Friday, October 31, 2014

Rash Alert: Henoch-Schönlein Purpura Part 2

Continuation from Rash Alert: Henoch-Schönlein Purpura Part 1

After we came back from SDMC ER Outpatient, I started researching on "non-blanching rash", "non meningitis rash" basically, I went through all type of info on rashes and went through all type of photos. As if I can sleep before I can narrow down what the heck is this rash that does not blanche, causes MY daughter pain but not so serious that it can wait until the morning?!

Since the ER Doctor assured me it, he strongly does not believe it is bacterial meningitis due to the lack of fever and blood test results, it was a huge relief but not quite. Because he have no idea what else it could be. Not even a clue (maybe he had a clue but not saying).

 There were rashes and bruises all below her knees to her feet.

Obviously I checked the soles of her feet and palm, it might? be Hand, Foot and Mouth Disease (again!?)
Nope. Not HFMD. Clear feet...and since Mummylicious had it herself after getting it from PP many years ago, I know what to look out for. 

It was not until I found the term Petechiae - Purpura was when I began to understand what was going on. Hei, I am not a doctor so a rash is a rash....Petechiae Purpura Pura-Pura what-what? Huh? Was my reaction. But let's google more about this Petechiae and Purpura because based on what I read on what it is 

Petechiae was what PP had and what we wrongly assumed some bug bites and Purpura is what the rash is now. Ahhhhh 

Then as I googling on Petechiae and Purpura, I stumbled into The Royal Children's Hospital Melbourne (RCH) site on this topic. That was when things began to click into place. First I read on their petechial and purpura topic. Which brings me to this "Fever and Petechial Flowchart PDF".

Though PP was in pain, she was considered "well" since there was an absence of a fever, she was active and fine except for the leg pain. So following the RCH's flowchart...

"Unwell child" --> No --> "Purpura (>2mm)" (I know what Purpura means now!) --> Yes --> Purpura on lower limbs +/- jointpain / swelling +/- abdominal pain --> YES, YES, NO? But YES --> See HSP Guideline. (Huh? HSP???!)

Which brought me to the strong suspicion that PP has Henoch - Schonlein Purpura (HSP).

 A simple glass test to see if the rash blanches or does not blanche. 
Petechiae are pinpoint non-blanching spots. Purpura are larger non-blanching spots (>2mm).
And HSP Rash....does NOT blanche.  

How PP's "bug bite" became inflamed rashes all over the sudden and causes her so much pain in her joints that she can't walk, can't stand, even us touching her leg was causing her pain. 
We now know this is signature HSP rash, the PURPURAAAA, localised below the knee.

HEH-nok SHOON-line PURR-puh-ruh
"HSP typically presents with the triad of  
  • purpuric rash on the extensor surfaces of limbs (mainly lower) and buttocks,  < yes, it looked initially like bed bugs/ mites bites all over her legs, between knee and toes which turned inflamed rash like all over the "bitten" areas. 
  • joint pain/swelling and < yes yes yes. and the Daddy thought she was being dramatic eh. 
  • abdominal pain. < not yet, not ever hopefully
Abdominal pain or arthralgia sometimes precede the rash.The commonest age group is 2 - 8 years. (Aww YES) The cause is unknown but there may be a recent history of an upper respiratory tract infection." < YES. PP just recovered from a cold/flu 

Here are what I, Mummylicious gathered about HSP from multiple sources 
(links to relevant sources below)

  • a condition that causes small blood vessels, to become swollen and irritated. This inflammation, called vasculitis, usually occurs in the skin, intestines, and kidneys. Inflamed blood vessels in the skin can leak red blood cells, causing a characteristic rash called purpura. Vessels in the intestines and kidneys also can swell and leak.  

  • Symptoms include a purple spotted skin rash, abdominal pain swollen painful joints, and gastrointestinal upsets such as diarrhea.

  • Joint symptoms (arthritis) occur in two thirds of the children. The knees and ankles, particularly, often become swollen, tender, and painful with movement. This arthritis can be quite debilitating, but usually resolves in just a few days < PP pain around her knees and ankles was quite severe. It was obvious she was in pain. Poor baby
  • Gastrointestinal symptoms occur because of inflammation of the blood vessels of the GI tract. Most of these children experience abdominal pain, often quite severe. They will often vomit -- sometimes vomiting blood. More than half of the children with Henoch-Scholein  will have bloody stools. Serious short-term complications most often come from the GI involvement. of pain and gastrointestinal bleeding, with possible complications of bowel rupture or intussusception < no complains of tummy pain yet
  • Kidney disease occurs in up to half of affected children, usually manifest by blood and protein in the urine. While more severe kidney involvement can occur and may even become more or less permanent, most children with kidney involvement recover fully. A very few do not clear up fully and may go on later to develop more serious chronic kidney disease. < no indication of kidney being affected yet.
  • occurs much more often in kids than in adults, usually between ages 2 and 11. It is one of the most common forms of vasculitis in children, and boys get it about twice as often as girls. 
  • No one knows what causes HSP. < so stop blaming yourself
  • Infectious agents, such as viruses and bacteria, are thought to be potential triggering factors for the disease, because it often appears following an infection. However, HSP has also been seen following prescription of medicines, insect bites, exposure to cold, chemical toxins and the intake of specific foods that can cause allergies. < basically....anything
  • In most cases, the symptoms disappear by themselves within one to four weeks.
  • Usually doesn't cause lasting problems. About half of people who had HSP once will get it again. A few people will have kidney damage because of HSP. This may occur in the first week or so of illness, but there may be a delay of weeks or months before it appears. < am hoping for 'The Usually' 
  • The disease is more or less the same in every child, but the extent of cutaneous and organ involvement may vary among patients. HSP can present as one single episode, or several recurrent relapses. < please let it be a minor case, as one single episode
  • There are no treatment
  • It is not contagious. <Thank God for that. #motheroftwo
Key points to remember
  • HSP causes inflammation of the small blood vessels in the skin causing a rash.
  • HSP can also affect blood vessels around the kidneys and intestines.
  • HSP occurs most often in children from two to 10 years.
  • The cause of HSP is unknown.
  • Paracetamol and anti-inflammatory drugs help painful joints and general discomfort. 
  • Prednisolone may be prescribed. 
  • Return to your doctor if there is increasing pain, swelling, blood in the stools (poo) or urine or if you are worried at all.
  • Long term follow-up for urine tests and blood pressure checks are very important.


The more I read on Henoch-Schönlein Purpura (HSP), the more convinced I was it is exactly this. It fits. Everything fits. But it is scary...because it can be a minor case, but there can also be serious complications. And that remains to be seen....

In my head, it is pretty much solved. I am just glad there is a name for this other than BACTERIAL MENINGITIS, because from what I know, non-blanching rash = bacterial meningitis = seek immediate medical help. Phew. I just need the Paediatric to confirm it in the morning...and Mummylicious can finally have her dinner at 1.30AM. 

Related posts on HSP

Useful reading on Purpuric rashes and  Henoch-Schönlein Purpura (HSP)

BTW: RCH is a very useful website because when one become overwhelmed by the medical mumbo jumbos terms, they have a Parent friendly HTML and PDF page! Yay! So one can read both versions. Just what I like. Massive amount of info (is it not obvious from this post alone?)

I hope this post have help some parents sleep well at night when face with circumstances like mine. It is always better when we know what exactly we are dealing with than facing a battle without a map. 

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