negative
pH :7 Ketone : negative
Epitel : 0-1 Protein : negative
Erythrocyte : negative Nitrite : negative
P Pharmacology :
- 1 cup of rice 130 g, 1 medium slice of chicken with skin, 1 tofu, 1
portion cassava leaves, 1 apple
Plan : discharge
23
May 4th, 2021 (7th observation day, Outpatient clinic)
S Ankle joint pain (-), redness spots (+) almost disappeared, abdominal pain
(-), bloody defecation (-)
Temperature : 36.6 0C
palpable
There were multiple painless palpable purpura of various size
that is almost disappeared, with well-defined borders on both
cruris region

P Pharmacology :
Methylprednisolone 2 x 28 mg, orally, tapering off
- 1 cup of rice 130 g, ½ sausages, 2 slice of tempe, 1 portion bean
sprouts, 1 slice papaya
24
Prognosis
Ad vitam : bonam
Ad functionam : bonam
Ad sanationam : dubia ad bonam
25
Disease Course Timeline
Observation Period
When chosen as a case
Apr 27th 2021 Apr 28th 2021 Apr 29th 2021 Apr 30th 2021 – May 2nd 2021 May 3th 2021 May 4th 2021
st
May 1 2021
Creatinine 0.5
mg/dL, sodium Complaints: Complaints:
Admitted to hospital with Complaints: 134 2 x 30 mg IV Complaints: Complaints:
Ankle joint pain (+) Ankle joint pain (-),
chief complaint reddish Ankle joint pain (+), redness Injection decreased, redness spots Ankle joint pain (-), Ankle joint pain (-),
omeprazole redness spots (+)
mEq/L, (+), abdominal pain (-) redness spots (+) redness spots (+)
spots. Additional complaints spots (+), abdominal pain (+) 2 x 20 decreased, abdominal
Potasium 4.85 decreased, bloody decreased, abdominal faded, abdominal
stools mixed with fresh blood decreased, bloody defecation (-) defecation (-) pain (-)
mEq/L, pain (-) pain (-)
Chloride 97.9
mg IV
mEq/L,
Paracetamol
since 1 day ago, abdominal Calsium Lower extremities :
375 mg
9.04 mg/dL, multiple painless palpable Lower extremities :
pain and pain in ankle joints tablet Lower extremities : Lower extremities :
CRP <6 mg/L, purpura of various size, decreased multiple
ASTO decreased multiple multiple painless
with well-defined borders painless palpable
painless palpable palpable purpura of
(if needed) on both femoral and cruris purpura of various
Lower extremities : multiple purpura of various various size was
region. size, with well-defined size, with well-defined faded, with well-
painless palpable purpura of Tenderness on ankle borders on both borders on both cruris defined borders on
200 IU/mL,
Erithrocyte joints decerased, no femoral and cruris region. both femoral and
various size, with well-defined
Sedimentation deformity region. cruris region.
Lower extremities : multiple Rate (ESR) 30
borders on both femoral and mm/hour, C3
133.49 mg/dL
painless palpable purpura of Consult gasroentero-
Urinlaysis : Feces culture: Urinalysis : within
hepatology division : feces Abdominal
cruris region. erythrocytes culture, no additional Eschericia coli normal limit
ultrasonography :
40-50 therapy
various size, with well-defined within normal limit
(+5) Consult ENT : no abnormalities
Tenderness on akle joints, no Stool analysis : Consult dental division :
borders on both femoral and erythrocytes necrosis pulp and gangrene Diagnosis: Henoch
10- radix Schonlein Purpura and
deformity 15, bacteria Diagnosis: Henoch
Diagnosis: Henoch Mild Malnutrition
cruris region. (+), benzidine Schonlein Purpura
test (+) Schonlein Purpura and Mild Malnutrition
Tenderness on akle joints, no and Mild Malnutrition
Diagnosis: Henoch
Schonlein Purpura and
deformity Mild Malnutrition Therapy :
Diagnosis: Methylprednisolone 2 x Therapy :
Diagnosis: Henoch Henoch 28 mg PO Methylprednisolone 2 x 28
Schonlein Therapy : Omeprazole 2 x 20 mg mg PO
Schonlein Purpura and Mild
Purpura and Therapy : Methylprednisolone 2 x PO (if needed) Omeprazole 2 x 20 mg
Malnutrition Mild Injection 28 Paracetamol 375 mg PO (if needed)
Malnutrition methylprednisolone 2 x 30 mg PO Paracetamol 375 mg
Lab : Hb 13.6 g/dL, Ht 34.5%, Omeprazole 2 x 20 mg
mg IV tablet (if needed) Plan :
3
Leukocyte 15,200/mm , Platelet Injection omeprazole 2 x PO (if needed) discharge
20 mg IV (if needed) Paracetamol 375 mg
3
357,000/mm , DC 3/5/0/65/22/5,
Paracetamol 375 mg tablet (if needed)
Therapy : tablet (if needed)
ALC 3,344, NLR 2.95, AST 29 Therapy :
U/L, ALT 12 U/L, Ureum 30 mg/dL, Injection methylprednisolone
Therapy :
Methylprednisolone 2 x 28
Redness spots was almost disappeared mg PO, tapering off
Lower extremities : multiple painless purpura was almost

