1. PED Case
Presented by R1 常景棠

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

3. 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

4. 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

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

6. 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 (-)

7. 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

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

9. Clinical Picture

10. Clinical Picture

11. 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]

12. Lab

13. 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

14. Review Article (Lancet Mar. 2007 )
Essential

15. 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

17. 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

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

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

20. Method

21. Result

22. Result

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

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

25. 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

26. 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

27. 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