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CASE PRESENTATION

HENOCH SCHONLEIN PURPURA

Preceptor: dr. UlynarMarpaung, Sp. A


Presenter: fajrin utami(1102007110)

DEPARTMENT OF PEDIATRIC
RADEN SAID SUKANTO POLICE CENTER HOSPITAL
FACULTY OF MEDICINE YARSI UNIVERSITY
Patien Identity
Name : AN
Birth Date : March 17th 2002
Age : 13 years old
Gender : Female
Address : Kampung makasar, East Jakarta
Nationality : Indonesian
Religion : Islam
Date of admission : March 23th 2016.
Date of examination: May 23th 2016- May 27th 2016
Parent Identity
Father Mother
Name Mr. M Mrs. T
Age 42 years old 36 years old
Job Employee Housewife
Nationality Indonesian Indonesian
Religion Islam Islam
Education Senior High School Senior High School
History Taking
Alloanamnesis from patients mother on
the date of admission, May 23th 2016.

Chief complain:

Abdominal pain since 3 days before entering the hospital.

Additional complains:

patients also complain of nausea and vomiting 3 times, containing


food, but it also is reddish rash on the legs, the rash appeared since
one week ago.
History of Present Illness

A child aged 13 years came with complaints of abdominal pain 3


days ago before entering the hospital. complaint accompanied by
nausea and vomiting 3x contains food. patients also complain of red
rash on both legs, arising since 1 week ago has brought health
centers and given skin ointments but the rash does not disappear.

Denied fever, cough and flue denied, diarrhea


denied, denied trauma, allergies denied
History Of Past Illness
Pharyngitis/ - Bacillary -
Tonsilitis Dysentry
Bronchitis - Amoeba -
Dysentry
Pneumonia - Diarrhea +
Morbilli + Thypoid -
Pertussis - Worms -
Varicella + Surgery -
Diphteria - Brain -
Concussion
Malaria - Fracture -
Polio - Drug Reaction -
Enteritis -
Prenatal History
Antenatal care
Antenatal check ups performed at the puskesmas by the
midwife. There was no problems during pregnancy.
No maternal illness during pregnancy
Drugs consumption:
Vitamins every antenatal care
Birth History
Labor : Puskesmas
Birth attendants : midwife
Mode of delivery : pervaginam
Gestation : 38 weeks
Infant state : healthy
Birth weight : 3200 grams
Body length : 47 cm
According to the mother, the baby started to cry and the
baby's skin is red, no congenital defects were reported
Post Natal History

Examination by midwife
The state of the infant: healthy
Development History
First dentition: 6 months
Psychomotor development
Head Up : 1 month old
Smile : 1 month old
Laughing : 1- 2 month old
Slant : 2,5 month old
Speech Initiation : 5 month old
Prone Position : 5 month old
Food Self : 5 6 month old
Sitting : 6 month old
Crawling : 8 month old
Standing : 12 month old
Walking : 13 month old
Conclusion: Growth and development status is still in the normal limits and was
appropriate according to the patients age
History of Eating

Breast Milk Exclusively 6 month..

Formula milk SGM since 1th year old

Biscuits regal
Baby biscuits

Fruit and vegetables Banana, spinach, apple,


manggo.

Solid foods and side dishes Rice, Carrots, Potatoes


Immunization History

Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times 0, 1, 6 months old

DPT 3 times 2, 4, 6 months old

Polio 4 times 0, 2, 4, 6 months


old
Morbilli 3 times 9, 24 months and
praschool
Family History

Patients both parents were married when they


were 24 years old and 21 years old, and this is
their first marriage.
There are not any significant illnesses or chronic
illnesses in the family declared.
History of her brother and sister
N Age Died Sumption
Child birth Gender Age
o Died
Spontan - -
19
pervaginam, Boy
years
1. gestation
old
aterm
Spontan Girl 13 - -
pervaginam, years
2.
gestation old
aterm
History of the disease people around the patient

Around the house


People who lived around the patients house are
in healthy condition
Physical Examination
Date :May 23th 2016

General condition :
mild ill Pulse: 98 x/min
Breathing rate: 20x/min
Awareness: Temperature: 37,2C
Compos Mentis

STATUS GIZI

WEIGHT = 40kg
HEIGHT = 155 cm
Physical Examination
Date :May 23th 2017
General Status
General condition : mild ill
Awareness : Compos Mentis
Pulse : 98 x/min, regular, full,
strong.
Breathing rate : 20x/min
Temperature : 37,2oC
Physical Examination (contd)

Antropometry Status
Weight : 40 kilograms
Height : 155 cm
Nutritional Status
Nutritional status measured based
on National Center for Health
Statistics (2000):

Interprestation based on WHO


WFA(Weight for Age): above
percentil 99
HFA (Height for Age): percentile
88

Interpretation based on lokarya


Antropometri Depkes 1974 and
puslitbang Gizi 1978
WFA (Weight for Age): 40/45 x
100 % = 88%
HFA (Height for Age): 155/156 x
100 % = 99%
WFH (Weight for Height): 40/45 x
100 % = 88%

Conclusion: Nutrition status of


the patient is good
Systematic Physical Examination
Head Normocephaly, hair (black, normal distributon, not easily removed
) sign of trauma (-), large fontanelle closed.

