Letters to the Editor - Case Report
Acute pancreatitis as initial manifestation in an adult patient with focal proliferative necrotizing purpura nephritis
Pancreatitis aguda como manifestación inicial en un paciente adulto con purpura y glomerulonefritis necrosante proliferativa focal
Dong Liu, Yanna Dou, Wenming Yuan, Zeyu Li, Songxia Quan, Jing Xiao, Zhanzheng Zhao
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Nephrology Center of The First Affiliated Hospital of Zhengzhou University, Zhengzhou University Institute of Nephrology, Zhengzhou, Henan, China
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Acute pancreatitis is an inflammatory disorder and may be life-threatening if it is severe. HSP could cause the acute pancreatitis rarely. It tends to develop in the first week of the illness after characteristic purpura, or develop later.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Exceptionally, acute pancreatitis developed during the course of HSPN as an initial presenting feature before the typical rash. Here we report an adult patient with HSPN presenting after the acute pancreatitis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 19-year-old man was admitted to our hospital with the chief complaint of “abdominal pain and abnormal urine test for 1 month, erythematosus purpura over legs for 5 days”. He received the treatment for pancreatitis in the local hospital. However, the pancreatitis did not get remission. On admission of our hospital, the patient had a normal blood pressure and respiratory rate. There was a diffuse purpuric rash located over the legs. Abdominal examination showed tenderness in all quadrants with rebound tenderness. There was no hepatosplenomegaly, and bowel sounds were normal. Blood testing showed hemoglobin (101<span class="elsevierStyleHsp" style=""></span>g/l), white cell count (19.6<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>g/l), neutrophil (9.7<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>g/l). Erythrocyte sedimentation rate and C-reactive protein were significantly high at 29<span class="elsevierStyleHsp" style=""></span>mm/h and 100.3<span class="elsevierStyleHsp" style=""></span>mg/l, respectively. Serum testing showed glucose (3.3<span class="elsevierStyleHsp" style=""></span>mmol/l), urea (6.31<span class="elsevierStyleHsp" style=""></span>mmol/l), creatinine (52<span class="elsevierStyleHsp" style=""></span>umol/l), albumin (28.5<span class="elsevierStyleHsp" style=""></span>g/l), total cholesterol (4.1<span class="elsevierStyleHsp" style=""></span>mmol/l), and triglyceride (1.6<span class="elsevierStyleHsp" style=""></span>mmol/l). Serum amylase (332<span class="elsevierStyleHsp" style=""></span>U/l) and lipase (85.2<span class="elsevierStyleHsp" style=""></span>U/l) were increased. Urinary sediment examination showed microscopic hematuria. The proteinuria of 24<span class="elsevierStyleHsp" style=""></span>h is 2.48<span class="elsevierStyleHsp" style=""></span>g/2<span class="elsevierStyleHsp" style=""></span>L. Rheumatoid factor and complements (C3, C4) were within the normal range, and antinuclear antibodies, anti-DNA, antiphospholipids, antineutrophil cytoplasmic antibodies, and hepatitis viral markers were negative. Abdominal ultrasound showed a peritoneal effusion. Abdominal computed tomography (CT) scan noted an edematous pancreas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The result of renal biopsy was focal proliferative necrotizing purpura nephritis. Focal granular staining for IgA and C3 in the mesangium was shown using immunofluorescence staining. By light microscopy, glomeruli showed a mild hypercellularity in mesangial cells and matrix, focal endocapillary hypercellularity, eight crescents of 10 glomerulis, 1 necrosis of capillary loop. There is interstitial edema and inflammation composed mainly of mononuclear leukocytes and tubular epithelial injury (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The result of the light microscopy was confirmed by the electron microscopy.