Henoch-Schoenlein Purpura Following Severe Acute Respiratory Syndrome Coronavirus-2 Infection: A Case Report

AUTHORS

Saeed Soleiman-Meigooni ORCID 1 , * , Ramin Yaghmayee 2 , Ramin Hamidi-Farahani ORCID 3 , Mousa Ahmadi 3 , Allahyar Taheri 4 , Ali Asgari ORCID 3 , Azam Soleimani Najafabadi 5

1 Infectious Diseases Research Center, AJA University of Medical Sciences, Tehran, Iran

2 Department of Pathology, Khanevadeh Military Hospital, Tehran, Iran

3 Department of Infectious Diseases, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran

4 Department of Dermatology, Faculty of Medicine, AJA University of Medical Sciences, Tehran, Iran

5 Department of Nephrology, Khanevadeh University Hospital, Tehran, Iran

How to Cite: Soleiman-Meigooni S, Yaghmayee R, Hamidi-Farahani R, Ahmadi M, Taheri A, et al. Henoch-Schoenlein Purpura Following Severe Acute Respiratory Syndrome Coronavirus-2 Infection: A Case Report. Nephro-Urol Mon.In Press(In Press):e116227. doi: 10.5812/numonthly.116227.

ARTICLE INFORMATION

Nephro-Urology Monthly: In Press (In Press); e116227
Published Online: August 3, 2021
Article Type: Case Report
Received: May 18, 2021
Accepted: June 13, 2021
Uncorrected Proof scheduled for 13 (3)
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Abstract

Introduction: As the novel coronavirus pandemic continues to affect people worldwide, immune-mediated inflammatory syndromes related to this virus have been reported. SARS Coronavirus-2 infection disease (COVID-19) may accompany various cutaneous symptoms, such as viral exanthems or wheels. These symptoms may occur at the early course of the disease or after that. Cutaneous symptoms of COVID-19 usually have a favorable outcome.

Case Presentation: We presented a rare case of inpatient COVID-19 pneumonia, who developed a purpuric rash, abdominal pain, and hematuria. His dermal histopathological study revealed small-vessel vasculitis. We diagnosed Henoch–Schoenlein purpura based on clinical and histopathological findings and treated him with intravenous dexamethasone followed by oral prednisolone. The purpuric rashes disappeared in two weeks.

Conclusions: Cutaneous manifestation of COVID-19 is usually diffuse maculopapular rashes. Other presentations include vesicular rashes and acral cyanosis. Dermal histopathological study in most patients with COVID-19 who developed cutaneous symptoms revealed perivascular inflammation and microthrombus in some cases. Thus, COVID-19 should be considered in any patient with a new onset of cutaneous symptoms.

1. Introduction

By the end of 2020, more than 83 million confirmed cases of Coronavirus infection (COVID-19) and 1.8 million deaths occurred worldwide (1). Several studies reported the correlation between COVID-19 and inflammatory syndromes, such as Guillain-Barre, myocarditis, and encephalitis (2-4). Indeed, a significant proportion of mortalities and morbidities in COVID-19 is due to non-pulmonary immune-mediated complications. These syndromes may affect any organ and play an essential role in tissue damage and death (5). The cutaneous symptom is a relatively common presentation in COVID-19. It may occur at the onset of this disease or a few days later and usually have a favorable outcome. We reported a rare case of COVID-19 pneumonia who developed Henoch–Schoenlein purpura (HSP) on admission.

2. Case Presentation

The patient was a 21-old-year male referred to the emergency department with three days of fever, myalgia, shortness of breath, and dry cough, five days after close contact with a patient with COVID-19. He also complained of abdominal pain and hematuria for two days. Physical examination revealed a blood pressure of 92/55 mmHg, a pulse rate of 128 beats per minute, a respiratory rate of 28 per minute, an oral temperature of 38.6°C, and O2 saturation of 88%. He also had crackle in both lungs and a mild diffuse abdominal tenderness. The pulmonary computed tomography scan showed diffusely scattered ground-glass opacities. The lab tests showed a white cell count of 5300 per cubic millimeter (consisting of 83% of polymorphonuclears, 13% lymphocytes, and 4% monocytes), a hemoglobin level of 11.4 mg/dL, a platelet count of 314,000 per cubic millimeter, and a creatinine level of 1.1 mg/dL. The first-hour erythrocyte sedimentation rate level was 89, and the C-reactive protein level was 68 mg per liter. Urine analysis showed mild proteinuria and 20 - 25 red blood cells in a 40x magnification field with 30% dysmorphic. The nasopharyngeal swab for the SARS Coronavirus-2 polymerase chain reaction (PCR) was positive.

