Rheumatology: Current Research
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Purpuric Lesions in the Rectum: Clinical Image

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Clinical Image

A 27 year-old woman was hospitalized because of abdominal pain and cutaneous purpura on her upper and lower extremities. The laboratory tests showed an inflammatory syndrome. A skin biopsy revealed a Leukocytoclastic Vasculitis (LCV). During her hospital course, she complained of diarrhea. Upper gastrointestinal endoscopic examination did not reveal any abnormality. Rectosigmoidoscpy revealed numerous purpuric lesions in the rectum as shown in Figure 1. Immunofluorescence method was negative in both skin and colic biopsy and positive with presence of IgA in gastric biopsies. The patient was diagnosed with Henoch-Schönlein Purpura (HSP) and was treated with corticotherapy. This resulted in the resolution of skin eruption and digestive symptoms.

Figure 1: Purpuric lesions in the rectum.

Discussion

HSP is an IgA-associated small-vessel LCV [1] that occurs commonly in children [2,3]. It is characterized by nonthrombocytopenic palpable purpura, arthralgia/arthritis, bowel angina, and hematuria/proteinuria [2,3]. Gastrointestinal (GI) involvement occurs in 50-75% of patients [2] and it includes acute abdominal pain, nausea, vomiting, bloody stools, and upper GI hemorrhage. HSP might present with severe GI involvement, or even life-threatening in the short term [3]. Endoscopic examination is of major importance in detecting the gastrointestinal manifestations of HSP. A large biopsy of purpuric lesions is more likely to detect the vasculitis in the small vessels of the mucosa [4]. Direct immunofluorescence of tissue specimens from skin, GI tract, or kidney may show IgA deposition in both involved and uninvolved tissues [2,4]. In our case, Ig A deposition was observed only in normal gastric mucosa. Although evolution may be spontaneously favorable, The efficacy of corticosteroids on digestive manifestations has been suggested through numerous observations as reported in this case.

References

1. Poterucha TJ, Wetter DA, Gibson LE, Camilleri MJ, Lohse CM. Histopathology and correlates of systemic disease in adult Henoch-Schönlein purpura: A retrospective study of microscopic and clinical findings in 68 patients at Mayo Clinic. J Am Acad Dermatol. 2013;68(3):420‑424.
2. Saulsbury FT. Clinical update: Henoch-Schönlein purpura. The Lancet.2007;369(9566):976-978.
3. Trouillier S, André M, Delèvaux I, Mahamedi H, Affo C, Kintossou R, et al. Digestive disorders of rheumatoid purpura in adults. Study of a retrospective series of 23 patients. J Int Med. 2009;30(8):661-670.
4. Poré G. GI lesions in Henoch-Schönlein purpura. Gastrointest Endosc. 2002;55(2):283-286.