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LETTER TO EDITOR
Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 299-300

A child with haemorrhagic bullous lesions: Atypical skin manifestation of henoch–Schonlein purpura


Department of Pediatrics, Teerthanker Mahaveer Medical College and Research Center, Moradabad, Uttar Pradesh, India

Date of Submission04-Apr-2022
Date of Decision16-Jul-2022
Date of Acceptance08-Sep-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Dr. Bablu Kumar Gaur
Department of Pediatrics, Teerthanker Mahaveer Medical College and Research Center, Moradabad - 244 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_30_22

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How to cite this article:
Gaur BK, Bari A, Agrawal D, Singh DR. A child with haemorrhagic bullous lesions: Atypical skin manifestation of henoch–Schonlein purpura. J Med Evid 2022;3:299-300

How to cite this URL:
Gaur BK, Bari A, Agrawal D, Singh DR. A child with haemorrhagic bullous lesions: Atypical skin manifestation of henoch–Schonlein purpura. J Med Evid [serial online] 2022 [cited 2023 Feb 1];3:299-300. Available from: http://www.journaljme.org/text.asp?2022/3/3/299/365877



Sir,

A previously healthy 11-year-old adolescent boy was admitted to our hospital with a history of abdominal pain for 7 days, followed by bilateral knee joint pain and palpable purpuric skin lesions over buttocks and both lower limbs 4 days later. After 48 h, lower limb purpuric lesions progressed to large vesicles and bullae. His past medical history was unremarkable. On general physical examination, he had multiple palpable purpuric skin lesions (size 0.2–2.0 cm) with scab formation over buttocks area and multiple bullous or blister lesion (size 0.2–2.5 cm) over extensor surface of both lower limbs [Figure 1]. No lesions were found over upper extremities, face, palm and sole area. His vitals were stable. He had normal complete blood counts with platelet count - 180,000/μl (reference range, 150,000–400,000/μl). His liver function test, coagulation profile and C3, C4 levels were normal. Sepsis screen parameters were negative. Microscopic haematuria (17 RBCs/HPF) and 2+ proteinuria were found on routine urine examination. Skin punch biopsy of purpuric lesion showed small vessel leucocytoclastic vasculitis [Figure 2]. On the basis of classical clinical finding and skin biopsy result, a diagnosis of haemorrhagic bullous type of Henoch–Schonlein purpura (HSP) was made. He had received oral prednisolone (2 mg/kg/day) along with supportive care. Joint pain and skin lesions were gradually subsided.
Figure 1: Palpable purpuric skin lesions over the buttocks area and multiple bullous lesions over the extensor surface of the dorsal surface of both lower extremities

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Figure 2: Skin punch biopsy of purpuric lesions showed small vessels leucocytoclastic vasculitis (H and E, ×400)

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Bullous lesions in children are commonly seen in bullous impetigo, toxic epidermal necrolysis, epidermolysis bullosa, staphylococcal scalded skin syndrome, erythema multiforme and dermatitis herpetiformis.[1] The occurrence of bullous lesions is rarely encountered in paediatric patients with HSP. Additional 42 children have been reported to have bullous lesions in HSP.[2] Only few cases have been reported from India. HSP or IgA vasculitis is the most common type of vasculitis seen in children. It is characterised by skin lesions, arthritis, gastrointestinal and renal manifestations.[3] Non-thrombocytopenic palpable purpura and petechiae mainly affecting the buttocks and legs is the classical skin lesion of HSP.[4] As per the European League Against Rheumatism criteria, the diagnosis of HSP is confirmed on the basis of palpable purpura (without any evidence of coagulopathy and thrombocytopenia) and along with one of the four following features: abdominal pain, arthritis/arthralgia, IgA deposition on skin biopsy and renal involvement (proteinuria, haematuria and red cell cast).[5] Our patient had palpable purpura, bullous lesions, abdominal pain, arthralgia, proteinuria, haematuria and skin biopsy finding confirmatory of haemorrhagic bullous HSP.

As conclusion, haemorrhagic bullous lesion is an unusual skin manifestation of HSP in children. In the evaluation of children with bullous lesions, paediatricians should be aware of the atypical skin manifestation of HSP. Bullous lesions along with joint pain and abdominal pain may raise the suspicion of atypical or haemorrhagic bullous vasculitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramelli V, Lava SA, Simonetti GD, Bianchetti MG, Ramelli GP, Milani GP. Blistering eruptions in childhood Henoch-Schönlein syndrome: Systematic review of the literature. Eur J Pediatr 2017;176:487-92.  Back to cited text no. 1
    
2.
Nothhaft M, Klepper J, Kneitz H, Meyer T, Hamm H, Morbach H. Hemorrhagic bullous Henoch-Schönlein purpura: Case report and review of the literature. Front Pediatr 2018;6:413.  Back to cited text no. 2
    
3.
Oni L, Sampath S. Childhood IgA vasculitis (Henoch-Schonlein purpura)-advances and knowledge gaps. Front Pediatr 2019;7:257.  Back to cited text no. 3
    
4.
Saulsbury FT. Henoch-Schönlein purpura. Curr Opin Rheumatol 2010;22:598-602.  Back to cited text no. 4
    
5.
Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, et al. EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis 2010;69:798-806.  Back to cited text no. 5
    


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