Arch Dis Child: first published as 10.1136/adc.22.112.242 on 1 December 1947. Downloaded from PURPURA AND INTUSSUSCEPTION BY H. WOLFSOHN, M.D., M.R.C.P., D.C.H. (From the Fulham Hospital, London) As early as 1808 Willan described visceral crises hours previously. On the outer side of the swollen occurring with purpura. Henoch published his right elbow he had an extensive ecchymosis, and in classical paper in 1874, after which date abdominal the right cubital fossa there was one definite purpuric purpura became associated with his name. The spot. He also had a boil on his right thigh. No urticarial lesions were seen. first report of intussusception with purpura appears Abdomen. Liver and spleen were not palpable. to have been that of Vierhuff (1893). Since then, In the right iliac fossa a hard irregular mass was f.lt as far as can be ascertained, this combination has which was very slightly tender. It could be readily been reported only nineteen times. It is for this moved up and down but less easily sideways. It reason and because of the many interesting points appeared to be in the peritoneal cavity. It occupied this conclition raises that a further case is recorded. most' of the right iliac fossa. A knob on its out-r side was attached to the main mass. On rectal examination semi-solid yellow faeces without blood Case Report were found, and no other abnormality was detected. Protected by copyright. A male child aged four years and eight months Cardiomuscular, respiratory, lymphatic, and central was admitted to hospital on Nov. 12, 1946. A nervous systems appeared normal. month earlier he had had an attack of abdominal INVESTIGATIONS. The Mantoux test, 1-10,000, pain an(i vomiting which subsided rapidly and was negative. Red blood cells numbered 6,180,000 which was labelled 'chill on the liver.' Otherwise per c.mm. of blood; haemoglobin was 120 per cent., his earlier childhood had been uneventful except colour index 0 9, white cells 18,100 per c.mm., for measles, whooping cough, and tonsillitis. He polymorphs 76 per cent., lymphocytes 20 per cent., was an only child. Both his parents were healthy monocytes 4 per cent., and blood platelets 238,000 and had not suffered from any of the 'allergic per c.mm. diseases. tThere was a trace of albumin in the urine; no Four days before admission he complained of red blood cells were seen. Culture was sterile, and pain in his left knee and the mother noticed that there was a yellow reduction of Benedict's there was much swelling. The next day his right solution. elbow became swollen and painful. He was then Bleeding time was 21 minutes, coagulation time taken to his doctor, who diagnosed rheumatic fever 31 minutes, and the tourniquet test negative. http://adc.bmj.com/ and prescribed sodium salicylate. On Nov. 12 the A tentative diagnosis of purpura with rheumatic swelling of his left knee had subsided but his right (Schonlein's) and abdominal (Henoch's) symptoms elbow and right wrist were painful. At noon on was made, but in view of the abdominal mass this day he suddenly developed severe abdominal the possibility of intussusception could not be pain, which was soon followed by vomiting. At the excluded. same time purpuric spots were observed on buttocks PROGRESS. On Nov. 13 he vomited watery fluid and right arm and he was transferred to hospital once during the night. He had no appetite and as a possible case of Henoch's purpura. His bowels became more dehydrated. The abdominal lump on September 30, 2021 by guest. had been regular until then, and no blood was could still be felt. Intravenous therapy (glucose noticed in the stool passed that morning. saline and plasma) was begun. Next day he was On examination he was found to be normally still vomiting and the petechiae were paler. At the developed and thin. He was apyrexial and quite advice of the paediatric consultant, expectant alert. His skin was of striking pallor, but the treatment was continued. conjunctival mucosa was well coloured. On Nov. 15 his general condition had deteriorated, Joints. He complained of no pain in the joints, anorexia, vomiting, and dehydration being marked. and all movements were unrestricted and painless. There' had been no bowel action since admission. There was some swelling of his right elbow, and The cardiac rate was now 150 per minute, although pogsibly also of the right wrist. temperature was still normal. The vomit contained Rash. A crop of petechial haemorrhages was upper intestinal contents. The abdomen was more found on his buttocks which, according to the distended; and the lump, unchanged in size and mother, had been larger and more distinct a few shape, was slightly more tender. Purpura was still 242 Arch Dis Child: first published as 