disappeared
Diagnosis: Henoch
Schonlein Purpura
and Mild
Malnutrition
Injection methylprednisolone 2 x 30 mg IV
Injection omeprazole 2 x 20 mg IV 26
Paracetamol 375 mg tablet (if needed)
CASE ANALYSIS
Girls, 9 years 11 months old Physical Examination:
- Redness spots on both legs Body Weight : 30 kg, Body Height : 144 cm
- Stools mixed with fresh blood since 1 Ext : multiple painless palpable purpura of various
day ago size, with well-defined borders on both femoral and
- Abdominal pain and ankle joint pain cruris region. Tenderness on ankle joints.
Allergy-Immunology
Diagnosis
Henoch Schonlein Purpura and Mild Malnutrition
Investigation • Complete blood count examination, urinalysis, stool analysis,
Feces culture, abdominal ultrasonography

• Consult gastroentero-hepatology, ENT, dental division
Methylprednisolone, omeprazole, paracetamol (if needed),

Treatment
Nutrition
Problem
Prognosis of 9 years 11
Ad Vitam : bonam • Parents education

Prognosis months old girl with Henoch
Ad functionam : bonam • Follow up plan
Schonlein Purpura and Mild
Malnutrition Ad sanationam : dubia ad bonam • Long term monitoring
Wang, et al. J Infect Public Health. 2020. Level of evidence 2b, recommendation B
Ekinci, et al. Mod Rheumatol. 2020. Level of evidence 2b, recommendation B
Bondin, et al. Malta Medical Journal. 2020. Level of evidence 2b, recommendation B
27
Gomez, et al. Arch Argent Pediatr. 2020. Level of evidence 2b, recommendation B.
CASE ANALYSIS
Henoch-Scholein Purpura (HSP) is a diffuse vasculitis that is secondary

