DEPARTMENT OF PEDIATRIC

RADEN SAID SUKANTO POLICE CENTER HOSPITAL

FACULTY OF MEDICINE YARSI UNIVERSITY
PERIOD DECEMBER 1st 2014 – JANUARY 30TH 2015
 Patien Identity
 Name :FS 
 Birth Date : February 6th 1999
 Age : 6 years old
 Gender : Female
 Address : Pondok Gede RT 07/04, East Jakarta
 Nationality : Indonesia
 Religion : Moeslem
 Date of admission: December 5th 2014.
 Date of examination: December 5th 2014- December 7th 2014
 Parent Identity
Father Mother

Name Mr. S  Mrs. PW

Age 42 years old 32 years old

Job Employee Housewife

Nationality Javanese Javanese

Religion Moeslem Moeslem

Education D3 High School

(graduated)s
 History Taking

 Alloanamnesis from patient’s mother on the date of
admission, December 5th 2014.

Chief complain:

• Abdominal pain since three days before admission to the hospital.

Additional complains:

• Palpable Purpura ,Nausea, Vomiting .

History of Present Illness


1 days before
admission the
patient redness
3 days before rash on skin
admission: the patient
has vomit, nausea
atralgia and
abdominal pain is felt
on the left.
 History Of Past Illness
Pharyngitis/Tonsilitis - Bacillary Dysentry -

Bronchitis

Pneumonia
-

-

Amoeba Dysentry

Diarrhea
-

Morbilli - Thypoid -

Pertussis - Worms -

Varicella - Surgery -

Diphteria - Brain Concussion -

Malaria - Fracture -

Polio - Drug Reaction -

Enteritis -
 Prenatal History

Antenatal care
Antenatal check ups performed at the puskesmas
by the midewife. There was no problems during
pregnancy.
No maternal illness during pregnancy
Drugs consumption:
Vitamins every antenatal care
 Birth History
Labor

: Puskesmas
Birth attendants : midwife
Mode of delivery : pervaginam
Gestation : 38 weeks
Infant state : healthy
Birth weight : 3600 grams
Body length : 51 cm
According to the mother, the baby started to cry and the
baby's skin is red, no congenital defects were reported
 Post Natal History

Examination by midewife
The state of the infant:
healthy
 Development History
 First dentition: 6 months 
 Psychomotor development
 Head Up : 1 month old
 Smile : 1 month old
 Laughing : 1- 2 month old
 Slant : 2,5 month old
 Speech Initation : 5 month old
 Prone Position : 5 month old
 Food Self : 5 – 6 month old
 Sitting : 6 month old
 Crawling : 8 month old
 Standing : 1 years old
 Walking : 1 years old

 Conclusion: Growth and development status is still in the normal
limits and was appropriate according to the patient’s age
 History of Eating


Breast Milk Exclusively 6 month..

Formula milk Dancow

Biscuits regal
Baby biscuits

Fruit and vegetables Banana, Papaya

Solid foods and side dishes White ricee, Carrots, Potatoes

Immunization History
Immunization Frequency Time

BCG 1 time 1 month old

Hepatitis B 3 times
 0, 1, 6 months old

DPT 3 times 2, 4, 6 months old

Polio 4 times 0, 2, 4, 6 months old

Morbilli 1 times 9 month old

 Family History

Patient’s both parents were married when they
were 21 years old and 19 years old, and this is
their first marriage.
There are not any significant illnesses or chronic
illnesses in the family declared.
 History of her brothers
Age Died Sumption
No Child birth Gender
 Age
Died

Spontan - -
Boy 16 years
1. pervaginam,
old
gestation aterm
Spontan Girl 10 years - -
2. pervaginam, old
gestation aterm
- -
Spontan
Girl
3. pervaginam, 6 years old
(patient)
gestation aterm
 History of the disease people
around the patient

Around the house
People who lived around the
patient’s house are in healthy
condition
 Sosial and Economic History

 The patient lived at the house with size 10 m x 8 m together with
father and mother.
 There are 1 door at the front side, 1 toilet near the kitchen and 3
rooms, in which 1 room is the bedroom of three of them and 1
room is for guest. There are 4 windows inside the house. The
windows are ocassionaly opened during the day.
 Hygiene:
 The patient changes her clothes everyday with clean clothes.
 Bed sheets changed every two weeks.
 Physical Examination

