Henoch-Schonlein Purpura

Updated: Mar 14, 2019

Author: Rajendra Bhimma, MBChB, MD, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal);
Chief Editor: Craig B Langman, MD more...

OVERVIEW

Practice Essentials

Henoch-Schönlein purpura (HSP) is an acute immunoglobulin A (IgA)–mediated disorder

characterized by a generalized vasculitis involving the small vessels of the skin, the
gastrointestinal (GI) tract, the kidneys, the joints, and, rarely, the lungs and the central
nervous system (CNS). It is the most frequent vasculitis in childhood, the incidence
decreasing with age. The disease if more benign in children than adults. See the image
below.

Characteristic rash of Henoch-Schönlein purpura.

Signs and symptoms

The typical prodrome of HSP includes the following:

• Headache
 • Anorexia

• Fever

Subsequently, symptoms develop, of which the following are the most common:

• Rash (95-100% of cases), especially involving the legs; this is the hallmark of the
disease

• Abdominal pain and vomiting (35-85%)

• Joint pain (60-84%), especially involving the knees and ankles

• Subcutaneous edema (20-50%)

• Scrotal edema (2-35%)

• Bloody stools

Because HSP can affect all organ systems, a full physical examination is indicated. Physical
findings in HSP may include the following:

• Skin findings (usually the first sign of HSP) - Erythematous macular or urticarial
lesions, progressing to blanching papules and later to palpable purpura; typically
symmetrical and tend to be distributed in dependent body areas, such as the ankles
and lower legs in older children and adults and the back, buttocks, upper extremities,
and upper thighs in young children; hives, angioedema, and target lesions can also
occur

• Renal findings - Acute glomerular lesions, including mesangial hypercellularity,

endocapillary proliferation, necrosis, cellular crescents, and leukocyte infiltration

• Gastrointestinal (GI) findings - Abdominal pain, melena, bloody diarrhea,

hematemesis, duodenal ulcers, and massive GI hemorrhage

• Joint findings - Arthralgia and swelling

• Arthralgia is the presenting feature in as many as 25% of cases. Joints may be

swollen, tender, and painful. Warmth, erythema, and effusions are not typically
associated with HSP. The knees and ankles are most commonly affected. On rare
occasions, symptoms involve the fingers and wrists. Findings are transient but can
occur again during active disease. The joints are not permanently deformed.

• Other findings - Vasculitis involving the myocardium or lungs; stenosing ureteritis,

priapism, penile edema, or orchitis; vasculitis involving the central nervous system
(CNS) and intracranial hemorrhage with confusion and convulsions; bilateral
subperiosteal orbital hematomas; adrenal hematomas; acute pancreatitis as the sole
presenting feature (rare); cystic changes of the ovaries

See Presentation for more detail.

Diagnosis

The diagnosis of HSP, as revised by the Paediatric Rheumatology European Society

(PRES) in 2008, includes the following criteria: palpable purpura(mandatory criteria) in the
presence of at least one of the following (diffuse abdominal pain; any biopsy sample
showing predominant IgA deposition; arthritis or acute arthralgia in any joint; and renal
involvement (any haematuria or proteinuria); and IgA deposition in a biopsy sample in
patients with atypical distribution of purpura. [83, 84]

No specific diagnostic laboratory test is available to assess for markers of HSP. The
following general laboratory tests may be helpful for excluding other diagnoses and
evaluating renal function:

• Antinuclear antibody (ANA) and rheumatoid factor (RF)

• Factors VIII and XIII

• Urinalysis

• Complete blood count (CBC)

• Platelet count

• Erythrocyte sedimentation rate (ESR)

• Stool guaiac test

• Blood urea nitrogen (BUN) and creatinine

• Amylase and lipase

• Electrolytes

• Plasma D-dimer

• Plasma thrombin-antithrombin (TAT) complex, prothrombin fragment (PF)-1, and PF-2

• Prothrombin time (PT) and activated partial thromboplastin time (aPTT)

• Serum IgA

• Antistreptolysin O (ASO)

• CH50

• C3 and C4

• Immunocomplexes of IgG and IgA

Imaging modalities that may be considered include the following:

 • Ultrasonography (abdominal, scrotal/testicular)

• Radiography (chest radiography; plain radiography of the abdomen; contrast

radiography of the small intestine; barium enema study)

• Magnetic resonance imaging (MRI; for assessing neurologic findings)

• Computed tomography (CT) of the head or abdomen

Other studies that may be warranted are as follows:

• Endoscopy

• Renal biopsy (particularly when nephrotic syndrome persists and when renal function
deteriorates)

See Workup for more detail.