to hypersensitivity characterized by IgA dominant immune complexes in
smaller venules, capillaries and arterioles, skin, joints, gastrointestinal and
1
kidney . Henoch-Schonlein Purpura is the most common type of vasculitis in
children, with incidence varying from 6 to 26 per 100,000 children per year.
The highest incidence is found in children aged 4-7 years (70 cases / 100,000
2-4
children per year). The average age is 6 years old, with most cases
5,6
affecting children less than 10 years old.
Caucasian and Asian children are most often affected, while African-
American children are least affected. Most studies show a male
7
predominance, with reported male to female ratios of 1.2:1 to 1.8:1 .
5,6
However, recent studies show similar incidence in males and females.
These are consistent with this case where the patient is a 9 years and 11
months old female.
Up to now, the cause of this disease is not yet clearly known, but
several risk factors such as genetics, infectious agents, vaccinations,
8
medications and food are thought to trigger the occurrence of HSP .
Henoch-Schonlein Purpura mainly occurs in the winter and has been
reported worldwide. This fits with several studies which showed that HSP
often occured after upper respiratory tract infections, and most of these
cases occured in fall and winter. Majority of the cases were preceded by
upper respiratory tract infections, showing infection as one of the
responsible factors. Streptococci, staphylococci and parainfluenza are
most commonly found, but there are case reports that described the
9,10
assocation between nearly all respiratory pathogens and HSP .
Approximately one-half of the cases of HSP are preceded by an
7
upper respiratory tract infection . Many organisms have been considered
as triggers, but group A β hemolytic Streptococci are the most common
organisms found in culture, comprising 36% of all results studied. Some
28
reports also desribed post-vaccination cases of HSP, which involved some
11
vaccines including the influenza (H1N1) vaccine . Also, there are several
other vaccinations involved such as measles, mumps, rubella (MMR),
10
pneumococci, influenza, meningococci and hepatitis B . The association
between medications and HSP has also been reported, although the role
of these medications in the pathogenesis of HSP is still uncertain since
5
most of these drugs are used at disease onset to treat infections . In this
patient, respiratory infection is suspected as the trigger of Henoch-
Schonlein Purpura due to the history of fever, cold and cough in this
patient 2 weeks prior to hospital admission.
Henoch-Schonlein Purpura is considered to be associated with
odontogenic infectious diseases as well. Jinous et al. have reported a case
of HSP that had developed after endodontic treatment. This report
suggested that root canal treatment could be a trigger for HSP, as it
assumed that trepanation of the apex may cause a streptococcal
bacteremia. Environment and microbiological flora changes in the root
12
canal may also cause a bacteremia .
Odontogenic focus infection can trigger HSP attack and can be
considered as one of the risk factors for HSP. Dental screening of HSP
patients could help to decrease the risk of renal and/or abdominal
1
complications and facilitate treatment . Inoue et al, also found that focus
infection on HSP with renal involvement was 70% caries dentis, 53%
periodontitis apical, 48% rhinosinusitis, 13% tonsillitis and 4% otitis media.
Microorganisms or toxin focus infection which localized on tissue could
spread systemically and could damage other tissue. Focus infection
odontogenic was one of the trigger infection that could spread systemically,
including in HSP. Tooth infection that reaches the root of the tooth will cause
inflammation and the defense of the oral secretory IgA-mediated mucosa fails
to eliminate the bacteria so that these pathogens will enter the bloodstream,
13
causing bacteremia and damage endothelium . In this
29
patient, we did dental screening and found that she had necrosis pulp and
gangrene radix, which could also be the trigger of relapse of HSP.
The pathological description of HSP is an IgA containing-immune
complex deposition at the vascular walls of the affected organs. IgA is
found in the serum and mucosa, and is an immunoglobulin that plays an
important role in the mucosal immunity. In human, more IgAs is produced
than other immunoglobulins because of the high synthesis in the mucosa
and the short half-life of IgA, which is 5-6 days. Of the two subclasses of
IgA, IgA1 is phylogenetically younger and different from IgA2 by the
insertion of amino acid 13-17 sequence at the hinge region of the IgA1
14
molecule. IgA1 hinge region is more glycosylated in normal individuals.
Glycosylation of IgA1 seems to play an important role in facilitating the
clearance of IgA1 molecules. Usually, the glycosylated IgA1 molecule will
interact with the asialoglycoprotein receptor (ASGP-R) expressed by
hepatocytes, followed by internalization and degradation of this molecule.
Patients with HSP expressed reduced Gal glycosylation on IgA1
molecules. Deposited immune complexes activate alternative complement
pathways (with C3 depositions) and recruit inflammatory cells. Immune
complex deposition containing IgA1 in the skin, intestines and joints leads
15-17
to specific clinical manifestations of HSP.
The dominant clinical sign is erythematous macular rash on the skin
which becomes palpable purpura without thrombocytopenia. Purpura is
mainly found on pressure-bearing surfaces, namely buttocks and lower