 Date :December 5th 2014
 General Status
 General condition : mild ill
 Awareness : Compos Mentis
 Pulse : 100 x/min, regular, full, strong.
 Breathing rate : 26x/min
 Temperature : 36,7oC (per axilla)
 Physical Examination (cont’d)

Antropometry Status
 Weight : 21 kilogram
 Height : 115 cm
 Interpretation based on lokarya
Antropometri Depkes 1974 and
puslitbang Gizi 1978
Nutritional Status based NCHS


(National Center for Health Statistics)
year 2000:

WFA (Weight for Age): 24/25 x 100 %

= 96% ( good nutrition)
HFA (Height for Age):115 /115 x 100
% = 100 % (good nutrition)
WFH (Weight for Height): 24/25x
100 % = 96 % (normal)

Conclusion: Nutrition status of the

patient is good
 Systematic Physical Examination
 Head Normocephaly, hair (black, normal distributon, not easily removed ) sign of
trauma (-), large fontanelle closed.

 Eyes 
Icteric sclera -/-, pale conjunctiva -/-, hyperaemia conjunctiva -/- , lacrimation
-/-, sunken eyes -/-, pupils 3mm/3mm isokor, Direct and indirect light
response ++/++
 Ears Normal shape, no wound, no bleeding ,secretion or serumen

• Mouth
Lips: dry
Teeth: no caries
Mucous: moist
Tongue: Not dirty
Tonsils: T1/T1, No hyperemia
Pharynx: No hyperemia

• Neck Lymph node enlargement (-), scrofuloderma (-)

Thorax Symmetric when breathing , no retraction, ictus cordis is
 Inspection: not visible

 Palpation: mass (-), tactile fremitus +/+

 Percussion: 
sonor on both lungs
 Auscultation
Cor : regular S1-S2, murmur (-), gallop (-)
Pulmo: vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen :
Inspection : Convex, epigastric retraction (-), there is no a widening of the
veins, no spider nevi.

 Palpation : supple, liver and spleen not palpable, fluid wave (-), abdominal
mass (-)

 Percussion: The entire field of tympanic abdomen, shifting dullness (-)

 Auscultation: normal bowel sound, bruit (-)

Thorax Symmetric when breathing , no retraction, ictus cordis is
 Inspection: not visible

 Palpation: mass (-), tactile fremitus +/+

 Percussion: 
sonor on both lungs
 Auscultation
Cor : regular S1-S2, murmur (-), gallop (-)
Pulmo: vesicular +/+, Wheezing -/- , Rhonchy -/-

Abdomen :
Inspection : Convex, epigastric retraction (-), there is no a widening of the
veins, no spider nevi.

 Palpation : supple, liver and spleen not palpable, fluid wave (-), abdominal
mass (-)

 Percussion: The entire field of tympanic abdomen, shifting dullness (-)

 Auscultation: normal bowel sound, bruit (-)

Anus

Hole intact, does not seem
that out of the mass of the
anus.

Extremities warm, capillary refill time < 2

second, edema(-),Purpura (+)

Skin Good turgor

Laboratory Investigation
Hematology (December 1th 2014)
Hematology 
Results Normal Value

Haemoglobin 12,4 g/dL 13-16 g/dL

Leukocytes 18.000/µL 5,000 – 10,000/µL

Hematocrits 39 % 40 – 48 %

Trombocytes 384.000/ µL 150,000 –

400,000/µL
Erythrocytes 4,60 million/µL 4 – 5 million/µL
 WORKING DIAGNOSIS


Purpura Henoch- Shonlein
DD/ ITP
 MANAGEMENT


IVFD RL, macro drip, 14 dpm 1000cc
/ 24 Hours.
Inj. Cefotaxime 2x500 mg IV
Metil Prednisolon
 Follow Up

December 5nd 2014 - DECEMBER 7th 2014.
 December 5nd 2014. First day of hospitalization

S Abdominal pain left regio

Vomiting and Nausea (-)

O
Purpura (+)
General condition: Compos mentis.

