A 7 years old girl
with Henoch Schonlein Purpura (HSP) : diagnosed by typical rash over both legs, skin biopsy - leucocytoclastic vasculitis, arthropathy, abdominal pain.
One episode of hematemesis. Urine within normal limit.
UGI endoscopy revealed two duodenal ulcers.
Should Intravenous Methylprednisolone be given under PPI coverage in case of severe flare up/recurrence?
Or
Are there other options of immunosuppressant i.e azathioprine, cyclophosphamide etc. as used in HSP nephritis?
Please highlight the role of IV or oral steroid in duodenal ulcer (non-bleeding) in HSP
Hi,
How did the duodenal ulcers (DU) appear endoscopically? If they are simple, I suspect they are likely to be stress induced +/- H pylori which may endemic in your area. Rarely can they be associated with a leukocytoclastic vasculitis or from ischaemic ulceration, which the appearances would be more dramatic.
From a literature review, DUs associated with HSP are "usually, irregular, ulcerating, nodular lesions or hematoma-like protrusions are characteristic of HSP in the duodenum. The site preference and appearance also help differentiate HSP from peptic ulcer disease"
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973562/
My personal thoughts are that if acute immunosuppression with high dose steroids is required, duodenal ulcers should not be a contraindication. If ulcers are at high risk of bleeding, e.g. Forrest 1a to Forrest 2b lesions, I would cover with IV PPI infusion. If Forrest 2c, I would suggest IV (BD). For Forrest 3, oral dosing should be adequate. Of course, H pylori should be ascertained and eradicated as necessary.
Hope this is of some help.
Keith
Dear Keith,
Thank you for replying. H.pylori work up had already been done and it was negative. The disease form is very severe with flaring up of skin leisons and severe arthralgia.
Best wishes
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