extremities. The purpura is initially red, gradually turns to purple, then
18-20
yellowish brown, and then disappears . Skin lesions usually last 3-10
days, and can reappear up to 4 months after the initial presentation. Skin
lesions are found in 100% of cases and represent 50% of patients
complaints when seeking treatment. Angioedema on the face (eyelids,
lips) and extremities (dorsal of the hands and feet) are found in 20% and
6,19,20
40% of cases respectively. In this patient, palpable purpura are seen
on both legs since 7 days prior to hospital admission.
30
Gastrointestinal manifestations of HSP occur in 80% of cases.
Gastrointestinal manifestations can be abdominal pain, vomiting, diarrhea,
paralytic ileus, melena / hematochezia, intussusception, and mesenteric
ischemia or perforation. Abdominal pain can manifests as severe
6
abdominal colic on the periumbilical region . Gastrointestinal bleeding was
usually occult (3.5%), but 2.17% of patients had grossly bloody or
21
melanotic stools . Occasionally, bowel perforation and ileoileal or
ileocolonal intussusception are found in 2-3% of cases. Intussusception or
perforation is caused by vasculitis of the intestinal wall resulting in edema
and submucosal and intramural bleeding. Endoscopic evaluation is usually
6,22,23
not necessary, but may identify intestinal purpura. In this patient,
there is a gastrointestinal complaint in the form of abdominal pain 7 days
before admission and hematochezia 1 day prior to hospital admission.
Arthritis or arthralgia can occur in three quarters of children with HSP.
Usually, the large joints of the lower extremities such as the knees and ankles
are affected, but the wrists, elbows and finger joints can also be involved.
Arthralgia or arthritis constitutes 25% of patients complaints when seeking
treatment. This disorder can appear earlier (1-2 days) than the skin lesions.
The affected joints can become swollen, tender and painful upon movement,
and usually are without effusion, redness or warmth. The disorder is mostly
periarticular and temporary, can recur during the active phase of the disease,
7,13,21 24
but does not cause permanent deformity . A study by Bukhari et al.
stated that joint involvement occurs in more than 80% of cases, as arthritis
(62%) or arthralgia (20%). They found that the ankles and knees were the
most often affected joints, followed by the elbows and wrists, while the
involvement of the hip and shoulder joints was very rare and only reported in
one case. In this patient, there is arthralgia on ankle joints.
Renal involvement was reported in 20-55% of children with HSP. The
most common manifestation is microscopic hematuria. Renal abnormalities
usually develop within 4 weeks after the onset of the disease. Proteinuria may
be present, and if severe, can appear as nephrotic syndrome. Renal
31
function is usually normal but patients can sometimes develop progressive
25-28 29
glomerulonephritis with significant renal damage . Tabel et al reported
microscopic hematuria in 27 children (22.5%), and severe hematuria in 5
cases (4.2%). Albuminuria was reported in 32 patients (26.7%), and there
were three cases (2.5%) that showed hematuria with albuminuria. In this
patient, there was renal involvement which is hematuria in urinalysis.
There are no specific abnormalities for HSP seen with laboratory
examination, thus, the diagnosis is mostly made from clinical
manifestations. Complete blood count is generally normal and without
thrombocytopenia, but can sometimes reveal leukocytosis. Serum IgA may
be increased in approximately half of the children with HSP. Increased
serum IgA is not a specific finding. There is no correlation between serum
IgA levels and clinical features of HSP. Serum IgA test is not routinely
done in patients with HSP. Normal serum antinuclear antibodies, anti-
neutrophil cytoplasmic antibodies, C3 and C4 can help to differentiate HSP
from other vasculitic processes, such as systemic lupus erythematosus or
anti-neutrophil cytoplasmic antibody vasculitis. The most important
laboratory examination in HSP is urinalysis, because kidney disorder is the
main cause of morbidity. Serial urinalysis (if protein is detected in urine) is
necessary for at least 6 months after diagnosis, with monitoring of at least
every week during the first 2 months after the initial presentation. The
goals of laboratory evaluation are to rule out other diseases and to identify
complications related to HSP. Fecal blood test can reveal gastrointestinal
30-32
bleeding associated with HSP . In this patient, laboratory results are
not significant. There is leukocytosis (15,300/μL) and other complete blood
count parameter are normal (hemoglobin 13.6 g/dL, hematocrit 43.5%,
platelets 357,000/μL). Liver and renal function tests are normal (AST 29
U/L, ALT 12 U/L, Ureum 30 mg/dL, creatinine 0.5 mg/dL). Urinalysis we
found hematuria, and from fecal examination came with positive benzidine
test, which means there was involvement of renal and gastrointestinal.
32
Histological analysis of skin biopsy is the most reliable
examination to diagnose HSP. However, skin biopsy is usually performed
in children only if the diagnosis of HSP is doubtful. Skin biopsy should be
performed at the edge of a fresh lesion to maximize the likelihood of
25
finding IgA deposition . Kidney biopsy is indicated if renal findings are
severe enough to consider treatment with immunosuppressives, such as
33
severe proteinuria and decreased glomerular filtration rate (GFR) .
In 2008, the European League against Rheumatism (EULAR) and
the Pediatric Rheumatology European Society (PRES) published a new
