Paradoxical and Persistent Renal Impairment in Henoch-Schönlein Purpura after High-Dose Immunoglobulin Therapy

Dr. Miguel A. González-Gay, MD, PhD, Division of Rheumatology, Hospital Xeral-Calde, c/Dr. Ochoa s/n, E-27004 Lugo (Spain) Dear Sir, Intravenous high-dose immunoglobulin (IVHDI) has proved to be effective in the treatment of several immune-mediated diseases, including systemic vasculitis [1, 2]. In this sense, Rostoker et al. [3, 4] have reported that both lowand high-dose immunoglobulin therapy may be effective in treating either moderate or severe nephritis in Henoch-Schönlein purpura (HSP) and IgA nephropathy (IGAN). However, concern about renal deterioration has been raised in cases of systemic vasculitis and systemic lupus erythematosus following IVHDI [5-7]. We report a patient diagnosed as having HSP who paradoxically presented an acute and persistent renal impairment after IVHDI. A 24-year-old man presented to our hospital with a history of abdominal pain and purpura involving the lower extremities and trunk. He was asymptomatic until 10 days before admission, when he abruptly developed palpable rapidly increasing purpura and edema in his lower extremities. At the emergency room he had colicky abdominal pain and arthralgias in his ankles and knees. The rest of the patient’s history was unremarkable. On examination his temperature was 36 °C, blood pressure 140/80 mm Hg and pulse 80/min. Cardiopulmonary examination was normal. The abdomen was soft with tenderness. Edema and palpable purpura were present in the lower third of the inferior extremities. There were also scattered purpuric lesions in the buttocks. On admission full blood count, coagulation tests, blood chemistry profile and urinalysis were normal. The Westergren erythrocyte sedimentation rate was 22 mm/h. Test for hepatitis B and C, human immunodeficiency virus serology, antinuclear antibodies, cryo-globulins, immunoglobulins (including IgA, IgG and IgM), rheumatoid factor, serum C3 and C4, and ANCA were negative or normal. Chest and abdomen X-ray films, electrocardiogram and echocardiogram were also normal. A skin biopsy showed a leukocytoclastic vasculitis with IgA immune deposits affecting capillaries and venules. Thirty-six hours after admission, nausea, vomiting and an increase in diffuse abdominal pain as well as melena along with new skin lesions were observed. Endoscopic examination showed petechial mucosal lesions in the duodenum. Treatment with 40 mg of intravenous meth-ylprednisolone every 6 h was started. A rapid improvement of the abdominal pain was observed within the first 5 days after the onset of