Problem Rounds

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Problem Rounds 12/7/06
3 yo female with abdominal pain and vomiting
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CC Abdominal pain and vomitingHPI Patient was
in good health without any problems until 3 days
prior to admission (11/9/06) when she developed
diarrhea (described as soft stool) and emesis
(yellow in color) once after breakfast. She was
seen in the pediatric emergency department,
diagnosed with AGE and discharged home. A urine
culture was sent at that time.   She has remained
afebrile since then.   On the night prior to
admission, she had one episode of emesis
(non-bloody, non-bilious). She has also had soft
stools (not watery) that are darker than usual.
THE CONTINUED EMESIS ALONG WITH ABDOMINAL PAIN
WAS THE REASON FOR PARENTS TO BRING THE PATIENT
BACK TO THE EMERGENCY DEPARTMENT.  
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HPI (continued) The patient has had decreased
PO intake for two days. Urine output decreased
to 4 diapers with dark yellow urine small in
volume, compared to her usual 6 or more wet
diapers of light yellow urine.   On initial
presentation to the emergency department with
review of her visit 2 days prior, it was noted
that her clean catch urine specimen from the
initial ER visit grew two species of 104
Enterococcus (11/9/06).   11/12/06 Early in the
morning, patient was admitted to the hospital by
the emergency department
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Take a moment to consider your differential
diagnosis
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WCH ED The patient was given a bolus of normal
saline (20cc/kg), several labs drawn (see ER
sheet significant values WBC 23.5 with 74N lt
10 bands, I O UA with pH 6, SG 1.025, trace
blood, no nitrites or leukocytes), patient given
1gram of ceftriaxone for presumed pyelonephritis,
and the patient was admitted to the
hospital.   Immediately on admission, the patient
was placed on triple antibiotics (ampicillin,
gentamicin, and metronidazole) for presumed
perforated appendicitis (clinical/laboratory).
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Labs
URINE DIP (I/O CATH) PH 6.0, SP GR
1.025, TRACE BLOOD, TRACE PROTEIN, NEG LEUK, NEG
NITRITES
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• Past Medical History
• PMD Dr. Evans T-7A
• Birth Hx
• FTNSVD at WCH
• 6-7 day NICU stay for fever (and mom with fever)
  IV antibiotics
• Jaundice hyperbilirubinemia requiring
  phototherapy for 1 day
• PMHx no surgeries, no hospitalizations, no
  known medical problems
• Allergies NKDA
• Meds None 

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• Past Medical History (continued)
•  
• Immunizations UTD (card verified)
• Family Hx
• Mom 22, Dad 30
• No known medical problems in the family
• Social Hx
• 1BR house in LA with above family
• no drugs/alcohol/smoking/pets
•  
• Developmental Hx
• Walked at 1 year, runs, climbs up and down
  stairs
• 1st word at 8 months (per parents), speaks in
  sentences (at least 4-5 words)

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• Past Medical History (continued)
•  
• Diet
• Eats everything (meals with parents)
• 24 oz whole milk daily

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Take a moment to consider your differential
diagnosis
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• PE Patient seen in the emergency department
  during ongoing initial work-up
•  
• Height 107cm (gt95), Wt (19.1kg (gt95), Ratio
  75
• Vitals (on the floor) T 98.8, BP 106/68, HR 103,
  RR 26, P 0/10 (reported, but appears 3-4/10
  FACES)
• General Sleeping, but easily arousable,
  especially with light palpation of the abdomen.
  When awake the patient appears uncomfortable.
• HEENT NCAT. PERRL/EOMI. No conjunctival
  injection. TM wnl B, OP pink/mmm/ no LAD
• CVS RRR, no murmur, CR lt 2sec, 2 pulses B

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• PE (continued)  
• Lungs CTA B, no w/r/r, no retractions
• Abdominal
• Bowel sounds present throughout
• Soft, non-distended
• Tender to palpation diffusely, definite guarding
• Patient AWAKENS to light palpation of the
  abdomen (whereas she did not awaken with
  stethoscope placed on chest or with palpation of
  extremity pulses)
• RLQ exquisitely tender with guarding, LLQ and
  BUQ also tender to palpation.
• No organomegaly appreciated
• No masses palpable
• GU Tanner I female