Heart rate = 100 x/min
Respiratory rate = 25x/min
Temperature = 36.6˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-
A Purpura Henoch Shconlein

P  IVFD RL, micro drip, 14 dpm 1000cc / 24 Hours.

 Inj. Cefotaxime 2x1 gr IV
 Metil Prednisolon 3x 8mg

 Rantin 2x ½ amp
December 5nd 2014. First day of hospitalization


December 6nd 2014. Second day of hospitalization

S Purpura in extremitas below

O General condition: .

Heart rate = 111 x/min
Respiratory rate = 26x/min
Temperature = 36.4˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Skin:Purpura in extremitas below

A Purpura Henoch Schonlein
P  IVFD RL, micro drip, 14 dpm 1000cc / 24 Hours.
 Inj. Cefotaxime 2x1 gr IV
 Metil Prednisolon 3x 8mg
 Rantin 2x ½ amp
December 6 2014. Second day of hospitalization


 December 7th 2014, Third day of hospitalization
S No complain

O General condition: Compos mentis.


Heart rate = 110 x/min
Respiratory rate = 30x/min
Temperature = 36˚C
Cardio : S1/S2, reguler, no murmur, no gallop
Pulmonary : vesiculer +/+, rhonchi -/-, wheezing -/-

Skin:Purpura in extremitas below

A Purpura Henoch Schonlein

P  IVFD RL, micro drip, 14 dpm 1000cc / 24 Hours.

 Inj. Cefotaxime 2x1 gr IV
 Metil Prednisolon 3x 8mg
 Rantin 2x ½ amp
December 7th 2014, Third day of hospitalization


 

Literature Review and Discussion

 Definiton

 Also called “anaphylactoid purpura”
 HSP is a systemic vasculitic syndrome with:
 Palpable purpura
 Arthralgias
 GI involvement
 Glomerulonephritis
 Palpable Purpura

Symmetrical
Dependent areas
 .


Epidemiology


90% of cases reported in
children
-Peak in children aged 4-7
Male:Female (1.5:1)
50% follow a URI
Renal disease is more severe in
adults
 PATHOGENESIS

 Likely mechanism thought to be an immune-
complex mediated disease with deposits in the
glomerular capillaries, dermal capillaries and GI
tract.
 Mesangial deposits of IgA are the same as those seen
in IgA nephropathy
 How to Approach ?
Criteria ITP Acute

Leukimia
Aplastic
Anemia
HSP


Hb/RBC Normal ↓ ↓ Normal
count
WBC count Normal ↑↑↑ ↓ ↑ in some
cases.
Platelet count ↓ ↓ ↓ Normal

 Clinical


Palpable
Purpura Joints

Abdominal
Renal
pain
 PRECIPITATING ANTIGENS

 INFECTIONS
 URI – C.difficile
 Measles – H.pylori
 Rubella – Adenovirus
 Parvovirus B19 – Legionella
 Mycoplasma
– Tuberculosis
 Coxsackie virus
– Mumps
 Toxocara
 Amebiasis – Streptococcus
 Salmonella – Morganella morganii
 PRECIPITATING ANTIGENS

 Other:
 Food hypersensitivity
 Cold exposure
 Autosomal recessive Chronic granulomatous disease
 Myelodysplastic syndrome
 Small cell lung cancer
 Breast cancer
 PATHOLOGIC FEATURES

DERMATOLOGIC FINDINGS:

Leukocytoclastic vasculitis with IgA deposition

 Diagnosis

 Lab. Serum IgA(50-70%)

 Abdominal U/S

 Biopsy .
 HISTOLOGY


H & E stain of skin biopsy showing leukocytoclastic

vasculitis with infiltration of neutrophils.
 HISTOLOGY


Skin biopsy: Leukocytoclastic vasculitis with

mononuclear and polymorphonuclear cell infiltrates in
the perivascular space
 Complications

DD:
 Kawasaki disease
 Polyarteritis nodosa
 Meningococcemia
 Systemic JRA
 Factor V Leiden / Protein C deficiency
 Prognosis

 Quo ad vitam : dubia ad bonam
 Quo ad functionam: dubia ad bonam
 Quo ad sanactionam: dubia ad bonam
THANKYOU