Management

Treatment remains primarily supportive in most cases, though pharmacotherapy,

plasmapheresis, and surgical interventions may also be considered in select cases.

Supportive measures may include the following:

• Ensuring adequate hydration

• Monitoring for abdominal and renal complications

• Treating minor symptoms of arthritis, edema, fever, or malaise

• Eating a bland diet

• Discontinuance of any drugs suspected of playing a causative role

Joint and soft tissue discomfort may be reduced by giving analgesics, such as the following:

• Acetaminophen

• Ibuprofen

• Flurbiprofen

• Ketoprofen

• Naproxen

Corticosteroids may be considered in the following situations:

• Persistent nephrotic syndrome

• Crescents in more than 50% of glomeruli

 • Severe abdominal pain

• Substantial GI hemorrhage

• Severe soft tissue edema

• Severe scrotal edema

• Neurologic system involvement

• Intrapulmonary hemorrhage

The beneficial effect of methylprednisolone pulses has been shown in patients receiving
combinations of multiple immunosuppressive drugs.

In HPS nephritis, a disease considered to be benign, long-term follow-up studies showed

delayed development of CKD in this population in the absence of rapidly progressive
glomerulonephritis when steroids and other immunosuppressants were used.

Other treatment regimens have included IV or oral steroids with or without any of the
following:

• Azathioprine

• Cyclophosphamide

• Cyclosporine

• Angiotensin converting enzyme inhibitors or angiotensin receptor blockers

• Dipyridamole

• High-dose IV immunoglobulin G (IVIg)

• Danazol

• Fish oil

Plasmapheresis may be effective in delaying the progression of kidney disease. Angiotensin

converting enzyme inhibitors or receptor blockers for moderately severe proteinuria.

Surgical interventions that may be considered in specific circumstances include the

following:

• Surgery for severe bowel ischemia

• Kidney transplantation for severe renal disease that is resistant to medical therapy

• Tonsillectomy together with corticosteroid pulse therapy for progressive HSP nephritis

See Treatment and Medication for more detail.

Background
Henoch-Schönlein purpura (HSP; also referred to as Schönlein-Henoch purpura,
anaphylactoid purpura, or purpura rheumatica). It was first described more than 200 years
ago by Heberdon in two male children presenting with abdominal pain, purpuric rash, and
arthralgia. [86] It is an acute immunoglobulin A (IgA)–mediated disorder characterized by a
generalized vasculitis involving the small vessels of the skin, the gastrointestinal (GI) tract,
the kidneys, the joints, and, rarely, the lungs and the central nervous system (CNS). [1, 2, 3] It
is a subset of necrotizing vasculitis characterized by fibrinoid destruction of blood vessels
and leukocytoclasis.

The prevalence of HSP peaks in children aged 3-10 years, but the condition is also seen in
adults. [4] It has been reported that 24 per 100 000 children younger than 17 years will
develop HSP and there is a strong ethic influence on the incidence of the disease with
approximately 70/100,000 cases of children per year in Asia. [21] In the Northern hemisphere,
the disease occurs mostly between November and January. The male-to-female ratio is
1.5-2:1.

The dominant clinical features of HSP include cutaneous purpura, arthritis, abdominal pain,
GI bleeding, orchitis, and nephritis. In one half to two thirds of children, an upper respiratory
tract infection (URTI) precedes the clinical onset of HSP by 1-3 weeks. In general, patients
with HSP appear mildly ill. They often have a fever, with a temperature that usually does not
exceed 38°C (100.4°F).

