Henoch–Schönlein purpura in a patient with diabetic nephropathy and vascular complications

Sir,

Despite the high incidence of diabetic nephropathy worldwide, diabetic patients seldom undergo renal biopsy. This usually occurs when an otherwise unexplained rapid loss of renal function or appearance of haematuria requires a histological evaluation, explaining why the incidence of superimposed glomerulopathies in diabetic patients is probably underestimated [1–6].

We report the case of a 59-year-old obese and hypertensive man with a 10 year history of type 2 diabetes mellitus, admitted to hospital because of progression of a necrotic foot ulcer. Four days before admission, vomiting, colicky abdominal pain and diarrhoea associated with diffuse, self-limiting arthralgias, and petechial rash of both legs and arms occurred. The past medical history showed proteinuria (1–2 g/24 h) and renal failure, with plasma creatinine stable at ~2.6 mg/dl. The patient denied use of drugs other than his usual medication (insulin, enalapril, amlodipine, doxazosin and furosemide) in the last 6 weeks.

On admission, the patient's body temperature was 36.7°C, heart rate 102 b.p.m. and blood pressure 180/80 mmHg. Ankle oedema and a diffuse, symmetric, palpable purpuric rash at the extensor surfaces of the upper and lower limbs were evident. The right second toe showed a deep ulcer with a sero-purulent exudation and perilesional oedema. A mild, non-proliferative diabetic retinopathy was also present. Laboratory investigations showed mild normocytic anaemia, white blood cell count of 8590/µl with 82.1% neutrophils and 4.2% eosinophils, blood glucose 190 mg/dl, haemoglobin (Hb)A1c 7.9%, C-reactive protein 55 mg/l, serum creatinine 3.4 mg/dl with creatinine clearance of 35 ml/min and proteinuria 1.13 g/day. An active sediment was found, showing 40 dysmorphic erythrocytes/field and hyaline casts. Increased levels of IgA (1003 mg/dl) and IgG (2650 mg/dl) with slight reduction of C3 and C4 were present. All autoimmune tests were negative. Staphylococcus aureus was isolated from the foot ulcer.

A kidney biopsy showed glomeruli with diffuse or nodular intercapillary glomerulosclerosis; some glomeruli had enlargement of mesangial stalks with minor cellular proliferation, mesangial hypercellularity and thickened basal membranes. Immunofluorescence revealed diffuse linear staining for IgG and mesangial granular positive staining for IgA, IgM and C3. The biopsy findings were compatible with a diabetic capillary glomerulosclerosis associated with IgA deposits, probably correlated to Henoch–Schönlein purpura (HSP). Post-infectious nephritis was excluded on the basis of the histological findings and primary glomerular IgA nephropathy and atheroembolism on the basis of the clinical picture of an active vasculitis. Tests for autonomic neuropathy, that might explain part of the symptoms, revealed cardiovascular involvement. A recent functional test excluded major gastrointestinal motility disorders. Levofloxacin combined with local antisepsis induced a rapid resolution of the petechial rash with partial improvement of the lesion of the foot; body weight decreased by 7 kg, plasma creatinine decreased to 2.7 mg/dl, proteinuria remained stable and haematuria disappeared. Ten days after discharge, the purpura relapsed. Due to the persistent septic toe, the patient was referred to the surgeons for amputation. After amputation, the petechial rash disappeared completely and has not recurred over a 12 month period.

In our patient, infection may have triggered HSP. Our observation supports the notion that a renal biopsy should be routinely used in the presence of a rapid deterioration of renal function in patients with presumed diabetic nephropathy.

Attention should be paid to foot care in diabetics, wounds should never be overlooked and local infections should be quickly and appropriately treated [7].

Conflict of interest statement. None declared.

Alessandro Cavarape1, Eva Quinkenstein1, Stefano Pizzolitto2, Giorgio Soardo1 and Leonardo Sechi1

1 Department of Experimental and Clinical Pathology and Medicine Chair of Internal Medicine University of Udine2 Department of Pathology and Laboratory Medicine Division of Anatomic Pathology General Hospital S. Maria della Misericordia I-33100 Udine Italy Email: alessandro.cavarape{at}dpmsc.uniud.it

References

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  2. Padilla B, Weiss M, Kant KS. Henoch–Schönlein purpura in a patient with diabetic nephropathy: case report and a review of the literature. Am J Kidney Dis 1992; 20: 191–194[ISI][Medline]
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  6. Bertani T, Olesnicky L, Abu-Regiaba S, Glansberg S, Pirani CL. Concomitant presence of three different glomerular disease in the same patient. Report of case and review of the literature. Nephron 1983; 34: 260–266[ISI][Medline]
  7. Consensus Development Conference on Diabetic Foot Wound Care: 7–8 April 1999, Boston, MA. Diabetes Care 1999; 22: 1354–1360[Free Full Text]




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