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• PE (continued)  
• Extremities
• No c/c/e
• Full passive range of motion. Uncooperative for
  active motion.
• Neuro Alert. Sensation in tact. 2 DTR

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Take a moment to consider your differential
diagnosis
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• Hospital Day 1 11/12/06
• Abdominal CT scan performed
• Initial read thickened sigmoid colon and
  bowel, no evidence of appendicitis.
• Non-trauma saw the patient, reviewed the CT
  scan, and decided that no surgical intervention
  was needed.
• That night, the patient started having
  watery/bloody/mucous-containing stools, which
  were sent for multiple studies.

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Abdominal CT Extraluminal fluid in pelvis with
intramural edema of distal sigmoid and rectum.
Although the appendix is not identified, these
findings are suspicious for appendicitis with
perforation.
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• Hospital Day 2 11/13/06
• Tm98, 101-113/60-88, 113-131, 26-30, 0/10
  (reported) 2559/1900
• Surgery re-consulted surgery vs. submarine.
  Perforated appendicitis outside the operative
  window, recommendation for 5 days antibiotics
  and then OR in 6 weeks.
• Surgery note 2 from the day given
  bloody/mucous stools, more clinically suspicious
  for infection/invasive diarrhea/colitis.

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• Hospital Day 3 11/14/06
• Tm99, 108-118/70-85, 119-129, 20-28, 0/10,
  2315/1975
•  
• Bloody stools continued
• CLD started

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• Hospital Day 4 11/15/06
• Tm 99.2, 110-124/67-84, 120-140, 26-30, 0/10,
  2501/1970 (670PO)
• Bloody stools continued 2-3 per day
• Abdomen now tender
• Labs resulted
• Ucx 100CFU gamma hem strep
• E.coli negative
• C.diff negative
• OP prelim negative
• GI consult obtained
• KUB and RLQ ultrasound performed

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KUB There is questionable thumbprinting in
several segments of bowel. This may indicate
edema or bowel wall thickening. There is a
nonobstructive pattern. No abnormal
calcifications are seen. Bones are
unremarkable. Impression bowel wall
thickening versus ascites.
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RLQ Ultrasound
() mesenteric inflammation. Loops of small
bowel with wall thickening. Moderate amount of
free fluid in pelvis. Cecum appears normal.
Suggests ileitis and colitis.
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• Hospital Day 4 11/15/06 (continued)
• That night, patient developed 2 punctate red
  lesions on the left inner thigh (not palpable) as
  well as non-palpable purpuric areas on the
  plantar aspect of both feet (especially at the
  base of the toes)

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Take a moment to consider your differential
diagnosis
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• Hospital Day 5 11/16/06
• Tm100, 113-120/73-76, 126-133, 24-30, 2711/2415
  (PO590)
•  
• 170 cc of bloody stools.
• Given clinical picture and labs, HSP considered
  most likely.
• CBC WBC 30.9, 80N, 10-24 bands

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• Hospital Day 6 11/17/06
• Tm98.8, 101-117/68-77, 126-135, 24-26, 0/10
•  
• Diarrhea no longer bloody
• All cultures resulted NEGATIVE (final)
• Antibiotics continued given initial concern for
  possible ongoing bacterial translocation

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• Hospital Day 7 11/18/06
• Tm98.8, 101-125/70-83, 86-131, 20-22, 0/10,
  2201/2770 (PO 480)
•  
• Abdomen NOT tender
• One soft stool, NO BLOOD
• Antibiotics discontinued

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• Hospital Day 8 11/19/06
• Patient remained afebrile
• Patient discharged home with close follow-up in
  continuity clinic

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Henoch Schonlein Purpura

• Most common vasculitic disease of childhood
• Annual incidence 20 per 100,000 children lt17yo
• Peak incidence 70 per 100,000 children 4-6 yo
• Half of cases preceded by URI
• Usually Streptococcus
• Also adenovirus, parvovirus, and mycoplasma