HSP is typically an acute, self-limited illness, and treatment is primarily supportive. However,
one third of patients have 1 or more recurrences. In the majority of children, the outcome of
HSP is excellent. Symptoms and signs of the disease in children usually resolve within
several days or months. The most important organ determining long-term morbidity is
kidney involvement. Up to 30-50% of children either have or will develop hematuria and/or
proteinuria within 4-6 weeks of the initial presentation. This is usually mild and self-limiting.
However, approximately 20% of HSP children with nephritis (7% of all HSP cases) will
develop either a nephritis or nephrotic syndrome [88, 89, 90, 91, 92, 93] .

Pathophysiology
IgA clearly plays a critical role in the immunopathogenesis of HSP, as evidenced by
increased serum IgA concentrations, IgA-containing circulating immune complexes, and IgA
deposition in vessel walls and renal mesangium. HSP is almost exclusively associated with
abnormalities involving IgA1, rather than IgA2. The predominance of IgA1 in HSP may be a
consequence of abnormal glycosylation of O-linked oligosaccharides unique to the hinge
region of IgA1 molecules. IgA aggregates or IgA complexes with complement deposited in
target organs, resulting in elaboration of inflammatory mediators, including vascular
prostaglandins such as prostacyclin, may play a central role in the pathogenesis of HSP
vasculitis.

A subpopulation of human lymphocytes bears surface Fc and/or C3 receptors (complement

receptor lymphocytes), which can bind circulating immune complexes or C3 generated by
activation of the alternative complement pathway. Such immune complexes appear in HSP
and may be part of the pathogenetic mechanism.

Some have speculated that an antigen stimulates the production of IgA, which, in turn,
causes the vasculitis. Allergens, such as foods, horse serum, insect bites, exposure to cold,
and drugs (eg, ampicillin, erythromycin, penicillin, quinidine, and quinine), may precipitate
the illness. Infectious causes include bacteria (eg, Haemophilus parainfluenzae,
Mycoplasma, Legionella, Yersinia, Shigella, or Salmonella) and viruses (eg, adenoviruses,
Epstein-Barr virus [EBV], parvoviruses, or varicella-zoster virus [VZV]). Vaccines such as
those against cholera, measles, paratyphoid A and B, typhoid, and yellow fever have also
been implicated. Evidence supporting a direct role of herpesvirus, retrovirus, or parvovirus
infection in the pathogenesis of HSP is lacking.

Alterations in the production of interleukins (ILs) and growth factors may also play a
pathogenetic role. Tumor necrosis factor (TNF), IL-1, and IL-6 may mediate the inflammatory
process present in HSP. Transforming growth factor (TGF)–β is a recognized stimulant of
IgA production. The elevated levels of hepatocyte growth factor present during the acute
phase of HSP may reflect endothelial-cell damage or dysfunction. Increased levels of
vascular endothelial growth factor (VEGF) may at least partly induce these changes.

Cytokines have been implicated in the pathogenesis of HSP, and endothelins (ETs), which
are vasoconstrictor hormones produced by endothelial cells, may also have a role. levels of
ET-1 are substantially higher during the acute phase of the disease than during remission or
in a control group of children. However, ET-1 levels do not appear to be correlated with
morbidity, severity of disease, or acute-phase reactant response.

Although several lines of evidence suggest a genetic susceptibility to HSP, the fundamental
basis for this abnormality remains unclear. A functional correlation of the IL1RN-2 allele and
IL-1ra production in patients with IgA nephropathy and HSP nephritis (HSPN) has been
described. Therefore, gene polymorphism may contribute to the diversity of clinical
responses to inflammatory stimulation. The prevalence of the human parvovirus B19
component NS1 gene in patients with HSP and hypersensitivity vasculitis is increased.
Results support a role of human leukocyte antigen (HLA)-B35 in the susceptibility to
nephritis in unselected patients with HSP.

