6 - Case Study

Question 1

Patient history

Answer 1

• 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

Question 2

Review of systems

Answer 2

• 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

Question 3

Social history

Answer 3

• Smokes 5-10 cigarettes daily for past year

- Social drinker

Question 4

Vitals

Answer 4

o BP 132/60, Pulse 58 and regular, Temp 98.1° F

o Well-nourished in no apparent distress

Question 5

Derm exam

Answer 5

o Nonblanchable macules and plaques on posterior calves, soles and palms  PURPURA
o Not tender to touch

Question 6

Vascular exam

Answer 6

o Right ankle shows non-pitting edema, pedal pulses 2/4

o Hands are swollen

Question 7

Musculoskeletal exam

Answer 7

o Pain with passive right ankle motion

o Muscle strength testing deferred

Question 8

Head and neck exam

Answer 8

o Pharynx  no erythema or exudate

o Neck exam  no lymphadenopathy or tenderness to palpation

Question 9

Abdominal exam

Answer 9

• Abdominal exam (for Hepatitis) and cardiorespiratory exam (for Wegener’s) unremarkable

Question 10

Differentials

Answer 10

• Vasculitis
• Inflammatory arthropathy
• Viral infection
• Lyme disease
• Hematologic dysfunction

Question 11

CBC

Answer 11

o WBC = 7.4 (normal)
o HGB = 12.4 (normal above 12)
o Platelets = 195,000 (normal)

Question 12

Kidney tests

Answer 12

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

Question 13

Liver tests

Answer 13

o Hepatitis B/C

o Enzymes ALT and AST (normal)

Question 14

Skin punch biopsy

Answer 14

o Small vessel leukocytoclastic vasculitis

Question 15

Sed rate

Answer 15

o PT = 1.08 (INR) (normal)

o PTT = 25.5 seconds (normal)

Question 16

ANA tests (double stranded DNA tests)

Answer 16

o ANA = negative
o Anti-dsDNA = negative
o ANCA = negative
o ASO titre = positive (previous strep test)

Question 17

Cryoglobulins and complement

Answer 17

o Cryoglobulins = negative

o Complement = normal

Question 18

Chest x-ray

Answer 18

CLear

Question 19

Diagnosis

Answer 19

Henoch Schonlein purpura***

• Palpable purpura in patients with neither thrombocytopenia nor coagulopathy
• Arthritis/arthralgia and abdominal pain
• Renal disease with biopsy showing IgA nephropathy

Question 20

Treatment

Answer 20

• Hospitalization with observation, most cases resolve in 4 weeks
• IV hydration and steroid therapy

Question 21

Patient outcome

Answer 21

• End-stage renal disease

Question 22

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

Answer 22

3 (skin biopsy) - DEFINITIVE DIAGNOSIS IS BY SKIN BIOPSY ***

Question 23

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

Answer 23

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