REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)
IgA Vasculitis (Henoch-Schönlein Purpura) - StatPearls (NCBI Bookshelf NBK537252) - https://www.ncbi.nlm.nih.gov/books/NBK537252/
IgA vasculitis usually settles on its own, and the two things that make it dangerous are an abdomen that turns surgical and a kidney that declares itself weeks later. Both are follow-up problems, which is why the urine matters more than any prescription. The article names paracetamol and prednisolone but states no amount for a child, so no dose is printed.
- WHAT MAKES THE DIAGNOSIS - IgA vasculitis is diagnosed on petechiae with a normal platelet count, or on palpable purpura falling mainly over the legs, together with at least 1 of 4 further features: pain in the abdomen; joint pain or frank arthritis; the kidney involved, shown by protein in the urine, red cell casts or blood; or, on histology, a proliferative glomerulonephritis or a leukocytoclastic vasculitis in which IgA is the dominant deposit.
- WHERE THE RASH SITS - it turns into purpura you can feel and into petechiae, sitting most often over the buttocks and the legs, and on the extensor surfaces above all. Every patient with IgAV has skin involvement, and it is usually what shows first.
- TEST THE URINE, AND KEEP TESTING IT - order a urinalysis with microscopy, looking for blood, protein, or red cell casts. Where the dipstick shows protein, follow it with a 24-hour collection to measure how much is being lost. What matters over the long run, in the article's own summing up, is following the child properly and testing the urine often, so that the kidney is caught if it becomes involved.
- THE KIDNEY DECLARES ITSELF AFTER THE RASH HAS GONE - renal symptoms tend to arrive 1 to 3 months after the rash appears, and they do so in 20% to 55% of affected children. Where proteinuria persists, the risk of a progressive glomerulonephritis is high. A child discharged the week the rash fades has been discharged too early.
- AND THE KIDNEY IS WHAT KILLS - dying of IgA vasculitis is rare, but of everything that makes these patients ill or kills them, kidney disease is the commonest.
- RED FLAG - THE ABDOMEN. The complications that can end a life are intussusception, a perforated bowel, gangrenous bowel, and torrential bleeding. Of those, intussusception is the one seen most, in 3% to 4% of children with IgAV. Severe abdominal pain in a child with purpura is a same-day surgical assessment.
- THE ABDOMEN CAN COME FIRST AND FOOL EVERYONE - in 10% to 40% of patients, the gut trouble shows up ahead of the rash.
- PREFER PARACETAMOL OVER AN NSAID WHEN THE GUT OR KIDNEY IS INVOLVED - where the bowel or the kidney is involved, paracetamol, or an opioid, is generally chosen for pain ahead of a non-steroidal anti-inflammatory. The article states no strength, frequency or maximum for a child, so no amount is printed here.
- STEROIDS ARE A SPECIALIST DECISION, NOT A FIRST PRESCRIPTION - where the abdominal pain is severe, prednisone or prednisolone with a tapering course is worth considering. It will not stop renal disease from happening, but it does lower the chance that renal complications persist in a child. No paediatric dose appears in the article.
- MOST OF IT IS SUPPORTIVE - where the kidney is not involved, treating the symptoms and supporting the child is what the management rests on.
- WHAT TO TELL THE PARENTS - teach them that the symptoms will probably clear inside a few weeks, though they may come back. Full recovery takes 4 weeks in most children. About one in three has a recurrence, 4 to 6 months after it first began.
- JOINTS ACHE BUT DO NOT SCAR - 75% of these children get joint pain or arthritis, and it passes without destroying the joint.
- THE SMALL MINORITY THAT ENDS BADLY - roughly 1% of patients with IgA vasculitis go on to end-stage renal failure and need a transplant. A child with proteinuria belongs to a nephrologist: where the renal involvement is severe, treatment must be aggressive and the care must be a nephrologist's.