Eyes Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- ,
lacrimation -/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct
and indirect light response ++/++
Ears Normal shape, no wound, no bleeding ,secretion or serumen

Mouth
Lips: dry
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: No hyperemia

Neck Lymph node enlargement (-), scrofuloderma (-)


Thorax Symmetric when breathing , no retraction,
Inspection: ictus cordis is not visible

Palpation: mass (-), tactile fremitus +/+

Percussion: sonor on both lungs


Auscultation
Cor : regular S1-S2, murmur (-), gallop (-)
Pulmo : vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen :
Inspection : Convex, epigastric retraction (-), there is no a widening
of the veins, no spider nevi.

Palpation : supple, liver and spleen not palpable, fluid wave (-),
abdominal mass (-)tenderness at regio epigastrium and
umilicalis (+)
Percussion: The entire field of tympanic abdomen, shifting dullness
(-)

Auscultation normal bowel sound, bruit (-)


:
Anus Normal

Extremities warm, capillary refill time < 2


second, edema(-)

Skin Good turgor


Multiple erythematous rash
appears scattered on both legs
Laboratory Investigation
Hematology (Mary 23th 2016)

Hematology Results Normal Value

Haemoglobin 13,2 13-16 g/dL

Leukocytes 19.300/L 5,000 10,000/L

Hematocrits 38 % 40 48 %

Trombocytes 318.000/ L 150,000


400,000/L

Erythrocytes 4,60 million/L 4 5 million/L


Differential Count

Basophil 0 0-1 %

Eosinophil 2 1-3 %

Neutrophil Rod 0 2-6 %

Neutrophil Segment 40 50-70 %

Lymphocyte 37 20-40 %

Monocyte 7 2-8 %

Erythrocyte Sedimentation Rate 10 <15 mm/hour


Clinical Chemistry Results Normal Value

Total Protein 7,2 6,0-8,7 g/dL

Albumin 4,2 3,5-5,2 g/dL

Globulin 1,4 2,5-3,1 mg/dL

Ureum 10 mg/dL 10-50 mg/dL

Creatinine 0,5 mg/dL 0,5-1,5 mg/dL


Working
diagnosis

Henoch-Schonlein
Purpura
MANAGEMENT

IVFD Ringer Lactate 16 tpm macro


Injection Cefotaxime 2x2mg
Inj. Metil Prednisolon 65mg 2x amp
Inj.Ranitidin 2x20mg
inj. Dexamethaxon 1x1gr
Tab.Paracetamol 3x250 mg
PROGNOSIS

QUO AD
QUO AD VITAM SANATIONAM

Bonam
Dubia ad Bonam

QUO AD FUNCTIONAM

Dubia ad Bonam
Follow Up
May 23th 2016 - may 27th 2016.
May 23th 2016. 1 day of hospitalization, 4th day of illness
S Abdominal pain left regio
Fever (+)
Vomiting and Nausea (+)
Purpura (+)

O General condition: Mild ill.


Heart rate = 120 x/min
Respiratory rate = 28x/min
Temperature = 36.6C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
abdomen : tenderness at regio epigastrium and umilicalis (+)
Skin at regio extermiti lower Multiple erythematous rash appears scattered on both legs

A Purpura Henoch- Shonlein

P IVFD Ringer Lactate 16 tpm macro


Injection Cefotaxime 2x2mg
Inj. Metil Prednisolon 65mg 2x amp
Inj.Ranitidin 2x20mg
inj. Dexamethaxon 1x1gr
Tab.Paracetamol 3x250 mg
Day 2, May 24th 2016
S Abdominal pain left regio
Fever (-)
Vomiting and Nausea (+)
Purpura (+)

O General condition: Mild ill.


Heart rate = 111 x/min
Respiratory rate = 26x/min
Temperature = 36.4C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
abdomen : tenderness at regio epigastrium and umilicalis (-)
Skin at regio extermiti lower : Multiple erythematous rash appears scattered on both legs
A Purpura Henoch- Shonlein

P IVFD Ringer Lactate 16 tpm macro


Injection Cefotaxime 2x2mg
Inj. Metil Prednisolon 65mg 2x amp
Inj.Ranitidin 2x20mg
inj. Dexamethaxon 1x1gr
Tab.Paracetamol 3x250 mg
Day 3, May25th 2016
S Abdominal pain left regio (-)
Fever (-)
Vomiting and Nausea (-)
Purpura (+)

O General condition: Mild ill.


Heart rate = 103 x/min
Respiratory rate = 26x/min
Temperature = 36,2C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
Abdomn : tenderness at regio epigastrium and umilicalis (-)
Skin at regio extermiti lower : Multiple erythematous rash appears scattered on both legs

A Purpura Henoch- Schonlein


IVFD Ringer Lactate 16 tpm macro
P
Injection Cefotaxime 2x2mg
Inj. Metil Prednisolon 65mg 2x amp
Inj.Ranitidin 2x20mg
inj. Dexamethaxon 1x1gr
Tab.Paracetamol 3x250 mg
Day 4, May 26th 2016

S No complain

O General condition: Mild ill.


