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CASE REPORT
Year : 1990  |  Volume : 56  |  Issue : 2  |  Page : 147-149

Henoch-schonlein purpura evolving into acute guttate psoriasis



Correspondence Address:
K Pavithran


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  Abstract 

A 12 year old girl developed clusters of urticarial and palpable purpuric lesions on the extremities associated with abdominal pain, polyarthraloa and microscopic hematuria. A throat swab culture yielded streptococci and the ASO tire in her blood was raised. The palpable purpuric lesions on her extremities were, observed to evolve gradually into scaly papules of acute, guttate psoriasis. It seems possible that the streptococcal throat infection triggered both Henoch-Schonlein purpura and acute in this patient.


Keywords: Henoch-Schonlein purpura, Anaphylactoid purpura, Guttate psoriasis, Transformation


How to cite this article:
Pavithran K. Henoch-schonlein purpura evolving into acute guttate psoriasis. Indian J Dermatol Venereol Leprol 1990;56:147-9

How to cite this URL:
Pavithran K. Henoch-schonlein purpura evolving into acute guttate psoriasis. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2020 Jun 2];56:147-9. Available from: http://www.ijdvl.com/text.asp?1990/56/2/147/3510


Erythema nodosum, erythema multiforme, Osler's nodes, erythema marginatum, purpura fulminans, impetigo, ecthyma, erysipelas and acute guttate psoriasis are some of the cutaneous lesions directly or indirectly related to strepto­coccal infection.[1] Henoch-Schonlein purpura, also known as anaphylactoid purpura, is chara­cterised by intermittent purpura, arthralgia, abdominal pain and hematuria. The skin lesions usually begin as urticarial clusters that become hemorrhagic within a day or two and are typically distributed on the extensor surface of extremities and buttocks. The cause of Henoch-Schonlein purpura is not known in all cases though in some cases there is a history of antecedent streptococcal infection of the throat. We report a case of Henoch, Schonlein purpura in a young girl, in whom the palpable purpuric lesions on her legs and arms gradually evolved into scaly papules of guttate psoriasis.


  Case Report Top


A 12-year-old girl developed a mildly pruritic papular and purpuric eruption on the extremities since 3 weeks. She also had abdominal pain and polyarthralgia affecting the knees and elbows. She denied having taken any drug but had had throat pain and fever three weeks prior to the development of the present illness. Exami­nation revealed multiple, discrete, urticarial based papules, and palpable purpuric and petechial lesions distributed bilaterally symmetri­cally on the extensor surface of both the upper and lower limbs [Figure - 1] and the buttocks. Left foot and right hand had pitting oedema. Both the knee and ankle joints were slightly swollen and tender. There was congestion of the throat and the tonsils were enlarged. All other systems were clinically normal.

Her hemoglobin was 12 gm %, TLC 10,400, DLC P70 L28 E2, ESR 34 mm. Blood VDRL was negative, blood urea 38 mg%, and ASO titer>333 Todd units. Urine showed micro­scopic hematuria. X-rays of the abdomen, knee joints and ankle joints did not show any abnormality. Throat swab culture yielded streptococci. Bleeding time and clotting time were normal. LE cell test was negative. Hess' test was positive. Histopathology of a papule on the leg revealed a normal epidermis, while the dermis showed inflammatory cell infiltration consisting of neutrophils, eosinophils and lymphocytes predominantly around and within the walls of blood vessels [Figure - 2]. There was leucocytoclasia and extravasation of red blood cells. A diagnosis of Henoch-Schonlein purpura was made and she was treated with oral erythro­mycin, vitamin C and antihistamine. She continued to develop recurrent bouts of cuta­neous eruptions. Some of the older papules and palpable purpuric lesions on the legs and forearms were observed to change gradually into papulo-squamous lesions [Figure - 3]. The scales were dry and micaceous and Auspitz's sign was positive. Histopathological study of the scaly papule revealed features typical of psoriasis [Figure - 4]. Within a month, all the papules and purpuric lesions evolved into papulo-squamous lesions of guttate psoriasis. She was treated with topical liquid paraffin and later with coal tar skin ointment. When seen after 2 months, all the signs and symptoms had subsided and the laboratory tests on blood and urine were normal except for persistence of an elevated ASO titre.


  Comments Top


Sudden development of clusters of urticarial and palpable purpuric lesions on the limbs, associated abdominal pain, polyarthralgia and hematuria and a history of preceding upper respiratory tract infection suggested a clinical diagnosis of Henoch-Schonlein purpura in our patient. A positive Hess' test, raised ASO titer and histopathological evidenceeof leucocyto­clastic angitis with extravasation of red blood cells in the dermis further supported this dia­gnosis. The interesting feature in our patient was the gradual transformation of the skin lesions of Henoch-Schonlein purpura into scaly papules of guttate psoriasis. The aetiology of psoriasis is still not fully known though various postulates have been put forth. Tonsillitis and upper respiratory infection is known to herald an explosive eruption of acute guttate psoriasis especially in children. Whyte and Baughman found abnormal ASO titres in 17 of their 20 patients with acute guttate psoriasis .[2] In all these 20 patients, severe upper respiratory infection preceded the onset of psoriasis by one or two weeks. Development of both Henoch­Schonlein purpura and acute guttate psoriasis, one immediately following the other, as observed in our patient is quite unusual. Therapeutic response to erythromycin further suggests that the throat infection played an aettologic role in causing both the diseases in our patient.

 
  References Top

1.Swartz MN and Weinberg AN : Infections due to Gram positive bacteria, in Dermatology in General Medicine, 2nd edition, Editors, Fitzpatrick TB, Eisen A, Wolf K et al : Me Graw Hill Book Company, London, 1979; pp 1426-1445.  Back to cited text no. 1    
2.Whyte HJ and Baughman RD : Acute guttate psoriasis and streptococcal infection, Arch Derma­tol, 1964; 89 : 350-356.  Back to cited text no. 2    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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