Researchers are currently investigating the importance of nitric oxide (NO) production in
disease activity. Inducible NO synthase polymorphism has been associated with
susceptibility to HSP in northwestern Spain. Aliyazicioglu et al have suggested that leptin
and NO may play a role in the immunoinflammatory process of HSP, especially in the acute
phase. [5]

HSP that is likely due to montelukast has been noted in patients who present with subacute
intestinal obstruction.
Yilmaz et al examined 28 children with HSP and 79 healthy children to evaluate activities of
protein C, free-protein S, and antithrombin; resistance to activated protein C; and levels of
fibrinogen. [6] D-dimer, thrombin-antithrombin (TAT) complex, prothrombin fragment (PF)-1,
PF-2, and von Willebrand factor antigen (vWAg) and its activity (RiCof) were also
investigated. The investigators found that in patients with HSP, fibrinogen, D-dimer, TAT
complex, PF-1, PF-2, vWAg, and RiCof levels were significantly higher during the acute
phase than during the recovery phase and were significantly higher than those of control
subjects. [6] The severity of disease was significantly correlated with TAT, PF-1, PF-2, vWAg,
and D-dimer levels. Higher levels of matrix metalloproteinase (MMP)-9 levels in urine and
serum appear to increase nephrologic severity in children with HSP. Use of TNF-α blockers
such as adalimumab may increase the risk of developing HSP.

HSP nephritis is characterized by an abnormal IgA1 glycosylation pattern with reduced

galactosylation. [84] The hinge region of IgA1 contains up to six major glycosylation sites at
serine and threonine residues. The O-glycans include a core GalNAc, usually extended with
Gal to form Galβ1,3GalNAc, which can bind to Neu5Ac. Thus, each IgA1 O-glycan can have
one of four short carbohydrate structures (types III, IV, V, and VI), leading to a mixture of
IgA1 forms with varying degrees of galactosylation. These patients have a high prevalence of
galactose-deficient (types I and II) IgA1. [84] The lack of terminal β1,3-galactosyl residues in
the hinge region of IgA, might be due to reduced activity of β1,3-galactosyltransferase in
IgA1- producing peripheral B cells. This reduction of galactosylation results in exposure of
N- acetylgalactosamine (GalNAc) residues in the IgA1 surface, forming a novel antigen and
inducing a humoral IgG autoimmune response. [94] Circulating complexes of mixed IgG and
galactose-deficienty IgA1 are not only detected in patients with HSP but also detected in the
serum of patients with mucosal infections. [95] The finding that galactose-deficient IgA1
molecules are only found in HSP during an episodes of nephritis lends support to the
pathophysiological role of galactose-deficient IgA1 molecules in HPS nephritis. [96]

HSP versus IgA nephropathy

HSP and IgA nephropathy appear to be related disorders. However, the precise relation
between them requires further definition. The question has been raised as to whether HSP
and IgA nephropathy are 2 aspects of a single disease entity or 2 distinct entities. The
following commonalities and differences have been noted:

• IgA nephropathy almost exclusively involves young adults and typically affects only the
kidneys, whereas HSP affects mostly children and involves the skin and connective
tissues, GI tract, joints, and scrotum, as well as the kidneys. [3, 7, 8]

• HPS nephritis is more benign in children than in adults with the latter tending to show a
chronic and relentless course similar to that of primary IgA nephropathy. [102, 62, 8]

• In HSP nephritis, repeated and prolonged episodes of acute glomerular inflammation

lead to fibrous scars and hyperfiltration in the remaiing areas, resulting in chronic
kidney disease that may progress to end-stage kidney disease. Thus the number and
severity of acute episodes of HSP nephritis have a crucial role in the subsequent
progression and loss of kidney function. In IgA nephropathy initiation and progression
 to end-stage kidney disease occurs slowly and often is asymptomatic with
development of glomerulosclerosis and tubulointerstitial fibrosis. [105]

• The occurrence of extrarenal manifestations in IgA nephropathy is similar to that in

HSP.

• IgA nephropathy has developed in patients with a history of HSP, and HSP and IgA
nephropathy have occurred in the same families; in a survey of 40 families in which 2
or more members had IgA nephropathy, 5 presented with HSP. [9]

• Patients with HSP who undergo renal transplantation develop IgA deposits in the graft.

• The prevalence of both conditions is high in certain geographic areas.

• Similar changes in the IgA system (ie, high IgA, IgA-1C, IgA1-IC, IgA-fibronectin
aggregates, aberrantly glycosylated IgA in the circulation) occur in both diseases. [10, 11,
12]

• Cystic changes in the ovaries of a prepubertal girl with HSP have been recorded.