We started treatment with parenteral ceftriaxone and pantoprazole, oral azithromycin and lopinavir/ritonavir, and oxygen supplement. The pulmonary symptoms recovered gradually during the following days, but abdominal pain and malaise continued. We also asked for a nephrology consultation and complete abdominopelvic ultrasound for evaluating hematuria. The ultrasound study was unremarkable. Other laboratory tests showed a urine protein level of 565 mg in a day, negative results for the urine culture, anti-nuclear antibody, anti-double-stranded DNA, antineutrophil cytoplasmic antibodies, HBs antigen, HCV antibody, and HIV antibody. Also, D-Dimer, prothrombin and partial thromboplastin times, peripheral blood smear, and the serum complements were normal. In the second week of admission, a palpable purpuric rash appeared on his back and lower extremities and extended in two days (Figure 1). Upon consultation with a dermatologist and rheumatologist, we performed a skin punch biopsy and started intravenous dexamethasone 4 mg three times a day, which improved his condition in the following days. The histopathology study revealed superficial lymphocytic infiltrate and small-vessel vasculitis in the dermis (Figure 2). We diagnosed HSP based on clinical presentations and histopathological findings. Finally, we discharged him on day 18 of admission without any vital organs damage with oral prednisolone and ferrous sulfate supplement. The purpuric rashes disappeared after two weeks.

Figure 1. The palpable purpuric rash appeared on the back and lower extremities on the second week of admission
Figure 2. Superficial lymphocytic infiltrate and small-vessel vasculitis in the histopathological study of the dermis

3. Discussion

Henoch–Schoenlein purpura is a small-vessel vasculitis, which mainly affects the skin and mucous membranes. It may develop after upper respiratory tract infections such as Streptococci, Adenoviruses, and coxsackievirus (6). In our case, HSP occurred after SARS Coronavirus-2 infection, which is a new manifestation of COVID-19. The cutaneous presentation of COVID-19 is often like the other viral exanthemas, such as maculopapular rash. Table 1 lists the different types of dermal histopathology in COVID-19. As we showed in the table, the most common cutaneous manifestations of COVID-19 are widespread maculopapular rashes, papulovesicular rashes, and acral cyanosis. Skin symptoms in COVID-19 are usually self-limited and leave with a favorable outcome, but severe dermal involvement such as vasculitis needs a systemic treatment. Physicians should consider COVID-19 in the differential diagnosis of a new-onset cutaneous symptom, even a rare dermal presentation such as vasculitis.

Table 1. Histopathological Findings of Skin Lesions in Patients with COVID-19
Number of Patients/Female to Male(Mean) Age (s)Types of Skin LesionHistopathological FindingsOutcomeReference
24Intraepidermal vesicles with mild acantholysis and ballooned keratinocytes(7)
15/340.5Vesicular skin rash including palms and solesRecovery
3/347.5Localized pattern (trunk)Recovery
22(8)
16/656.4Diffuse (73%) or scattered (27%) papulovesicular rash on trunk and limbsHyperkeratosis, vacuolar degeneration of the basal layer with multinucleate hyperchromatic keratinocytes and dyskeratotic cellsThree Death Twelve Recovery
4(9)
F66.7Erythema multiform-like exanthema, target lesionsSpongiosis in epidermis. dilated vessels filled with neutrophils, extravasation of RBCs, lymphocytic perivascular and interstitial infiltrateRecovery
3(10)
2/168.3Widespread erythematous macules on arms, trunk, and lower limbs, exanthem on the trunk and armsSuperficial perivascular dermatitis, small thrombus, extravasated of RBCsRecovery
1(11)
M16Chilblains or multiple asymptomatic erythematous and edematous, partially eroded, macules and plaques on dorsal aspects of the fingersEdema of the papillary dermis superficial and lymphocytic infiltrateRecovery
1(9)
M68Morbilliform rash in trunk, acral cyanosis, ulcerated purpuric plaqueViral exanthem, thrombotic vasculopathyNA
1(12)
F65Rash under breasts, back, and genital area
Viral exanthema or urticariform dermatitis with discrete blood extravasationRecovery
1(13)
F83Purple palpable papules. blisters on both her legs, feet, and toes, five days before pulmonary symptomsLeukocytoclastic vasculitis affecting dermal vessels, extravasation of RBC, basal epidermal layer necrosis, dermal perivascular neutrophil infiltration, and fibrin depositionRecovery
1(14)
M22Multiple Red Raised Lesions Symmetrically in Extremities.Perivascular Mixed Inflammatory Infiltration of Neutrophils and Lymphocytes and Extravasation of RBCs in Upper DermisRecovery
1This case
M21Purpuric Rash on the Trunk and Lower Extremities.Leukocytoclastic Vasculitis Affecting Dermal VesselsRecovery

Footnotes

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