Heart rate = 110 x/min
Respiratory rate = 30x/min
Temperature = 36C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
abdomen : tenderness at regio epigastrium and umilicalis (-)
Skin at regio extermiti lower : Multiple erythematous rash appears scattered on both legs

A Purpura Henoch-Shonlein
P IVFD Ringer Lactate 16 tpm macro
Injection Cefotaxime 2x2mg
Inj. Metil Prednisolon 65mg 2x amp
Inj.Ranitidin 2x20mg
inj. Dexamethaxon 1x1gr
Tab.Paracetamol 3x250 mg
Before After
Literature Review and Discussion
Definision
HENOCH SCHONLEIN PURPURA
is the most common vasculitis of childhood
and is characterized by leukocytoclastic
vasculitis and immunoglobulin (Ig) A
deposition in the small vessels in the skin,
joints, gastrointestinal tract, and kidney.
EPIDEMIOLOGY

Especially in children aged 2 years to 15


years
The boys: female = 1.5: 1
HSP benign self limitide disorder
<5% T-shirts become chronic
<1% of cases develop into kidney failure
Etiology
Not yet known
Infection
Vaccine
Allergen
Idiopathic disease : Glomrulocysic kidney
disease
Patofisiology

Inflammation of the small blood


Deposit of immune Activation of vessels in the skin, kidneys,
complexes and inflammatory mediators joints and abdomen and occurs
complement (including vascular in the skin purpura, neritis,
activation prostaglandins) arthritis and bleeding
gastrontstinal
Patofisiology
Immunological
factors

changes interleukins and growth


factors that play a role in
inflammatory mediators

increased levels of hepatocyte growth factor during


the acute phase of HSP may indicate the
possibility of damage or dysfunction of endothelial
cells

cytokines thought to be involved in the


pathogenesis of HSP, and endothelin, a
vasoconstrictor hormone produced by cells
endotelia
Clinical manifestations
Prodromal symptoms with fever no more
than 38C headache and anorexia
Abdominal pain or kidney disorders
Rash purpura of the lower extremities
Arthritis
laboratory
Laboratory
No laboratory finding is diagnostic of
HSP. Common but nonspecific findings
include leukocytosis, thrombocytosis,
mild anemia, and elevations of
erythrocyte sedimentation rate (ESR)
and C-reactive protein (CRP). Occult
blood is frequently found in stool
specimens.
Laboratory
Autoantibody testing is not useful
diagnostically except to exclude other
diseases. Serum IgA values are often
elevated but are not routinely measured.
Laboratory
Assessment of renal involvement with blood pressure,
urinalysis, and serum creatinine is necessary.
Ultrasound is often used in the setting of
gastrointestinal complaints to look for bowel wall edema
or the rare occurrence of an associated intussusception.
Barium enema can also be used to both diagnose and
treat intussusception. Although often unnecessary in
typical HSP, biopsies of skin and kidney can provide
important diagnostic information, particularly in atypical
or severe cases.
DIAGNOSIS

The diagnosis of HSP is a clinical one and is


often straightforward when the typical rash is
present. However, in at least 25% of cases,
the rash appears after other manifestations,
making early diagnosis challenging.
DIAGNOSIS
The differential diagnosis for HSP
depends on specific organ involvement but
usually includes other small vessel
vasculitides, infections, coagulopathies,
and other acute intra-abdominal
processes.
TREATMENT
Treatment of HSP is supportive, with an
emphasis on assuring adequate hydration,
nutrition, and analgesia. Controversy continues
concerning the appropriate use of
glucocorticoids in the management of HSP,
but steroids are most often used to
treatsignificant gastrointestinal involvement
or other life-threatening manifestations.
TREATMENT
Empiric use of prednisone (1 mg/kg/day for 1 to
2 wk, followed by taper) reduces abdominal
and joint pain but does not alter overall prognosis
nor prevent renal disease. Chronic HSP renal
disease is managed with a variety of
immunosuppressants, including azathioprine,
cyclophosphamide, and mycophenolate mofetil.
End-stage renal disease develops in up to 8% of
children with HSP nephritis.
COMPLICATIONS

Acutely, serious gastrointestinal involvement


such as intestinal perforation imparts
significant morbidity and mortality. Renal
disease is the major long-term complication,
occurring in 1-2% of children with HSP. Renal
disease can develop up to 6 mo after
diagnosis but rarely does so if the initial
urinalyses findings are normal
Prognosis
HSP is generally a benign disease with an
excellent prognosis. Most patients experience
complete resolution of symptoms within 8
weeks, and probably fewer than 5% experience
chronic symptoms, although, Serious GI and
renal complications may occur Recurrences
occur in as many as 25-50% of patients within 6
weeks but can happen as late as 7 years after
the initial disease. The higher the number of
recurrences, the higher the likelihood of
permanent renal damage.