Overall, the data tend to support the view that HSP and IgA nephropathy are distinct
diseases. [13] Zhou et al examined 31 children aged 3-15 years with IgA nephropathy and
120 children aged 4-15 years with HSP, noting their clinical manifestations, blood
biochemistries, serum immunology, and follow-up data. [14] Renal pathologic findings on light
microscopy, immunofluorescence study, and electron microscopy were analyzed and
compared between 31 children with IgA nephropathy and 32 children with HSP.

The age of onset was greater than 12 years in 25.8% of the children with IgA nephropathy
but in only 10% of those with HSP. [14] Clinical patterns of IgA nephropathy were similar to
those of HSP, but extrarenal manifestations were observed more often in patients with HSP.

All of the HSP patients had skin purpura, 59% had GI symptoms, and 47% had arthralgia.
Abdominal pain occurred in only 3.2% of children with IgA nephropathy. [14] In patients with
IgA nephrology and in patients with HSP, renal pathology revealed global sclerosis in 35.5%
and 3.1%, mesangial sclerosis in 41.9% and 6.3%, endothelial proliferation in 29% and
65.6%, and thin basement-membrane nephropathy in 6.5% and 0%, respectively.

In HSP, electronically dense deposits in HSP were sparse, loose, and widely spread in the
glomerular mesangium, in the subendothelial area, and even in the intrabasement
membranes, whereas in IgA nephropathy, the deposits were dense, lumpy, and mostly
limited to mesangium and paramesangium. [14]

Immunoglobulin G (IgG) was found in glomerular immune deposits in 71.9% of patients with
HSP but in only 19.4% of patients with IgA nephropathy. [14] No IgG deposit was observed in
81.6% of those with IgA nephropathy; most had IgA and immunoglobulin M (IgM) or C3
deposits. Predominant IgG deposits were found in 12.5% of HSP patients, with relatively
weak IgA deposits. Moreover, 6.3% of HSP patients had linear IgG deposits in the
glomerular capillary wall, a finding that was not noted in patients with IgA nephropathy.
The rate of complete remission was 72.5% in patients with HSP at an average of 20 months’
follow-up; the corresponding rate was 19.4% in those with IgA nephropathy after 34 months’
follow-up. [14] Moreover, 64.5% of patients with IgA nephropathy had consistent hematuria
and proteinuria, and 16.1% had active nephritides.

The important clinicopathologic differences Zhou et al found between HSP and IgA
nephropathy argue against the single-disease hypothesis.

Etiology
The etiology of HSP remains to be clearly defined but is thought to be multifactorial, with
genetic, environmental, and antigenic components. More than 75% of patients report
antecedent URTI, pharyngeal infection, or GI infection. Multiple bacterial and viral infectious
agents have been associated with the development of HSP, and cases also have been
reported after drug ingestions and vaccinations. [15]

Infections that may precede the development of HSP include the following:

• Group A streptococcal infection (most common)

• Infectious Mononucleosis

• Subacute bacterial endocarditis

• Hepatitis

• Hepatitis C–related liver cirrhosis

• Mycoplasma infection

• Campylobacter enteritis

• Helicobacter pylori infection [16, 17, 18] (specifically noted in China [19] )

• Yersinia infection

• Shigella infection

• Salmonella infection

• Brucellosis

• Legionella species

• Parvovirus

• Adenovirus
 • EBV infection

• VZV infection

• Rotavirus

Vaccinations that may precede the development of HSP include the following:

• Typhoid and paratyphoid A and B

• Measles

• Yellow fever

• Cholera

Environmental exposure to the following may precede the development of HSP:

• Drugs (eg, ampicillin, erythromycin, penicillin, quinidine, quinine, losartan, and

cytarabine [20] )

• Foods

• Horse serum

• Cold exposure

• Insect bites

Glomerulocystic kidney disease has also been noted.

