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 emergency department by his mother due to a 2-day history of a rash on his legs and buttocks, accompanied by painful knees and mild abdominal pain. One week prior, he suffered from a mild upper respiratory tract infection that resolved without specific treatment. On examination, he is comfortable at rest but cries when moving his knees. Abdominal examination reveals mild, diffuse tenderness without guarding, rigidity, or rebound. Capillary refill time is 2 seconds.
Vital signs
- HR
- 108 bpm
- BP
- 102/64 mmHg
- RR
- 20/min
- Temp
- 37.3 °C
- SpO₂
- 98%
Examination findings
- Palpable non-blanching purpuric lesions distributed symmetrically over the buttocks and lower limbs
- Bilateral knee joint swelling and mild restriction in range of movement secondary to pain
- Mild, diffuse abdominal tenderness with active bowel sounds
Investigations
| Haemoglobin | 12.5 g/dL | reference: 11.5-13.5 |
| White blood cell count | 9.5 10^9/L | reference: 5.0-14.5 |
| Platelets | 280 10^9/L | reference: 150-450 |
| Urine dipstick | Protein 1+, Blood 2+ qualitative | reference: Negative |
Question 1 of 3
What is the most likely diagnosis?
Henoch-Schönlein purpura (IgA vasculitis) classically presents in children following a upper respiratory tract infection with a tetrad of non-thrombocytopenic palpable purpura (predominantly on buttocks and lower limbs), arthralgia/arthritis, abdominal pain, and renal involvement (haematuria/proteinuria). Platelet count is characteristically normal. Immune thrombocytopenic purpura (ITP) causes petechiae/purpura due to low platelets, whereas this patient has a normal platelet count. Meningococcal septicaemia causes a rapid-onset non-blanching rash associated with severe systemic toxicity and high fever. Kawasaki disease is diagnosed clinically by fever lasting at least 5 days plus at least 4 of the 5 principal features: bilateral non-exudative conjunctivitis, oral mucosal changes (cracked lips, strawberry tongue), extremity changes (erythema and oedema of the palms and soles), polymorphous rash, and cervical lymphadenopathy (>1.5 cm). Coronary artery abnormalities are the complication that prompt treatment exists to prevent rather than a diagnostic criterion, and the echocardiogram is usually normal at presentation. This child is afebrile, and his rash is palpable and purpuric rather than the blanching polymorphous rash of Kawasaki disease.
Teaching point: Henoch-Schönlein purpura presents with palpable purpura on the lower limbs, joint pain, abdominal pain, and renal involvement in the presence of a normal platelet count.
Question 2 of 3
Which of the following is the single most appropriate long-term monitoring requirement for this patient?
Renal involvement (HSP nephritis) is the primary determinant of long-term prognosis in Henoch-Schönlein purpura. Most cases resolve spontaneously, but persistent nephritis can lead to hypertension and chronic kidney disease. Monitoring mandates regular blood pressure measurements and urinalysis (urine dipsticks) for up to 6-12 months post-diagnosis. Monthly full blood counts are not indicated since platelet levels and cell counts are normal in HSP. Serial echocardiograms are indicated for monitoring coronary artery aneurysms in Kawasaki disease. Abdominal ultrasound is performed acutely if intussusception is suspected, but not as routine long-term surveillance.
Teaching point: Long-term follow-up in Henoch-Schönlein purpura focuses on monitoring for progressive renal involvement via regular blood pressure checks and urine dipsticks.
Question 3 of 3
What is the next best management step for this patient's acute presentation?
Uncomplicated Henoch-Schönlein purpura is a self-limiting disease. Management is supportive, consisting of adequate oral hydration, rest, and simple analgesia (such as paracetamol) for joint and abdominal discomfort. IVIG and high-dose aspirin are used for Kawasaki disease. Corticosteroids (e.g., oral prednisolone) are reserved for severe abdominal pain, severe renal disease, or scrotal involvement, but are not routine for mild presentations. Intravenous broad-spectrum antibiotics are indicated for bacterial sepsis (e.g., suspected meningococcal disease), not immune-mediated IgA vasculitis.
Teaching point: The management of mild, uncomplicated Henoch-Schönlein purpura is primarily supportive with hydration and simple analgesia.
Key learning points
- Henoch-Schönlein purpura (IgA vasculitis) presents with non-thrombocytopenic palpable purpura, arthralgia, abdominal pain, and potential renal involvement.
- A normal platelet count distinguishes IgA vasculitis from thrombocytopenic causes of purpura such as ITP.
- Long-term monitoring of blood pressure and urine protein/blood is crucial to detect progressive HSP nephritis early.
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