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Pathogenesis

• Poorly understood
• Small vessel vasculitis
• Perivascular infiltration of PMNs and
  mononuclear cells
• IgA deposition

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Most commonly affected organs
Joints
Kidneys
GI tract
Skin

Erythematous macular wheals ? ecchymoses,
petechiae, palpable purpura
Transient or migratory arthritis/ arthralgia,
large joints
N/V Abd pain Transient paralytic
ileus Hemorrhage Bowel ischemia
necrosis Intussusception Bowel perforation
Hematuria Proteinuria Nephritic syndrome Renal
insufficiency Nephrotic syndrome
100 of cases
60-84 of cases
21-54 of cases
Up to 76 of cases
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Palpable purpura

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Palpable purpura

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Palpable purpura

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Classification Criteria for HSP

• EULAR/PReS endorsed consensus criteria for the
  classification of childhood vasculitides
• Ozen S, et al. Ann Rheum Dis 200665936-941.
• Palpable purpura (mandatory criterion) in the
  presence of at least one of
• Diffuse abdominal pain
• Any biopsy showing predominant IgA deposition
• Arthritis or arthralgia
• Renal involvement (any hematuria and/or
  proteinuria)
• European League against Rheumatism/Paediatric
  Rheumatology European Society

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Differential Diagnosis of HSP
Septicemia ITP HUS Leukemia Coagulopathies AHEI Hy
persensitivity vasculitis Wegeners
granulomatosis Microscopic polyangiitis Churg-Stra
uss syndrome SLE

Purpura
SLE JRA Septic arthritis
Arthritis/Arthralgia
Abdominal pain
Appendicitis
IgA nephropathy Bergers disease
Renal disease
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Diagnosis of HSP

• Clinical diagnosis
• When to biopsy
• Unusual presentation no rash or atypical rash
• Significant renal disease
• Labs non-diagnostic, nonspecific findings
• Serum anemia, thrombocytosis, leukocytosis (esp
  if following bacterial infection), elevated ESR
• Need normal platelet count and PT to distinguish
  from other causes of purpura
• UA RBCs, WBCs, casts, proteinuria

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Treatment of HSP

• Self-limited disease, mainstay is supportive
  care
• Hydration
• Rest
• Symptomatic relief of pain
• When to hospitalize
• Cannot tolerate PO intake
• Severe abdominal pain
• Significant GI bleeding
• Changes in mental status
• Severe joint involvement limiting ambulation
• Renal insufficiency, HTN, nephrotic syndrome

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Treatment of HSP

• Watch out for complications most common GI
  complication is intussusception ? evaluate with
  abdominal ultrasound
• Role of steroids controversial, can help
  alleviate severe abdominal pain, but has not been
  shown to alter course of disease

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Prognosis of HSP

• Most cases resolve within one month
• HSP recurs in 1/3 of cases, usually within 4
  months
• Main cause of morbidity due to renal disease
• Follow-up
• UA and BP monitoring
• Weekly for first two months, then monthly or
  every other month for one year

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HSP in Adults

• Presentation is very similar
• 2 main distinctions
• Intussusception is extremely rare
• Increased risk for significant renal involvement

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References

• Dedeoglu F, Kim S. Clinical manifestations and
  diagnosis of Henoch-Schonlein purpura. UpToDate,
  2006.
• Dedeoglu F, Kim S, Sundel R. Management of
  Henoch-Schonlein purpura. UpToDate, 2006.
• Jennette JC and Falk RJ. Small-Vessel
  Vasculitis. The New England Journal of Medicine.
  1997 Nov337(21)1512-1523.
• Haroon M. Should children with Henoch-Schonlein
  purpura and abdominal pain be treated with
  steroids? Archives of Disease in Childhood. 2005
  Nov90(11)1196-8.
• Ozen S, et al. EULAR/PReS endorsed consensus
  criteria for the classification of childhood
  vasculitides. Annals of the Rheumatic Diseases
  200665936-941.

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• Thanks to Sean Williams who provided the write up
  of the case and Alicia Lwin who put it all
  together into this power point and provided the
  excellent case discussion at the end.