An 8-year-old, previously healthy girl presents to the emergency department (ED) with a rash “that looks likes bruises” and joint pain (Figure). Her mother reports that the rash started over her daughter’s lower legs a week earlier and has since spread to her thighs and buttocks. The red patchy rash is not painful and not pruritic. The girl denies new exposures to food or topical products, recent travel, camping, or recent injury.
History and examination
There is no previous history of easy bleeding or bruising. Both patient and mother deny abuse. No other family members have a similar rash. The patient also reports a 2-day history of new onset left knee and left ankle pain associated with knee swelling, which has since spontaneously resolved. No recent trauma is noted.
The patient denies swelling of her hands or shoulders. She denies chest pain, abdominal pain, dysuria, or hematuria. A week prior to the rash, she was evaluated for fever and sore throat and tested negative for streptococcal infection.
On exam, the child is well appearing, alert, and hydrated. Her weight is 87 lb (98th percentile); temperature is 98.5°F; pulse is 98; respiratory rate is 24 breaths/min; blood pressure is 110/60 mm Hg; and pulse oximetry is 100% on room air.
Her physical exam is negative for conjunctivitis, oral ulcers, or lymphadenopathy. Respiratory and cardiovascular exams are within normal limits. Abdominal exam is negative for tenderness on palpation without guarding or rigidity, and bowel sounds are normal. No hepatosplenomegaly is palpated.
The ankle joints are tender on palpation over the lateral and medial malleolus without any swelling, erythema, deformity, or restriction of motion. The knee and hip joints are normal. Neurologic exam is normal without any focal neurologic defects identified.
Her skin exam is positive for palpable purpuric rash that is nonblanchable and nontender (Figure). She also has an interspersed petechial rash over the lower extremity that extends from the ankles to the thighs, lower abdomen, and buttocks. The soles of her feet are not involved.
Initial blood work revealed a complete blood count (CBC) with a slightly elevated white blood cell (WBC) count of 10.5 X 109 /L (3.40-9.5 X 109/L) with a normal differential; hemoglobin, 12.9 g/dL (12-14 g/dL); platelet count of 481 X 10 9/L (150-450 X 109/L). A complete metabolic panel showed normal liver function tests and a normal urea/creatinine ratio. Urinalysis was negative for protein, blood, or leukocytes. Serum antinuclear antibody (ANA) test was negative.
1. Weiss JE. Pediatric systemic lupus erythematosus: more than a positive antinuclear antibody. Pediatr Rev. 2012;33(2):62-73; quiz 74.
2. Carriveau A, Poole H, Thomas A. Lyme disease. Nurs Clin North Am. 2019;54(2):261-275.
3. Webb RH, Grant C, Harnden A. Acute rheumatic fever. BMJ. 2015;351:h3443.
4. Buchanan GR. Thrombocytopenias during childhood. Pediatr Rev. 2005;26(11):401-409.
5. González LM, Janniger CK, Schwartz RA, Pediatric Henoch Schnolein purpura. Int J Dermatol. 2009:48(11):1157-1165.
6. Trnka P. Henoch-Schönlein purpura in children. J Paediatr Child Health. 2013;49(12):995-1003.
7. Trapani S, Micheli A, Grisolia F, et al. Henoch-Schonlein purpura in childhood: epidemiological and clinical analysis of 150 cases over a 5-year period and review of literature. Semin Arthritis Rheum. 2005:35(3):143-153.
8. Choong CK, Beasley SW. Intra-abdominal manifestations of Henoch-Schönlein purpura. J Paediatr Child Health. 1998;34(5): 405-409.
9. Roache-Robinson P, Hotwagner DT. Henoch-Schonlein purpura (anaphylactoid purpura, HSP). StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK537252/. Updated December 26, 2018. Accessed December 4, 2019.
10. Sano H, Izumida M, Shimizo H, Ogawa Y. Risk factors of renal involvement and significant proteinuria in Henoch-Schönlein purpura. Eur J Pediatr. 2002;161(4);196-201.
11. Narchi H. Risk of long-term renal impairment and duration of follow-up recommended for Henoch-Schonlein purpura with normal or minimal urinary findings: a systematic review. Arch Dis Child. 2005;90(9):916-920.
12. Weiss PF, Feinstein JA, Luan X, Burnham JM, Feudtner C. Effects of corticosteroid on Henoch-Schönlein purpura: a systematic review. Pediatrics. 2007;120(5):1079-1087.
13. Tizard EJ, Hamilton-Ayres MJ. Henoch-Schonlein purpura. Arch Dis Child Educ Pract Ed. 2008;93(1):1-8.