Epidemiology
United States statistics

In the United States, the prevalence of HSP is approximately 14-15 cases per 100,000
population in children compared to 1-3 cases per 100,000 per year in adults. [98, 99, 100, 101]

International statistics

In the United Kingdom, the estimated annual incidence of HSP is 20.4 cases per 100,000
population. [21] In a Norwegian community hospital, the prevalence of Henoch-Schoenlein
purpura was 3.3 cases per 100,000 inhabitants. [22]
In a study that examined the renal biopsy results of 65 children younger than 18 years
obtained by the Clinical Hospital in the Croatian region of Dalmatia over a 10-year period
(1995-2005), 10.8% of glomerulonephritis cases were due to HSP. [23]

Nong et al reviewed the records of 107 Taiwanese pediatric patients diagnosed with HSP
between 1991 and 2005 who had a mean age of 6.2 ± 2.5 years (range, 2-13 years); the
male-to-female ratio was 1:0.7. [24] The primary symptoms included the following:

• Rashes (95.3%)

• GI symptoms (72.0%)

• Joint involvement (46.7%)

• Kidney involvement (28.0%)

The most common first manifestations were as follows:

• Rashes (56.1%)

• GI symptoms (35.5%)

• Joint involvement (12.1%)

From January 1983 to June 2004, Suehiro et al followed 4502 patients at the Pediatric
Rheumatology clinic in Brazil. [25] A diagnosis of HSP was made in 203 cases (4.5%); 5
patients (0.1%) had acute hemorrhagic edema of infancy (AHEI). All patients with AHEI were
male, and the mean age at onset was 18 months (range, 8-21 months).

Age-related demographics

HSP primarily affects children; it may be seen in adults, but much less frequently. [2, 8] In the
United States, the prevalence peaks in children aged 5 years. Approximately 75% of cases
occur in children aged 2-11 years; HSP is rare in infants and young children. Older age at
the onset of HSP is associated with the development of chronic renal disease. [26] AHEI, a
related but milder condition, occurs in infants younger than 2 years. [27]

Ghrahani et al conducted a retrospective study in children with HSP in Hasan Sadikin

Hospital from 2006 to 2011 to evaluate renal involvement in children with HSP. The authors
reported that there were 128 patients with an age range from 6 month to 15 years. Peak
morbidity was between 5-10 years old. In most patients (71%) purpura was the first
symptom. Seventy-one patients (44.5%) had arthritis and 89 patients (69.5%) had
abdominal pain, while renal involvement was in 28 patients (21.8%). Gastrointestinal
manifestations tend to manifest in patients less than 5 years old, while renal involvement
tend to manifest in age group 11-15 years old. The authors concluded that renal involvement
in children with HSP is more common in age group 11 to 15 years old. [28]

A study by Hennies et al that included data from 202 pediatric patients with Henoch-
Schönlein purpura nephritis reported that children older than 10 years of age had more
insidious onset of non-nephrotic proteinuria, impaired renal function, longer delay to biopsy,
and more chronic histopathological lesions than younger children. [29]

Sex-related demographics

HSP occurs more often in boys than in girls. In children, the male-to-female ratio is 1.5-2:1.
In adults, the male-to-female ratio is approximately 1:1.

Race-related demographics

Whites are affected more often than blacks.

In a study from Thailand, patients most commonly presented between the ages of 3 and 5
years. [30] Frequency peaked from December to February. Organs involved included the skin
(100%), GI tract (74.5%), and kidneys (46.8%). Joints were also affected (42.6%). Renal
involvement was detected within the first 2 months in 16 patients (72.7%); however, it was
delayed until 6 months after diagnosis in 6 patients.

No risk factors for renal involvement could be identified in this study. [30] Mean follow-up time
was 2.6 years (range, 1-5 years). Residual renal disease occurred in 6 (38%) of 16 patients,
but none had end-stage renal disease (ESRD).

In a study from China, a male predominance was observed in children but not in adults. [31]
Preceding infection was noted in 40.5% of children and 31.6% of adults; 8.3% of children
and 13.2% of adults were receiving medication at the onset of the disease.

The investigators found that abdominal pain was more common in children than adults
(70.2% vs 28.9%), but renal involvement was more common and severe in adults than in
children; this involvement manifested as frequent hypertension and heavy proteinuria. [31]
During acute attacks, leukocytosis, thrombocytosis, and elevated serum C-reactive protein
(CRP) levels were most frequently observed in children, whereas elevated serum IgA and
cryoglobulin levels were most common in adults.

