PED Case Presented by R1 常景棠

General Data No.: 8644601 Age: 11 y/o Gender: Male Chief complaint: Right calf pain with swelling for 1 day.

Present Illness 1 week ago - URI symptoms  Cough (+) Rhinorrhea (+) Fever (–) Headache (–) - Intermittent peri-umbilicus cramping pain  Radiation pain (-) N/V (+)  Watery diarrhea (+) Bloody stool (-) Melena (-) - Dysurea (-) Hematurea (-) Tx at LMD as AGE - Intermittent stool impaction & watery diarrhea

Present Illness Bilateral calf skin rash - Size: 0.2x0.2 cm - Itching (+) - Resolved spontaneously One day before admission - New onset skin rash over calf and hand  Echymosis (+)  Finger joint tenderness - Right lower leg pain with swelling  Redness (-) Pain while walking (+)  Ankle: tender mass 1x1 cm

History Past Hx: Admission (-) Birth Hx: NSD GA:40 wks BW: 2950g Allergy: NKA Vaccine: as schedule

PE GENERAL APPEARANCE: - Fair - Activity & Appetite: decreased HEENT: - Sclera: anicteric - Conjunctiva: Pale (-) Exudate (-) - Eardrum: not injected - Throat: not injected - Tonsil: not injected, enlargement (-), exudate (-) - Oral cavity: ulcers (-) vesicles (-) thrush (-)

PE NECK: - Free supple - LAP (-) CHEST: - Breathing sound: clear - Heart sound: RHB. Murmur (-) ABDOMEN: - Soft and flat - Tenderness (-) Rebound pain (-) Muscle guarding (-) - Palpable mass (-) Hepatosplenomegaly (-) - Bowel sound: normoactive

PE EXTREMITIES: - Freely movable - R’t calf swelling Skin: - Rash & petechia & echymosis over 4 limbs  Lower limbs > upper limbs - Vesicle (-) Desquamation (-)

Clinical Picture

Clinical Picture

Impression? 此處有討論可能的DDx 臨床表現是否有像vasculitis 或者是其他血小板減少的疾病 [區分thrombocytopenia or coagulation factor deficiency]

Lab

Diagnosis? ? 另外有問到如果Lab 發現血小板真的有低 那還需要考慮甚麼? Petechia Abd. pain Arthritis

Review Article (Lancet Mar. 2007 ) Essential

Review Article (Lancet Mar. 2007 ) HSP (Henoch-Schönlein Purpura ) - Most common vasculitis in children - IgA is pivotal in pathogenesis - Often followed respiratory infection - 20.4/100,000 children per year - Boy > girl - Mean age 6 y/o (90% < 10 y/o) - No distinctive Lab abnormality (clinical diagnosis) - Prognosis depend on nephritis severity

Background The use of corticosteroids to treat HSP - 1st appeared around 1950 Existing data - Efficacy of corticosteroid is controversial Only 1 placebo controlled trial - 40 patients - Not effective on renal involvement

Objective Evaluate the efficacy of - Early prednisone therapy - Preventing renal symptoms - Treating extra-renal and renal symptoms

Method Oral prednisone - 1st 14 days  1 mg/kg/day (BID) - 2nd 7 days - 3rd 7 days  0.5 mg/kg/day (QD)

Method

Result

Result

Result Placebo 74 had renal symptoms 71/74 in the 1st month Prednisone

Result Placebo Prednisone Mild renal symptoms All Patient No prevention Age > 6 y/o with mild renal symptoms Age> 6 y/o

Conclusion Ameliorate GI & joint symptoms Hasten the resolution of mild nephritis Not effective in - Tx purpura - Shortening the duration of disease - Prevent development of renal symptoms - Prevent recurrence

Conclusion Predictive factors for renal involvement - Persistent purpura [OR 3.7] - Severe abdominal pain [OR 8.2] - Mild renal symptoms at onset [OR 10.7] Not all HSP need early steroid treatment - Tx should be targeted at  Age > 6 y/o  Renal symptoms at onset  Severe extrarenal symptoms

Take home message Patient with abd. pain or arthritis - Don’t forget to check skin Treatment with steroid - Not routine use - Base on clinical symptoms