Case Study: Adult-Onset Henoch–Schönlein Purpura (HSP)

Linda Dharmaraj

Clinical Pharmacist, Kauvery hospital, Alwarpet, Chennai

Introduction

Henoch–Schoenlein Purpura (HSP), also known as IgA vasculitis, is a small-vessel vasculitis characterized by the deposition of immune complexes containing IgA. Although common in children, adult-onset HSP is rare and may exhibit more severe manifestations, especially renal and gastrointestinal involvement.

This case describes a 32-year-old male diagnosed with adult-onset HSP, who developed abdominal pain, arthritis, and nephritis, with intolerance to oral steroids that required hospital readmission for IV therapy.

Presenting complaints

  • Joint pain
  • Hematuria
  • Abdominal pain
  • Rash (purpura)

Past Medical & Surgical History

  • Recently diagnosed Adult-Onset Henoch–Schoenlein Purpura
  • No other significant medical or surgical history reported.
  • History of recent Travel to abroad (Deloitte, Dubai/ Panama Canal ,USA

Physical Examination

  • General Condition: Conscious, oriented, afebrile
  • Pulse Rate (PR): 83 beats/min.
  • Blood Pressure (BP): 140/78 mmHg
  • SpO₂: 98% on room air
  • Capillary Blood Glucose (CBG): 150 mg/dL
  • Respiratory System: Normal
  • Cardiovascular System: S1, S2 +
  • Per Abdomen: Soft, bowel sounds present.
  • Central Nervous System: No focal neurological deficit

Investigations

Urine Routine: Hematuria and Proteinuria

  • Skin Biopsy: Features of Leucocytoclastic Vasculitis (Direct Immune Fluorescent Test not done)
  • CECT Abdomen: Thickening of distal ileum suggestive of vasculitic involvement

Course in the Hospital

The patient was initially treated with IV steroids (Inj. Solumedrol 500 mg for 3 days) and responded well. Upon switching to oral steroids, he developed recurrent abdominal pain and intolerance. He was readmitted and restarted on IV Dexamethasone (6 mg/day) with supportive care (Esogress, Esoz, Sucralfil).

He improved significantly and was discharged on a tapering steroid plan along with gastroprotective and immunosuppressive medications.

Condition at Discharge

  • Vitals: Stable
  • General condition: Asymptomatic and tolerating oral intake.
  • Abdominal pain: Resolved
  • Plan: Continue oral medications and follow-up after completion of therapy

Medications at Discharge

1. Inj. DEXA (Dexamethasone) – 6 mg IV twice daily (9 AM & 7 PM), after food for 3 days
2. Tab. ESOGRESS HP – Oral, three times daily, after food for 2 weeks, then taper
3. Tab. ESOZ 40 mg – Oral, once daily, before food for 2 weeks
4. Tab. AZORAN (Azathioprine) 50 mg – Oral, once daily, after food for 5 days (initial course)

Diet & Lifestyle Advice

  • Diet: Normal, healthy, balanced diet
  • Hydration: Adequate oral fluids
  • Activity: Resume normal activities gradually
  • Follow-up: Regular outpatient review to monitor renal and gastrointestinal status

Role of the Clinical Pharmacist

The clinical pharmacist plays a crucial multidisciplinary role in the management of complex vasculitic conditions like HSP. In this case, the pharmacist’s interventions focused on medication optimization, patient education, and safety monitoring.

Medication Review and Optimization

  • Verified dosages, duration, and routes for corticosteroids (IV to oral transition)
  • Ensured gastroprotective coverage with Esogress HP and Esoz
  • Reviewed drug interactions, especially between Azathioprine and other medications
  • Confirmed proper steroid tapering schedule

Patient Counseling

  • Educated on adherence, side effects, and correct timing of medications
  • Explained importance of not abruptly stopping steroids
  • Advised on hydration and dietary precautions

Prevention of Drug-Related Problems

  • Ensured protection against steroid-induced gastritis
  • Monitored for duplicate therapies and interactions
  • Encouraged prompt reporting of new symptoms
  • Ensured dose adjustments
  • Documented all pharmaceutical interventions to improve outcomes

Monitoring and Follow-Up

  • Recommended renal and liver function monitoring
  • Advised regular blood glucose and BP checks
  • Suggested CBC monitoring for Azathioprine

Discussion
This adult-onset case of HSP highlights the severity of gastrointestinal and renal complications that may arise in adults compared to pediatric cases. The patient’s intolerance to oral steroids necessitated IV therapy and careful management. The inclusion of Azathioprine reflects an initiative-taking approach to minimize steroid dependency and control disease relapse

Conclusion.

This case emphasizes:

  • The complexity of managing adult-onset HSP with systemic involvement
  • The importance of close monitoring during corticosteroid and immunosuppressive therapy
  • The clinical pharmacist’s integral role in improving medication safety, ensuring adherence, and preventing adverse effects
  • Prognosis: Favorable, with regular monitoring and adherence to therapy.

 

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