classification of vasculitis in children. Based on this consensus, the
diagnostic criteria for HSP require the presence of purpura or petechiae
predominantly on the lower extremities, with at least one of the following:
abdominal pain, skin biopsy showing predominantly IgA deposition, acute
arthritis or arthralgia, and renal involvement defined as hematuria or
proteinuria. This criteria yields a sensitivity of 100% and specificity of 87%
18,25,34
for diagnosis of HSP . This patient fulfilled the 2008’s European
League against Rheumatism (EULAR) and Pediatric Rheumatology
European Society (PRES) criteria, in whom, palpable purpura are found in
various sizes, multiple, non-pruritic and painless on the lower extremities,
acute arthralgia, and there was abdominal pain and renal involvement is
hematuria.
The diagnosis of Henoch-Schonlein Purpura is usually clear, by
finding palpable purpura or petechiae, but other disorders must also be
considered. Thrombocytopenia and clotting disorders must be excluded as
causes of purpura and petechiae. Sepsis, especially meningococcal
septicemia, can present with purpuric lesions, but the diagnosis of
septicemia is generally obvious. Drug allergy, urticaria and erythema
multiforme can resemble skin manifestations of HSP. If there is doubt, the
diagnosis of HSP must be confirmed by a skin or kidney biopsy.
Predominantly IgA deposition seen in skin or kidney biopsy is
35,36
pathognomonic for HSP .
33
In most cases, HSP is mild and self-limiting, usually requiring only
symptomatic treatment. Rest and administration of analgesics may be
needed in acute arthralgia or abdominal pain. Intravenous fluids may be
needed in abdominal pain and vomiting. Acetaminophen is preferred, while
non-steroidal anti-inflammatory drugs should be avoided, especially in
patients with gastrointestinal and renal manifestations. Skin lesions rarely
require treatment, but there are reports of success with corticosteroid. A
meta-analysis on the role of corticosteroids in the treatment of HSP,
identified 3 randomized and 12 observational studies involving 1309
patients treated with corticosteroids or supportive care. Corticosteroids
reduce the average time to treat abdominal pain, as well as the recurrence
rate and frequency of intussusception, although the difference is not
significant. In Randomized Control Trial, methylprednisolone given for 5 –
7 days is shown to reduce the severity and duration of gastrointestinal and
37-40
joint symptoms and can hasten the resolution of mild nephritis . This
patient is being treated with methylprednisolone for one week then the
dose is gradually reduced. Paracetamol was given as analgesics.
Relapse/recurrence was defined when a patient previously
diagnosed with HSP and asymptomatic for at least 2 weeks, presented
again a new flare of cutaneous lesions or other systemic manifestations of
the vasculitis. In study of Wang et al, the number of relapse/recurrence
ranged from 2 weeks to 139 weeks, with a mean of 11.4 weeks after initial
resolution of symptoms. The infection was the most common trigger of
21
HSP onset whether or not the relapse/recurrence existed . In this patient,
she had relapse with the same cutaneous symptoms since 2019 but never
went to a doctor because it disappear by itself.
Henoch-Schonlein Purpura is a self-limiting disease, with
resolution of symptoms within 4 to 6 weeks from the onset. One third of
patients experienced recurrence within 1 year from the initial presentation.
However, long-term follow-up is important because complications such as
hypertension and chronic kidney disease have been observed to occur in
34
up to 10 years after the episode of HSP. Renal involvement is a predictor
6
of poor prognosis . A good therapeutic response in this patient is indicated
by the disappearance of the erythematous rash from the legs and other
symptoms.
Around one third of cases of children with HSP experience
recurrence, usually in a few months after the first episode. It usually occurs
in older children. If HSP does not recur, the prognosis is usually good.
Since recurrence is possible, it is important to educate the parents to avoid
giving the children certain medications if there are possibilities that the
drugs are the cause of HSP, to be cautious if the children will get
6
vaccinated, and to maintain hygiene to avoid infection .
Malnutrition in children, which refers to both protein energy malnutrition
(PEM) and micronutrient deficiency, is a great challenge in many developing
nations, being directly or indirectly accountable for 3.1 million child deaths
annually, or 45% of all child deaths in 2011 in low income and middle income
countries. According to the United Nations International Children's Emergency
Fund (UNICEF), the World Health Organization (WHO) and the World Bank,
out of the 161 million under-fives estimated to be stunted globally in 2013,
over a third resided in Africa. In addition, about one-third of the 51 million
under-fives who were wasted and the 99 million who were underweight were
also from Africa. Apart from marasmus and kwashiorkor, deficiencies in iron,
iodine, vitamin A and zinc are the main manifestations of malnutrition in
developing countries. In these communities, a high prevalence of poor diet
41
and infectious disease regularly unites into a vicious circle . Protein-Energy
Malnutrition (PEM) state is classified as mild and severe malnutrition. Mild
malnutrition has not yet show typical symptoms, no biochemistry abnormality,
42
only growth disorder .
Anthropometry is used to measure nutritional status of preschool and

