A 5-year-old boy is brought to the emergency department by his parents due to difficulty walking. The patient first developed pain in the legs this morning and has not wanted to walk today. He played 2 soccer games yesterday with no pain or trauma. A week ago, the patient had a low-grade fever and cough that have since resolved. He has had no nausea, emesis, diarrhea, weight loss, or night sweats. The patient has no significant medical history and takes no daily medications. Temperature is 36.7 C (98.1 F), blood pressure is 90/40 mm Hg, pulse is 138/min, and respirations are 20/min. Examination shows an uncomfortable-appearing boy lying in bed; the patient cries with any attempt to move his legs. A purplish, nonblanching rash is noted over the buttocks and posterior thighs. The abdomen is soft with active bowel sounds. There is mild, diffuse tenderness to palpation with no rebound or guarding. Lower extremity joints demonstrate no deformity, erythema, swelling, or warmth. The patient refuses to walk due to pain in his legs. Laboratory results from urinalysis are as follows: This patient is at greatest risk for developing which of the following complications?

Question

A 5-year-old boy is brought to the emergency department by his parents due to difficulty walking.  The patient first developed pain in the legs this morning and has not wanted to walk today.  He played 2 soccer games yesterday with no pain or trauma.  A week ago, the patient had a low-grade fever and cough that have since resolved.  He has had no nausea, emesis, diarrhea, weight loss, or night sweats.  The patient has no significant medical history and takes no daily medications.  Temperature is 36.7 C (98.1 F), blood pressure is 90/40 mm Hg, pulse is 138/min, and respirations are 20/min.  Examination shows an uncomfortable-appearing boy lying in bed; the patient cries with any attempt to move his legs.  A purplish, nonblanching rash is noted over the buttocks and posterior thighs.  The abdomen is soft with active bowel sounds.  There is mild, diffuse tenderness to palpation with no rebound or guarding.  Lower extremity joints demonstrate no deformity, erythema, swelling, or warmth.  The patient refuses to walk due to pain in his legs.  Laboratory results from urinalysis are as follows:  This patient is at greatest risk for developing which of the following complications?

Quizplus · Accepted Answer

11ec25c8_d73b_30ab_bc81_65f8a47cc9f3_MD0003_00 This patient likely has Henoch-Schönlein purpura (HSP), an IgA-mediated, small-vessel vasculitis that occurs most commonly in school-aged children. Classic manifestations include nonblanching palpable purpura on the legs and buttocks, lower extremity arthralgia/arthritis (which can result in refusal to ambulate), abdominal pain, and renal disease (hematuria ± proteinuria). Symptoms are often preceded by a mild upper respiratory infection, as seen in this child. Classic manifestations Typical abdominal symptoms are caused by localized bowel wall inflammation and include colicky, diffuse pain often associated with nausea and vomiting. However, severe abdominal pain in HSP should prompt further workup for gastrointestinal complications, most commonly intussusception. Intestinal edema and bleeding associated with HSP can act as a lead point for the intestines to telescope into the adjacent bowel. In contrast to most pediatric cases of idiopathic intussusception, which is typically ileocolic, intussusception in HSP is usually confined to the small bowel (ileoileal). Intussusception typically presents with severe, episodic abdominal pain and currant jelly or bloody stools. Although ileocolic intussusceptions are treated with air or contrast enema, ileoileal intussusceptions that do not reduce spontaneously often require surgical management. bloody stools (Choice A) Hemolytic uremic syndrome (HUS) is characterized by hemolytic anemia, thrombocytopenia that can lead to petechiae and ecchymosis, and acute kidney injury. In contrast to HSP, HUS is typically preceded by a diarrheal illness and does not cause leg pain. (Choice C) Septic arthritis, which can result in joint destruction if untreated, typically presents with fever and inflammation (eg, swelling, erythema) of a single joint, features not seen in this patient. Arthritis associated with HSP is self-limiting and does not cause long-term joint damage. (Choice D) Urethritis occurs with reactive arthritis, which presents with joint swelling and is typically preceded by an enteric infection (eg, Campylobacter, Shigella) causing diarrhea rather than an upper respiratory illness. In addition, purpura would not be seen with reactive arthritis. (Choice E) Uveitis is a complication of juvenile idiopathic arthritis (usually oligoarticular or polyarticular), which typically presents with chronic joint swelling. This patient with acute joint pain has no swelling and therefore has arthralgia, not arthritis. In addition, his hematuria and purpuric rash make HSP more likely. Educational objective: Henoch-Schönlein purpura is an IgA-mediated vasculitis that presents most commonly in children with palpable purpura, abdominal pain, arthralgia/arthritis, and hematuria. Patients are at increased risk for ileoileal intussusception due to intestinal edema and bleeding. References: Henoch Schonlein purpura. (http://www.ncbi.nlm.nih.gov/pubmed/30725937)

A 5-Year-Old Boy Is Brought to the Emergency Department by His