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treatment&#44; and patient evolution&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Our patient was a 61-year old white male with a history of macrohaematuria and arterial hypertension after an oropharyngeal infection at 21 years of age&#46; A renal biopsy &#40;RB&#41; was taken at 31 years of age in Australia &#40;unknown result&#41;&#46; In December 2006&#44; at 57 years of age&#44; the patient was started on peritoneal dialysis&#46;</p><p class="elsevierStylePara">In April 2008&#44; the patient received a kidney transplant from a cadaveric donor&#46; The patient&#8217;s creatininaemia upon discharge was 0&#46;8mg&#47;dl&#44; with no proteinuria&#46; Immunosuppression therapy included cyclosporine&#44; mycophenolate mofetil &#40;MMF&#41;&#44; and prednisone&#46; 26 months after transplantation&#44; the patient showed dry cough&#44; feverish symptoms&#44; abdominal distension&#44; and pain&#46; Prior to hospitalisation&#44; we observed violate erythematous papullae on the legs and buttocks&#46; An examination revealed a congestive pharynx&#46; The violet coloured erythematous papullae were 1-3mm in size&#44; and did not disappear with compression of the thighs&#44; buttocks&#44; or feet &#40;Figure 1 A&#41;&#46; Palpation of the epigastric area produced pain&#46; The transplanted kidney was without pain or increased size&#46;</p><p class="elsevierStylePara">Laboratory results are summarised in Table 1&#46; Serology tests were negative for hepatitis B and C viruses&#44; human immunodeficiency virus&#44; anti-nuclear antibodies&#44; and anti-neutrophil cytoplasmic antibodies&#46; Complement was normal&#44; and blood was found in the faeces using immunological methods&#46;</p><p class="elsevierStylePara">The clinical presentation of signs and symptoms suggested HSP&#46; We performed a skin biopsy &#40;Figure 1 B&#41;&#44; with negative immunofluorescence results&#46; We observed a progressive increase in proteinuria&#44; which led us to take a renal biopsy that revealed intra- and extra-capillary proliferative glomerulonephritis with cellular and fibrocellular crescents&#44; mostly segmental in nature &#40;Figure 1 C&#41;&#44; with 14 of 25 glomeruli affected&#46; We also observed foci of necrosis and leukocytoclasia &#40;Figure 1 D&#41;&#46; Mesangial and pericapillary deposits were primarily IgA&#46;</p><p class="elsevierStylePara">In accordance with nationally recommended treatment protocols &#40;<a href="http&#58;&#47;&#47;www&#46;nefroprevencion&#46;org&#46;uy&#47;" class="elsevierStyleCrossRefs">www&#46;nefroprevencion&#46;org&#46;uy</a>&#41;&#44; we started treatment with boluses of methylprednisolone at 1g&#47;d for three days and cyclophosphamide at 15mg&#47;k for 6 months&#44; continuing with prednisone at 1mg&#47;k&#46; We maintained cyclosporine treatment at 2mg&#47;k&#47;d and suspended treatment with MMF&#46; The patient&#8217;s evolution is summarised in Table 1&#46;</p><p class="elsevierStylePara">Approximately 22 months after the appearance of HSP&#44; creatininaemia was 1&#46;21mg&#37;&#44; proteinuria was 0&#46;32g&#47;d&#44; and red blood cells were observed in urine samples&#46;</p><p class="elsevierStylePara">Moroni et al&#46;<span class="elsevierStyleSup">1</span> and Han et al&#46;<span class="elsevierStyleSup">2</span> described a risk of recurrence of HSP that varies between 0&#37; and 61&#37;&#44; with a greater rate of recurrence in the case of living donors related to the recipient&#46;</p><p class="elsevierStylePara">Thervet et al&#46;<span class="elsevierStyleSup">5</span> described histological recurrence &#40;IgA deposits&#41; of immunoglobulin A nephropathy &#40;IgAN&#41; one year after transplantation in 69&#37; of individuals&#46;</p><p class="elsevierStylePara">Shimizu et al&#46;<span class="elsevierStyleSup">3</span> described a case of post-transplant extra-capillary IgA glomerulonephritis&#46; The presence of abdominal pain suggested atypical HSP&#46; With the exception of this doubtful diagnosis&#44; there have been no cases described of post-transplant <span class="elsevierStyleItalic">de novo</span> appearance of HSP&#46; In the case described&#44; the absence of purpura prior to transplantation suggests