school age children. For children above 5 years old, CDC Curve 2000 is used.
Weight-for-height is the reference to measure normal anthropometry value.
When taken as a case repot, the patient’s body weight was 30 kg and
35
body height 144 cm, nutritional status based on CDC Curve 2000 for girls
aged 2-20 years weight-for-height was 81%, nutritional status of this
patient was mild malnutrition.
21
A study by Wang et al , 1200 HSP children were recruited from
January 2015 to December 2017. The annual incidence of HSP was 8.13
– 9.17 per 100,000. 123 cases (10.25%) of HSP relapsed or recurred
more than one time within a 3-year observational period; the mean number
of relapse/recurrence was 2.92 and the mean interval was 11.4 weeks.
The infection was the most common trigger of HSP onset whether or not
the relapse/recurrence existed (Level of evidence 2B, recommendation B)
43
Study by Ekinci et al , with 420 HSP patients, 48.6% females and
51.4% males. The mean±SD age at diagnosis was 7.68±3.15 years, and
74.8% were diagnosed below 10 years of age. The patients were followed
up for a median of 19.6 months (range, 6-30 months) in our department.
Disease recurred for at least once, in 16.4% patients, with a median of 1.4
months (range, 1-28 months) time interval after the first episode. The
symptoms at HSP relapse were purpura in 60.9%, abdominal pain in
17.4%, both purpura and abdominal pain in 21.7%. (Level of evidence 2B,
recommendation B)
44
A retrospective analysis conducted by Bondin et al , of the 96 cases
diagnosed with HSP at Mater Dei Hospital between January 2008 and
January 2016, male to female ratio was 1.35:1 and 99% had the typical rash
at presentation with 75% having other associated clinical findings. The results
was 93 children (96.9%) were followed-up in clinic at least once; the rest were
lost to follow-up. 87.5% cases showed complete resolution of signs and
symptoms within 2 months from presentation and were subsequently
discharged by 6 months from the first presentation. Rash recurrence occurred
in 12.5% cases, with the majority (75%) of these recurrences occurring within
2 months from the initial presentation with no easily recognisable trigger.
(Level of evidence 2B, recommendation B)
36
45
Gomez et al , conducted a retrospective study of 339 patients
younger than 15 years old with HSP from January 2008 until December
2017. From this study, one or more recurrences occurred in 52 patients
(15%). The median time since the onset of HSP until recurrence was 65
days. The most common clinical manifestation of recurrence was isolated
purpura (27.52%), whereas the rest had purpura accompanied with other
type of involvement. (Level of evidence 2B, recommendation B)
The prognosis of this patient according to ad vitam was bonam and
ad functionam was bonam. The ad sanationam was dubia ad bonam
because HSP can relapse.
37
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41
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42
APPENDIX
PATIENT’S PHOTO
43
NUTRITIONAL STATUS
KZM, ♀ ,9 yrs 11 mo old
Weight/ age = 30/32 x100% = 93.7%

