6 - Case Study Flashcards
Patient history
- 20 year old reserve duty male soldier presents with a 3 day history of a burning rash that began in his feet – It has now spread to the legs
- He was recently on a training mission in Wisconsin where he spent at least 20 hours a day for several days in a foxhole in rainy, cold weather
- The day before the rash he developed a sore throat
- He also complains of right ankle pain and swelling the past month after he did a 20 km hike with a 60 lb back pack – It has worsened with the onset of the rash
Review of systems
- Fatigue related to military training, swelling and pain of right ankle, current rash
- Denies pruritus, fever, chills, abdominal pain, diarrhea, changes in urine color, dysuria, STD
Social history
- Smokes 5-10 cigarettes daily for past year
- Social drinker
Vitals
o BP 132/60, Pulse 58 and regular, Temp 98.1° F
o Well-nourished in no apparent distress
Derm exam
o Nonblanchable macules and plaques on posterior calves, soles and palms PURPURA
o Not tender to touch
Vascular exam
o Right ankle shows non-pitting edema, pedal pulses 2/4
o Hands are swollen
Musculoskeletal exam
o Pain with passive right ankle motion
o Muscle strength testing deferred
Head and neck exam
o Pharynx no erythema or exudate
o Neck exam no lymphadenopathy or tenderness to palpation
Abdominal exam
- Abdominal exam (for Hepatitis) and cardiorespiratory exam (for Wegener’s) unremarkable
Differentials
- Vasculitis
- Inflammatory arthropathy
- Viral infection
- Lyme disease
- Hematologic dysfunction
CBC
o WBC = 7.4 (normal)
o HGB = 12.4 (normal above 12)
o Platelets = 195,000 (normal)
Kidney tests
o Creatinine = 1.1 mg/dL (normal)
o Urinalysis
–2+ protein (nephrotic syndrome)
–2+ blood, 25-50 RBC/HPF (nephritic syndrome)
–No casts (normal)
o Renal biopsy = Findings consistent with IgA nephropathy
Liver tests
o Hepatitis B/C
o Enzymes ALT and AST (normal)
Skin punch biopsy
o Small vessel leukocytoclastic vasculitis
Sed rate
o PT = 1.08 (INR) (normal)
o PTT = 25.5 seconds (normal)
ANA tests (double stranded DNA tests)
o ANA = negative
o Anti-dsDNA = negative
o ANCA = negative
o ASO titre = positive (previous strep test)
Cryoglobulins and complement
o Cryoglobulins = negative
o Complement = normal
Chest x-ray
CLear
Diagnosis
Henoch Schonlein purpura***
- Palpable purpura in patients with neither thrombocytopenia nor coagulopathy
- Arthritis/arthralgia and abdominal pain
- Renal disease with biopsy showing IgA nephropathy
Treatment
- Hospitalization with observation, most cases resolve in 4 weeks
- IV hydration and steroid therapy
Patient outcome
- End-stage renal disease
If the clinician is suspicious of Henoch-Schonlein purpura in a patient, which test is most likely to give a definitive diagnosis? o Urine protein o Electrophoresis o Skin biopsy o Serum complement leels o 24 hour urine protein o CBC
3 (skin biopsy) - DEFINITIVE DIAGNOSIS IS BY SKIN BIOPSY ***
Which of the following statements about Henoch-Schonlein purpura is true?
o a. Henoch-Schönlein purpura treatment requires corticosteroids
o b. Henoch-Schönlein purpura treatment requires dialysis
o c. Henoch-Schönlein purpura treatment requires plasmapheresis
o d. Most cases of Henoch-Schönlein purpura spontaneously resolve within 1 month
o e. Most cases of Henoch-Schönlein purpura treatment are steadily progressive and typically manifest significant renal pathology
o a. Henoch-Schönlein purpura treatment requires corticosteroids YES
o b. Henoch-Schönlein purpura treatment requires dialysis NO
o c. Henoch-Schönlein purpura treatment requires plasmapheresis NO
o d. Most cases of Henoch-Schönlein purpura spontaneously resolve in 1 month YES
o e. Most cases of Henoch-Schönlein purdpura treatment are steadily progressive and typically manifest significant renal pathology NO