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was diagnosed as purpura nephritis complicated by acute pancreatitis. He was started on therapy with methylprednisolone 40<span class="elsevierStyleHsp" style=""></span>mg/d intravenously for 5 days before the renal biopsy result. Afterwards, 0.5<span class="elsevierStyleHsp" style=""></span>g bolus of methylprednisolone was given intravenously for 3 days and after that prednisone orally (30<span class="elsevierStyleHsp" style=""></span>mg/day) and MMF orally (1.5<span class="elsevierStyleHsp" style=""></span>mg/day). Abdominal pain disappeared at the third day of the treatment and the pancreas was normal after two weeks’ treatment. After 1-year follow-up, the patient recovered well with prednisone (10<span class="elsevierStyleHsp" style=""></span>mg/day) and MMF (0.25<span class="elsevierStyleHsp" style=""></span>mg/d), and renal function was normal, proteinuria was less than 150<span class="elsevierStyleHsp" style=""></span>mg/day, and abdominal CT scan was normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The association between pancretitis and Henoch–Schönlein Purpura Nephritis is rare. In our case, purpura nephritis complicated by acute pancreatitis was showed in this 19-year-old man. HSP is a rare cause of acute pancreatitis that can occur before or after the characteristic rash. In our case, the symptoms occurred before the rash. The pancreatitis tends to develop on the first day of the illness but may develop as late as day 75.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Acute pancreatitis is presumed to be caused by vasculitic involvement of the pancreas.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical feature of HSP nephritis is quite variable. The pathology of this patient showed a mild hypercellularity in mesangial cells and matrix, focal endocapillary hypercellularity, eight crescents of ten glomerulis, 1 necrosis of capillary loop. In the literature, only two cases got renal biopsy of purpura nephritis with pancretitis. One case showed moderate-to-severe increase of mesangial matrix with crescent formation<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> and one case showed endocapillary proliferative glomerulonephritis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> There is no special feature in the pathology of those patients.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Steroids have been used to treat HSP patients with pancretitis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4–7</span></a> For most HSP related pancretitis without nephritis, parenteral nutrition and Nasogastric suction was used to treat the pancretitis,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> and the outcome of pancretitis improved. In our case, the patient's pancretitis did not improve with the supportive treatment; however, the symptoms of pancretitis disappeared with the steroids usage. In the literature, two patients were diagnosed as HSP related pancretitis with nephritis. In the study by Frirui et al., kidney biopsy showed endocapillary proliferative glomerulonephritis and the patient was given 1<span class="elsevierStyleHsp" style=""></span>g bolus methylprednisolone intravenously for 3 days and after that prednisone orally (60<span class="elsevierStyleHsp" style=""></span>mg/day).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> And in the study by Nie et al., as HSP nephritis (severe) was confirmed, intravenous methylprednisolone (500<span class="elsevierStyleHsp" style=""></span>mg/d) was given to the patient for 3 days followed by oral dehydrocortisone of 30<span class="elsevierStyleHsp" style=""></span>mg/d.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The two patients got complete remission in pancreas and kidney.</p><p id="par0040" class="elsevierStylePara elsevierViewall">HSP is a rare and benign cause of acute pancreatitis. This complication could occur before the characteristic rash and shown as an initial manifestation of HSPN. Steroids could improve the outcome of the HSPN patients with pancreatitis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 532 "Ancho" => 996 "Tamanyo" => 62906 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Edematous pancreas in abdominal CT scan.