To the Editor:
The observation by A. Hakim (1) of four patients who had atypical skin rash is interesting. There are some similarities in those patients to the ones we described previously (2). There are also differences. The features which are similar are recurrent abdominal pain which was severe enough to cause crying and require a surgical consult. In contrast to our patients, however, all of the four patients described by Hakim had a rash. The rash was described as atypical. If the skin rash in Henoch-Schönlein purpura (HSP) is atypical, a skin biopsy should be done to look for the classic leukocytoclastic vasculitis. If such an examination was done, it was not reported by the authors.
A rash in Henoch-Schönlein purpura is not always the presenting manifestation and as Hakim has stated, the rash may not be typical. Physicians understand the challenge in diagnosing HSP in patients in the absence of a rash. Our report and others have raised awareness of HSP in certain clinical situations and have suggested modalities for making an appropriate diagnosis. The dictum we learned from our patients is that if we have a young child with colicky abdominal pain of 1 to 2 weeks duration and there is no surgical cause think of HSP, particularly if the stools are positive for occult blood. In that situation, an upper GI endoscopy is helpful and may show the typical findings of HSP. Colonoscopy may also aid in the diagnosis.
Regarding the etiology, prodromal viral illness has been described as an etiology of HSP. Though there is a higher occurrence of HSP in the late fall and spring, some patients are seen throughout the year. The observation of Hakim about the high incidence during winter may also suggest a specific viral etiology leading to the vasculitis. To use different ways of writing HSP reflecting the severity of the skin rash is interesting. Hakim is proposing that we use HSP if it is with a typical rash, HSp if it is with an atypical rash. We add that we use HSP-P (HSP minus P) if there is no rash in this condition.
T. S. Gunasekaran M.D.
James Berman M.D.
1. Hakim A. A rash of Hsp cases. J Pediatr Gastroenterol Nutr
2. Gunasekaran T, Berman J, Gonzalez M. Duodeno jejunitis: is it idiopathic or is it Henoch Schönlein purpura without the purpura? J Pediatr Gastroenterol Nutr 2000; 30:22–28.