Paediatrics · Moderate
This case is fictional and exists for study. It describes no real patient.
6 years · male
A 6-year-old boy is brought to the clinic by his mother due to a rash that developed over the last 2 days. His mother notes that he had a mild cold two weeks ago. He now complains of dull abdominal pain and sore ankles. On examination, he is alert and interactive. There is a symmetrical, raised, non-blanching rash clustered over his buttocks and the back of both lower legs. His ankle joints are mildly swollen and tender to touch, though passive range of movement is intact. Abdominal examination reveals mild diffuse tenderness without guarding.
Vital signs
- HR
- 102 bpm
- BP
- 104/66 mmHg
- RR
- 22/min
- Temp
- 37.3 °C
- SpO₂
- 98%
Examination findings
- Symmetrical palpable purpura over buttocks and lower limbs
- Bilateral mild ankle joint swelling and tenderness
- Mild diffuse abdominal tenderness without peritoneal signs
Investigations
| Haemoglobin | 12.4 g/dL | reference: 11.5-14.5 |
| White blood cells | 9.8 10^9/L | reference: 4.5-13.0 |
| Platelets | 290 10^9/L | reference: 150-450 |
| C-reactive protein | 10 mg/L | reference: 0-8 |
Question 1 of 3
Which of the following is the most likely diagnosis?
Henoch-Schönlein purpura (IgA vasculitis) classically presents in children following an upper respiratory tract infection with palpable purpura on the lower legs and buttocks, arthralgia/arthritis, and abdominal pain. The normal platelet count rules out idiopathic thrombocytopenic purpura (ITP), which presents with non-palpable petechiae/purpura due to low platelets. Meningococcal septicaemia causes acute collapse with severe fever and sepsis signs. Erythema multiforme presents with targetoid cutaneous lesions rather than palpable purpura.
Teaching point: Henoch-Schönlein purpura is an IgA-mediated vasculitis presenting with non-thrombocytopenic palpable purpura mainly affecting the lower limbs and buttocks.
Question 2 of 3
Which of the following is the most appropriate initial investigation to screen for potential complications in this patient?
Renal involvement (nephritis) is the most significant long-term complication of Henoch-Schönlein purpura. Initial and serial monitoring using urine dipstick (to check for protein and blood) and blood pressure measurement is essential. Stool culture is unnecessary as the abdominal pain is vasculitic. Abdominal ultrasound is indicated only if intussusception is clinically suspected (e.g., severe severe colicky pain, red currant jelly stool). Skin biopsy is rarely required when clinical presentation is classic.
Teaching point: All children with suspected Henoch-Schönlein purpura require urinalysis and blood pressure monitoring to evaluate for renal involvement.
Question 3 of 3
Assuming renal monitoring and blood pressure are normal, which of the following is the most appropriate initial management step?
Uncomplicated Henoch-Schönlein purpura is self-limiting and managed supportively with adequate hydration, rest, and simple analgesia (e.g., paracetamol or NSAIDs if no renal impairment) for joint and abdominal pain. Routine corticosteroids are not recommended for mild disease unless severe gastrointestinal involvement or significant renal complication occurs. Antibiotics are not indicated as this is an immune-mediated vasculitis. IVIG is reserved for severe or refractory cases.
Teaching point: Uncomplicated Henoch-Schönlein purpura is managed supportively with analgesia and regular follow-up to check blood pressure and urine.
Key learning points
- Henoch-Schönlein purpura (IgA vasculitis) features palpable non-thrombocytopenic purpura predominantly on the legs and buttocks.
- Renal involvement is the primary prognostic determinant; serial urine dipsticks and blood pressure monitoring are mandatory.
- Management of uncomplicated disease focuses on supportive symptomatic relief with paracetamol or NSAIDs.
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