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Rheumatology 2001; 40: 1430-1431
© 2001 British Society for Rheumatology
Letters to the Editor |
Colchicine for the treatment of recurrent Henoch–Schönlein purpura in an adult
Homerton Hospital, London, UK
SIR, The efficacy of colchicine has been proved in gout, Behçet's disease and familial Mediterranean fever [1]. Colchicine has also been reported to be helpful in the treatment of cutaneous leucocytoclastic vasculitis in a number of series [2–4].
Henoch–Schönlein purpura is a syndrome classically presenting with purpura, joint pains, glomerulonephritis and haemorrhagic gastrointestinal involvement. The condition usually presents in childhood but its occurrence in adulthood is also well recognized [5]. Biopsy of skin lesions typically reveals a leucocytoclastic vasculitis of small vessels. Here we report a case of adult Henoch–Schönlein purpura in which colchicine was used to control the cutaneous manifestations.
A 42-yr-old Asian female was admitted in June 1996 to another hospital with arthralgia of her large joints and palpable purpuric lesions on both her lower legs. Initial investigations showed a normal full blood count (including differential white cell count), normal renal function, an elevated erythrocyte sedimentation rate (ESR) (41 mm/h), a normal C-reactive protein (CRP) concentration, negative results in tests for antinuclear antibodies, extractable nuclear antigens, antineutrophil cytoplasmic antibodies, screening for hepatitis B and C and in the HIV test, normal complement levels and a borderline increase in serum IgA level. Urinalysis showed 3+ blood cells but no protein and microscopy revealed no casts. A skin biopsy revealed a leucocytoclastic vasculitis with fibrin deposition and this was followed by a renal biopsy, which showed a diffuse mesangial proliferative glomerulonephritis with IgA deposits on immunoperoxidase staining. A diagnosis of Henoch–Schönlein purpura was made. In the absence of necrotizing or crescentic glomerular lesions and the lack of gastrointestinal involvement, no specific treatment was started initially and the patient was reviewed routinely as an out-patient by the nephrologist. However she continued to develop purpuric lesions intermittently on the anterior surface of the lower limbs over the next few months until October 1997, when the purpura was found to have cropped aggressively, involving the legs, buttocks and abdomen. Treatment with azathioprine 100 mg and prednisolone 40 mg was started and within a few months the lesions had faded and the patient was weaned off the steroid. Azathioprine was discontinued by the patient herself in May 1999 because of concern about potential side effects and because she was asymptomatic. In November 1999 the patient was referred by her general practitioner to the rheumatology clinic. Over the preceding few weeks she had developed a recurrence of purpura involving the legs, accompanied by large-joint arthralgia. She had no proteinuria or haematuria, a normal full blood count, elevated ESR (52 mm/h), normal CRP concentration, normal renal function and normal blood pressure. We elected to try colchicine 0.5 mg per day to control her cutaneous manifestations, on the basis of previous reports of colchicine treatment for cutaneous vasculitis. The patient showed a dramatic response, all her lesions resolving within a few days. She has now been under follow-up for 13 months with no recurrence of the purpura.
Leucocytoclastic vasculitis is a histopathological description of immune complex-mediated inflammation of small and medium-sized arteries to the skin. This initially produces polymorphonuclear infiltration with the release of vasoactive amines and lysozymes, resulting in increased vascular permeability, oedema and polymorph lysis with nuclear debris. There is a later stage in which mononuclear infiltration occurs. Leucocytoclastic vasculitis can be seen in Henoch–Schönlein purpura but also in a number of other conditions, including rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis and malignancy, and it may also occur as a secondary result of drug treatment and infection.
Colchicine is an alkaloid derived from Colchicum autumnale (autumn crocus), which was first used for articular pain in the sixth century. It was used for the treatment of acute gout by Von Storch in 1763. It inhibits polymorphonuclear leucocyte chemotaxis by inhibiting spindle formation. It blocks lysosome formation and stabilizes lysosomal membranes. The suppressive effect of colchicine on the inflammatory pathway may explain its effect on the skin lesions in Henoch–Schönlein purpura [6]. Case series have suggested that low doses of colchicine (0.5–1 mg once daily) are effective in treating leucocytoclastic vasculitis and that 80% of patients treated will respond, usually within the first 4–7 days [3]. When a response occurs, if colchicine is discontinued the purpura may return and on reinstitution of treatment the lesions are again suppressed [7].
We propose that, in patients with Henoch–Schönlein purpura with predominant cutaneous manifestations and lack of systemic involvement, low-dose colchicine could be tried as initial therapy. To the best of our knowledge this is the first report of the use of colchicine in Henoch–Schönlein purpura.
Notes
Correspondence to: R. Mootoo, Rheumatology Department, Homerton Hospital, Homerton Row, London E9 6SR, UK. 
References
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[Abstract/Free Full Text] - Garcia-Porrua C, Gonzalez-Gay MA. Comparative clinical and epidemiological study of hypersensitivity vasculitis versus Henoch–Schönlein purpura in adults. Semin Arthritis Rheum1999;28:404–12.[Medline]
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