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Indian Pediatr 2010;47: 448 |
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Henoch Schonlein Purpura as an Extra-Hepatic
Manifestation of Hepatitis A |
Neelam Mohan and Sakshi Karkra,
Pediatric Gastroenterology and Hepatology Unit, Centre
for Child Health,
Sir Ganga Ram Hospital, New Delhi, India.
Email: [email protected]
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Henoch Schonlein Purpura (HSP) is the commonest vasculitis of childhood.
To the best of our knowledge only two cases of hepatitis A virus (HAV)
infection associated with cutaneous vasculitis have been reported out of
which one was a child(1,2). We describe a 2 y 9 mo old girl with acute
hepatitis A infection who developed cutaneous vasculitis during the first
month of her illness. She presented to us with yellowish discoloration of
eyes and skin for 1 month associated with mild fever and loss of appetite.
After 3 weeks of jaundice, she developed swelling over dorsum of hands and
feet with bluish palpable rash on both lower limbs with arthritis in right
knee joint (Fig.1). A day prior to admission, child passed
small amount of blood in stool. Liver was palpable 3 cm below the costal
margin in mid clavicular line. Rest of the systemic examination was within
normal limits. Past history was unremarkable. Investigations showed
leukocytosis with low hemoglobin. Her platelets, ESR , kidney function
tests and autoimmune markers were normal. ALT and AST were 599 IU/L and
288 IU/L, respectively while PT and PTTK were normal. Her anti, HAV IgM
antibody was positive and all immunoglobulin subtype levels were raised.
As she satisfied all the criteria set by European League Against
Rheumatism and Pediatric Rheumatology(3), we kept a diagnosis of Henoch
Schonlein Purpura and performed a skin biopsy which was suggestive of
leukocytoclastic angitis. She was put on analgesics and gradually improved
within 4 days. On a followup of 9 months, child is doing well with no
recurrence of symptoms.
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Fig.1 Palpable rash of HSP. |
HSP has been reported in infections with streptococci,
hepatitis B, herpes simplex virus, parvo B 19, coxsackie virus,
adenovirus, H. pylori, MMR, Mycoplasma etc(4). Hepatitis A virus,
unlike hepatitis B virus, has rarely been associated with extrahepatic
features. Two adult patients have been reported with relapsing hepatitis A
complicated by arthritis and only one patient has been reported with
cutaneous vasculitis(5). One pediatric case has been reported with
vasculitis and confirmed cholestatic hepatitis A virus infection(2). Most
cases are self limiting and require no treatment except symptom control
but disease may relapse in a third of cases. Henoch Schonlein purpura may
be a rare extrahepatic manifestation of viral hepatitis A infection in
children.
References
1. IlanY, Hillman M, Oren R , Zlotogorski A, Shouval D.
Vasculitis and cryoglobulinemia associated with persisting cholestatic
hepatitis A virus infection. Am J Gastroenterol 1990; 85: 586-587.
2. Chemli J, Zouari N, Belkadhi A, Abroug S, Harbi A.
Hepatitis A infection and Henoch-Schonlein purpura: a rare association.
Arch Pediatr 2004; 11: 1202-1204.
3. Ozen S, Ruperto N, Dillon MJ, Bagga A, Barron K,
Davin JC, et al. EULAR/ PReS endorsed consensus criteria for the
classification of childhood vasculitides. Ann Rheum Dis 2006; 65: 936-941.
4. Rai A, Nast C, Adler S. Henoch schonlein purpura
nephritis. J Am Soc Nephrol 1999; 10: 2637-2644.
5. Inman RD, Hodge M, Johnston ME, Wright J, Heathcote
J. Arthritis, vasculitis, and cryoglobulinemia associated with relapsing
hepatitis A virus infection. Ann Intern Med 1986; 105: 700-703.
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