Height/age = 144/137 x 100% = 105.1%
Weight/Height = 30/37 x 100% = 81%
44
CHEST X-RAY
45
ABDOMINAL X-RAY
46
ABDOMINAL ULTRASONOGRAPHY
47
ABDOMINAL ULTRASONOGRAPHY
48
FECES CULTURE
49

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With all due respect to :

HENOCH-SCHONLEIN PURPURA AND

Department of Child Health

1.2. PARENTS IDENTITY

2.1. HISTORY OF PRESENT ILLNESS

2.2 HISTORY OF PREVIOUS ILLNESS

STRUCTURE OF FAMILY MEMBERS

1. YK Father M 39 y.o. Healthy

2.4. PERSONAL / SOCIAL HISTORY

The patient was routinely carried out to Public Health Care to

The patient was able to sit at 6 months old, crawling at 7

E. History of Basic Needs Physic-biomedic

F. Socio-economic and Environement Conditions

III. PATIENT’S HOSPITAL ADMISSION SUMMARY BEFORE

IV. PHYSICAL EXAMINATION WHEN ACCEPTED AS A CASE

Nutrition Status and Anthropometric

Skin : Light brown colored, BCG scar on right upper arm,

Vertebrae : deformity (-)

Cranial nerves examination

Patient, a girl, 9 and 11 month years old, admitted to hospital on April

VII. MANAGEMENT PLAN

b. Medication treatment plan :

Protein needed : 1 gr/kgBW/day = 37 gr/day

Mineral water : 2590 - 3145 mL/day

e. Monitoring and evaluation:

Gastroentero-hepatology consult results : feces culture, no additional

Conclusion : abdominal ultrasonography is within normal limit

Feces culture : Eschericia coli (normal flora)

A Henoch Schonlein Purpura (D69.0)

Lower extremities : multiple painless purpura was almost

Henoch Schonlein Purpura and Mild Malnutrition

Investigation • Complete blood count examination, urinalysis, stool analysis,

Feces culture, abdominal ultrasonography

Methylprednisolone, omeprazole, paracetamol (if needed),

Ad Vitam : bonam • Parents education

Henoch-Scholein Purpura (HSP) is a diffuse vasculitis that is secondary

Anthropometry is used to measure nutritional status of preschool and

KZM, ♀ ,9 yrs 11 mo old

Weight/ age = 30/32 x100% = 93.7%

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