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1389 "Ancho" => 990 "Tamanyo" => 409828 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Crescents observed by light microscopy in Masson stained section (upper one, 400) and PAS stained section (lower one, 400).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Henoch–Schonlein purpura: a review article" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 63 | 39 | 102 |
| 2024 September | 74 | 29 | 103 |
| 2024 August | 83 | 55 | 138 |
| 2024 July | 85 | 25 | 110 |
| 2024 June | 80 | 38 | 118 |
| 2024 May | 91 | 35 | 126 |
| 2024 April | 83 | 46 | 129 |
| 2024 March | 81 | 26 | 107 |
| 2024 February | 77 | 36 | 113 |
| 2024 January | 78 | 22 | 100 |
| 2023 December | 65 | 31 | 96 |
| 2023 November | 102 | 28 | 130 |
| 2023 October | 93 | 31 | 124 |
| 2023 September | 101 | 29 | 130 |
| 2023 August | 82 | 34 | 116 |
| 2023 July | 114 | 25 | 139 |
| 2023 June | 133 | 44 | 177 |
| 2023 May | 125 | 36 | 161 |
| 2023 April | 76 | 17 | 93 |
| 2023 March | 91 | 20 | 111 |
| 2023 February | 65 | 21 | 86 |
| 2023 January | 90 | 26 | 116 |
| 2022 December | 95 | 31 | 126 |
| 2022 November | 76 | 36 | 112 |
| 2022 October | 89 | 43 | 132 |
| 2022 September | 77 | 35 | 112 |
| 2022 August | 79 | 50 | 129 |
| 2022 July | 89 | 44 | 133 |
| 2022 June | 72 | 39 | 111 |
| 2022 May | 76 | 38 | 114 |
| 2022 April | 95 | 51 | 146 |
| 2022 March | 69 | 54 | 123 |
| 2022 February | 84 | 48 | 132 |
| 2022 January | 180 | 24 | 204 |
| 2021 December | 73 | 39 | 112 |
| 2021 November | 71 | 37 | 108 |
| 2021 October | 75 | 35 | 110 |
| 2021 September | 73 | 34 | 107 |
| 2021 August | 71 | 34 | 105 |
| 2021 July | 75 | 29 | 104 |
| 2021 June | 68 | 18 | 86 |
| 2021 May | 88 | 41 | 129 |
| 2021 April | 153 | 31 | 184 |
| 2021 March | 132 | 23 | 155 |
| 2021 February | 118 | 22 | 140 |
| 2021 January | 66 | 27 | 93 |
| 2020 December | 53 | 18 | 71 |
| 2020 November | 46 | 17 | 63 |
| 2020 October | 41 | 13 | 54 |
| 2020 September | 58 | 8 | 66 |
| 2020 August | 46 | 14 | 60 |
| 2020 July | 46 | 8 | 54 |
| 2020 June | 64 | 6 | 70 |
| 2020 May | 49 | 13 | 62 |
| 2020 April | 64 | 10 | 74 |
| 2020 March | 74 | 19 | 93 |
| 2020 February | 73 | 18 | 91 |
| 2020 January | 98 | 16 | 114 |
| 2019 December | 77 | 24 | 101 |
| 2019 November | 82 | 24 | 106 |
| 2019 October | 50 | 11 | 61 |
| 2019 September | 86 | 15 | 101 |
| 2019 August | 46 | 21 | 67 |
| 2019 July | 57 | 24 | 81 |
| 2019 June | 53 | 18 | 71 |
| 2019 May | 77 | 20 | 97 |
| 2019 April | 92 | 31 | 123 |
| 2019 March | 65 | 17 | 82 |
| 2019 February | 42 | 20 | 62 |
| 2019 January | 48 | 15 | 63 |
| 2018 December | 138 | 41 | 179 |
| 2018 November | 192 | 22 | 214 |
| 2018 October | 201 | 14 | 215 |
| 2018 September | 106 | 19 | 125 |
| 2018 August | 123 | 20 | 143 |
| 2018 July | 100 | 17 | 117 |
| 2018 June | 71 | 11 | 82 |
| 2018 May | 80 | 19 | 99 |
| 2018 April | 79 | 4 | 83 |
| 2018 March | 54 | 10 | 64 |
| 2018 February | 61 | 5 | 66 |
| 2018 January | 48 | 5 | 53 |
| 2017 December | 56 | 4 | 60 |
| 2017 November | 33 | 6 | 39 |
| 2017 October | 45 | 7 | 52 |
| 2017 September | 42 | 10 | 52 |
| 2017 August | 41 | 10 | 51 |
| 2017 July | 50 | 6 | 56 |
| 2017 June | 35 | 8 | 43 |
| 2017 May | 65 | 15 | 80 |
| 2017 April | 36 | 18 | 54 |
| 2017 March | 34 | 9 | 43 |
| 2017 February | 30 | 11 | 41 |
| 2017 January | 28 | 8 | 36 |
| 2016 December | 46 | 6 | 52 |
| 2016 November | 57 | 14 | 71 |
| 2016 October | 65 | 23 | 88 |
| 2016 September | 76 | 9 | 85 |
| 2016 August | 79 | 3 | 82 |
| 2016 July | 98 | 5 | 103 |
| 2016 June | 61 | 0 | 61 |
| 2016 May | 104 | 0 | 104 |
| 2016 April | 79 | 0 | 79 |
| 2016 March | 73 | 0 | 73 |
| 2016 February | 91 | 0 | 91 |
| 2016 January | 68 | 0 | 68 |
| 2015 December | 39 | 0 | 39 |
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