Henoch–Schonlein purpura presenting sequentially as nodular rash, erythema nodosum, and palpable purpura
A 26-year-old farm laborer presented to our outpatient department (OPD) with a nodular rash that had developed on both elbows [Figure and ] following an insect bite while she sleeping. She had pruritus over the affected areas and her lower limbs as well, but without any rash []. She was treated with antihistamines in the emergency department. Two days later, she presented to the OPD with complaints of tender and erythematous nodules on the legs []. Her investigations revealed the following: Hemoglobin 10.9 g/dl, total leukocyte count 10.6 × 109/l with 76% neutrophilia, erythrocyte sedimentation rate 40 mm/h, urea 9.94 mmol/l, creatinine 44 μmol/l, platelets 284 × 109/l, and 40-50 RBCs/hpf on urinalysis without proteinuria. She was unwilling to be admitted and was, therefore, sent home and was prescribed acetaminophen and chlorpheniramine. She came back 1 week later with a purpuric rash on her lower limbs [], diffuse abdominal pain, and arthralgias of the knees, ankles, and elbows. Examination showed non-palpable purpura, pedal edema, tender peri-umbilical region, and an otherwise normal systemic examination. Her urea and creatinine were 12.07 mmol/l and 52.8 μmol/l, respectively. Microscopic hematuria persisted while the spot urinary protein was 23 mg/dl. Her electrocardiogram and liver function tests were normal, while ultrasonogram showed minimal free fluid in the pelvis. Her immunological profile was as follows: Rheumatoid factor negative, antistreptolysin O (ASO) titer <200 IU, antinuclear antibody 0.6 U (<1.0 U), complement C3 0.94 g/l, and complement C4 0.41 g/l. Testing for cytoplasmic- antineutrophil cytoplasmic antibodies (c-ANCA) could not be done since the patient refused to undergo any further investigations. She did not want a skin biopsy. She was initiated on methylprednisolone 8 mg daily, ranitidine, and hydroxyzine, and over the next 3 days, her signs gradually subsided. Her urine became bland prior to discharge, 7 days after admission.