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Rheumatology 2001; 40: 717
© 2001 British Society for Rheumatology
Letters to the Editor |
Adrenal haematoma in Henoch–Schönlein purpura
Department of Internal Medicine, Centre Hospitalier Universitaire La Milétrie, 86000 Poitiers and
1 Department of Internal Medicine, Hôpital Saint-Michel, 16000 Angoulême, France
SIR, The expected sites of bleeding in Henoch–Schönlein purpura (HSP) are gastrointestinal and renal. We report for the first time a patient with incidental adrenal haemorrhage.
An 18-yr-old man was hospitalized because of a recent purpuric rash involving the legs associated with abdominal pain and fever (38°C). The patient also complained of arthralgia involving the knees and the ankles. The medical history was unremarkable.
Laboratory results were as follows: haemoglobin 14 g/dl, white blood cell count 7500/mm3, platelet count 323000/mm3, erythrocyte sedimentation rate 17 mm/1st h and C-reactive protein 25 mg/dl. The prothrombin time was normal. The serum albumin level was 35 g/l and the creatinine level 0.9 mg/dl. Tests for antinuclear antibodies, cryoglobulin and rheumatoid factor gave negative results. The C3 level was 98 mg/dl (normal range 70–150) and the C4 level was 35 mg/dl (normal range 16–45). Urinalysis disclosed proteinuria (0.34 g/l) with microhaematuria. There was no blood in stool samples. The diagnosis of HSP was suspected. A biopsy of the purpuric lesion revealed leucocytoclastic vasculitis in the small vessels, with epidermal necrosis. Immunofluorescence was positive for C3. Duodenal biopsies were also performed and histological results noted: mild inflammatory lesions with mononuclear cells and neutrophils without necrosis.
Two days after admission, the patient felt a sharp diffuse abdominal pain with guarding and emesis. An abdominal computed tomographic (CT) scan revealed marked thickening of the ileal and jejunal walls and a 35-mm haematoma of the right adrenal gland (Fig. 1
). The patient responded dramatically to prednisone (30 mg/day). Treatment was slowly reduced and stopped after 6 months. The haematoma was still observed on a CT scan performed 6 months later.
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Our patient fulfilled the 1990 criteria of the American College of Rheumatology for HSP [1]. This disease rarely occurs in adults. Unusual presentations of HSP include ocular, pulmonary, genitourinary and neurological involvement [2, 3]. Non-traumatic adrenal haemorrhages have been reported, related to meningococcal septicaemia, stress, tumours, coagulopathy and idiopathic disease [4]. Other causes of abdominal pain, such as intussusception, which is a common surgical complication of HSP in children [5], were ruled out in our patient. To our knowledge, this is the first report of HSP with abdominal pain due to adrenal haematoma. As only a small minority of HSP patients ever have CT scans as part of their diagnostic evaluation, this complication may be a hitherto unsuspected feature of HSP.
Notes
Correspondence to: M. Paccalin, Service de Médécine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire La Milétrie, BP 577, 86021 Poitiers cedex, France. 
References
- Mills JA, Michel BA, Bloch DA, Calabrese LH, Hunder GG, Arend WP et al. The American College of Rheumatology 1990 criteria for the classification of Henoch–Schönlein purpura. Arthritis Rheum1990;33:1114–21.[Web of Science][Medline]
- Saulsbury FT. Henoch–Schönlein purpura in children. Report of 100 patients and review of the literature. Medicine1999;78:395–409.[Medline]
- Vats KR, Vats A, Kim Y, Dassenko D, Sinaiko AR. Henoch–Schönlein purpura and pulmonary hemorrhage: a report and literature review. Pediatr Nephrol1999;13:530–4.[Medline]
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Kawashima A, Sandler CM, Ernst RD, Takahashi N, Roubidoux MA, Goldman SM et al. Imaging of nontraumatic haemorrhage of the adrenal gland. Radiographics1999;19:949–63.
[Abstract/Free Full Text] - Choong CK, Kimble RM, Pease P, Beasley SW. Colo-colic intussusception in Henoch–Schönlein purpura. Pediatr Surg Int1998;14:173–4.[Medline]
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