that this is indeed a case of <span class="elsevierStyleItalic">de novo</span> HSP&#46;</p><p class="elsevierStylePara">In 1995&#44; Araque et al&#46;<span class="elsevierStyleSup">6</span> published the first case describing the appearance of HSP in a patient who had not received a transplant&#44; years after being diagnosed with IgAN&#46; In our case&#44; the patient&#8217;s previous medical history also suggests IgAN&#44; and the patient currently has HSP&#46;</p><p class="elsevierStylePara">The recurrence of HSP has a worse prognosis&#58; 50&#37; of patients lose their transplants within 30 months of recurrence&#44; as opposed to 11&#37; in the case of recurrent IgAN&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">HSP in adults is more severe and involves a worse prognosis than in children&#46; The study by Pillebout et al&#46;<span class="elsevierStyleSup">7</span> &#40;250 cases&#41; reported a 25&#37; rate of extreme renal failure in adult patients&#46; Initial renal function and level of proteinuria are both markers for poor prognosis&#44; as well as glomerular necrosis&#44; and chronicity elements&#46; Our case showed an important inflammatory component&#44; cellular crescents&#44; and necrosis in more than 50&#37; of glomeruli&#46; Soler et al&#46;<span class="elsevierStyleSup">8</span> reported that the renal prognosis worsened in the presence of cellular crescents&#46;</p><p class="elsevierStylePara">The discordance between clinical and histological results suggests the need for performing a renal biopsy on all adult patients with compromised renal function in the context of HSP&#46;</p><p class="elsevierStylePara">As regards treatment&#44; immunosuppression following transplantation did not prevent the appearance of HSP&#46; This has been reported in other studies as well&#46;<span class="elsevierStyleSup">2&#44;9&#44;10</span></p><p class="elsevierStylePara">While the treatment strategy for HSP is a source of controversy&#44; small studies have demonstrated a benefit from aggressive treatment protocols in these patients&#46; However&#44; the study published by Pillebout in September 2010&#44;<span class="elsevierStyleSup">11</span> after our patient was treated&#44; showed that cyclophosphamide provides no additional benefits&#46; In this study&#44; extra-capillary proliferation ranged between 27&#37; and 37&#37; of patients in each treatment group&#46; Our patient had more severe active lesions&#46; Maintenance therapy was carried out using azathioprine&#44; given the reports of scarce usefulness of MMF in treating IgAN from the medical literature&#46;<span class="elsevierStyleSup">12&#44;13</span> We observed a progressive reduction in proteinuria&#44; which currently is below 0&#46;5g&#47;d&#44; with stable renal function&#46;</p><p class="elsevierStylePara">The notable conclusions from this case report are&#58;</p><p class="elsevierStylePara">1&#46;&#160; The <span class="elsevierStyleItalic">de novo</span> appearance of post-transplant HSP despite the use of immunosuppression therapy&#46;</p><p class="elsevierStylePara">2&#46;&#160; The need for an early histological analysis given the discordance between clinical and pathological findings&#46;</p><p class="elsevierStylePara">3&#46;&#160;The controversy regarding how to treat this condition&#44; taking into account that the evolution of HSP is quite severe in adults&#44; and the fact that more aggressive treatment strategies were recently questioned by the Pillebout group&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors state that they have no potential conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><a href="grande&#47;11468&#95;108&#95;39801&#95;en&#95;t111&#46;jpg" class="elsevierStyleCrossRefs"><img src="11468_108_39801_en_t111.jpg" alt="Laboratory results and treatment provided"></img></a></p><p class="elsevierStylePara">Table 1&#46; Laboratory results and treatment provided</p><p class="elsevierStylePara"><a href="grande&#47;11468&#95;108&#95;39802&#95;en&#95;f111&#46;jpg" class="elsevierStyleCrossRefs"><img src="11468_108_39802_en_f111.jpg" alt="Skin and kidney histology "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Skin and kidney histology </p>"
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