10.1136/adc.22.112.242 on 1 December 1947. Downloaded from PURPURA AND INTUSSUSCEPTION 243 present but only very faintly. In.spite of dehydra- were petechial spots on both elbows. He vomited tion there was now frequency of micturition and the after taking salicylate, so this was changed to.aspirin urine gave an orange reaction to Benedict's solution tablets and to calcium aspirin gr. 10, three times #i and contained ketone 'bodies. Capillary blood day. Sulphadiazine was discontinued. sugar at 4 p.m. was 313 mg. per cent. The occur- On Nov. 24 the rash round the elbows had become rence of diabetic symptoms was considered to be more profuse. Some spots were truly petechial, due to a temporary toxic exhaustion ofislet function. others were raised. At night the temperature was As conservative measures, continued over three still 990 F. By Nov. 25 there was swelling and days,. had not resulted in any improvement, as the bruising of the right metacarpo-phalangeal joint of abdominal mass had remained unchanged during the right thumb, with recurrence ofswelling ofright the time of observation, and as the child had-become wrist and dorsum of the right hand. There was extremely ill from acute intestinal obstruction, more purpura also on the left elbow, but no other laparotomy was decided on. The intravenous drip petechiae were seen. The chest was now clinically was carried on throughout the operation and during clear, and penicillin and all salicylates were stopped. the next two days. Penicillin (15,000 units every He was afebrile. three hours) was given intramuscularly, and soluble On Nov. 29 he complained of abdominal pain insulin in doses oftwenty units at 4 p.m., at 5.30 p.m., and pain in the right lower chest. There were no and again at 7 a.m. the next day, when his urine abnormal signs. On Dec. 11 a swelling appeared stilLgave a green reaction to Benedict's solution. over left tempero-mandibular joint, and also over OPERATION. At operation (under nitrous oxide the right frontal region and in the right knee joint.. and ether anaesthesia) blood-stained fluid appeared The temperature had risen to 1020 F. by next morn- when the peritoneum was opened. An irreducible ing, but gradually fell to normal by Dec. 17. The ileo-ileal intussusception was found, with its apex right testis was tender and slightly enlarged. A about six inches from the ileo-caecal valves. This radiograph of the skull showed nothing abnormal. was resected from four inches above to two inches By Dec. 17 he was afebrile and symptom-free, below the intussusception and a side-to-side the bowels were regular, the abdomen soft, and Protected by copyright. anastomosis performed to restore' the continuity of there were no signs or symptoms in the joints and the gut. Rapid examination of the peritoneal no urticarial or purpuric eruptions. The blood contents showed no purpuric haemorrhages. The sedimentation rate was 40 mm. in the first hour. wound was closed in layers. The removed specimen On Dec. 31 he was transferred to Queen Mary's consisted of about eight inches of intussuscepted Hospital, Carshalton. Radiography ofchest, joints, small intestine causing haemorrhagic infarction. and long bones revealed nothing abnormal. The On Nov. 16 the general condition was much better. blood sedimentation rate varied between 35 mm. The pulse was full and good, and there was no and 1-0 mm. per hour up till the middle of March, further vomiting. At 3.30 p.m. the child became 1947, and has been normal since then. He has had suddenly worse and failed to respond to questions. several short febrile episodes, one accompanied by He was unable to swallow and had a squint and a abdominal pain, two by finger sepsis, and one by right plantar extensor response. As this attack neck pain radiating in turn to either ear. He has occurred so rapidly, and more than eight hours received dental treatment and has had aspirin after his last dose of soluble insulin, it was not administered for several weeks. No further purpura considered to be due to hypoglycaemia, particularly has been noted. http://adc.bmj.com/ as his intravenous glucose saline infusion was still In July, 1947, there was a further attack of in progress. The blood sugar was, however, not abdominal pain, accompanied on one occasion by examined. The possibility of a purpuric intra- passage of bright red blood. There were no other cerebral haemorrhage was dismissed as unlikely. purpuric manifestations, and he was symptom-free The attack was probably due to a small cerebral after two days. embolus. On the next day he was gradually regain- ing consciousness, and by Nov. 18 was fully Analysis of this and Previously Reported Cases conscious, talking, and swallowing well, with no on September 30, 2021 by guest.