A study of 450 cases from Turkey showed that girls, patients with atypical presentations, and
patients undergoing early corticosteroid treatment had an increased risk of developing
kidney disease; relapses occurred more often in children treated with corticosteroids. [32]

Familial kindreds with HSP have been noted in Taiwanese aboriginal people. [33]

Prognosis
HSP is generally a benign disease with an excellent prognosis. Spontaneous resolution is
usual: Most patients experience complete resolution of symptoms within 8 weeks, and
probably fewer than 5% experience chronic symptoms. Initial attacks of HSP can last
several months, and relapses are possible. HSP is fatal only in the rarest of cases.
A clinical course with complete resolution of the disease usually occurs in patients with the
following:

• Mild kidney involvement

• No neurologic complications

• Disease that lasts less than 4-6 weeks initially

Children younger than 3 years usually have a shorter, milder course than older patients do,
as well as fewer recurrences.

Recurrences occur in as many as 50% of patients within 6 weeks but can happen as late as
7 years after the initial disease. A study by Calvo-Río et al indicated that in patients with
HSP, the chance of relapse is greater in those with GI and joint manifestations, with 72.3%
of patients in the study with abdominal pain relapsing, compared with 62.3% of those who
did not, and 27.8% of patients with joint manifestations relapsing, compared with 15.5% of
those who did not. [34]

Although HSP generally resolves without permanent consequences, serious GI and renal
complications may occur, and the higher the number of recurrences, the higher the
likelihood of permanent renal damage. Potential GI complications include intussusception
(usually ileoileal), bowel infarction, bowel perforation, hydrops of the gallbladder,
pancreatitis, and massive GI bleeding.

Kidney damage related to HSP is the primary cause of morbidity and mortality. As many as
15% of patients may have long-term renal insufficiency, but no more than 1-2% will have
ESRD. As many as 20% of children who have HSP and are treated in specialized centers
require hemodialysis. The renal prognosis appears to be worse in adults than in children (in
particular, those aged ≤6 years).

Predictors of serious nephropathy or ESRD include the following:

• Bloody stools

• Rash persistence

• Predictors of long-term renal outcome in HSP that can be used to prognosticate on

progression to chronic kidney disease leading to end-stage kidney disease include [84] :

◦ Nephrotic and nephritic syndrome (CKD >50%)

◦ Nephrotic syndrome (CKD ±40%)
◦ Nephritic syndrome (CKD ±15%)
◦ Heavy non-nephrotic proteinuria (CKD ±15%)
◦ Hematuria and/minimal proteinuria (CKD < 5%)
◦ Nephrotic syndrome persisting for < 3months (almost non progress to ESRD)
◦ Nephrotic syndrome persisting for >3 months (±40% progress to ESRD)

However, patients with a normal urinalysis at 6 months and without previous renal
involvement have not gone on to develop kidney problems. [35]
Pregnant women who had HSP during childhood appear to be at increased risk for
developing hypertension and proteinuria during pregnancy. [36]

Long-term prognosis of HSP nephritis is determined by the development of CKD which

sometimes is difficult to predict from the initial clinical and histological presentation. CKD can
develop long-term even after apparent complete recovery from HSP-nephritis. [84]

Patient Education
Patients should be informed that the disease is most likely to resolve with few residual
adverse effects but that relapses are possible. The clinician should explain that severe
kidney involvement is rare but that if it does occur, aggressive treatment may be required.

For patient education resources, see Blood in the Urine.

Pathology of HSP Nephritis

The International Study of Kidney Disease in Children (ISKDC) classification is widely used
for patients with HSP nephritis [91] . Nephritis may be graded as follows:

• Grade I - minimal glomerular abnormalities

• Grade II. - mesangial proliferation without crescents or sclerosing lesions
• Grade III (a). - focal segmental mesangial proliferation with < 50% crescents or
sclerosing lesions
• Grade III (b). - diffuse mesangial proliferation with < 50% crescents or sclerosing
lesions
• Grade IV. - mesangial proliferation with 50% - 70% crescents or sclerosing
lesions
• Grade V. - >75% crescents or sclerosing lesions
• Grade VI. - membranoproliferative-like lesions

Clinical Presentation