Abdominal wall and labial edema presenting in a girl with Henoch-Schönlein purpura: a case report

<p>Abstract</p> <p>Introduction</p> <p>Henoch-Schönlein purpura is a common immunoglobulin A-mediated vasculitic syndrome in children, characterized by purpuric rash, arthritis and abdominal pain. Renal involvement, manifested by the presence of hematuria and/or proteinuria, is also frequently seen. In most cases, patients with this disease achieve complete recovery, but some progress to renal impairment. Gastro-intestinal manifestations are present in two-thirds of affected patients and range from vomiting, diarrhea, and peri-umbilical pain to serious complications such as intussusception and gastrointestinal hemorrhage.</p> <p>Case presentation</p> <p>We report the case of a 7-year-old Caucasian girl who presented with abdominal pain, labial swelling, and a large abdominal ecchymosis two weeks after having been diagnosed with Henoch-Schönlein purpura. A computed tomography scan revealed abdominal wall edema extending to the groin, without any intra-abdominal pathology. She was successfully treated with intravenous steroids.</p> <p>Conclusion</p> <p>Circumferential anterior abdominal wall edema and labial edema have never been reported previously, to the best of our knowledge, as a complication of Henoch-Schönlein purpura. These findings further contribute to the wide spectrum of manifestations of this disorder in the literature, aiding in its recognition and management.</p

Surgical vs. nonsurgical management of post-traumatic intercostal lung herniation in children

Background: Intercostal lung herniation (ILH) is an exceptionally rare condition in pediatric patients, characterized by disruption of fascial planes and intercostal musculature allowing for protrusion of a portion of the lung parenchyma into this space. In most cases it is a consequence of blunt chest trauma. Due to the rarity of the condition, diagnostic and management approaches are based on the experience in adults, where CT is the most often used diagnostic tool, and surgery is the primary management approach. Recent published experience in adult and pediatric patients supports the use of less invasive imaging and management strategies, particularly in otherwise asymptomatic patients, giving us the opportunity to reconsider our clinical approaches in the diagnosis and management of these patients. Methods: We present a recent case of posttraumatic ILH. In addition, we conducted a systematic review of the literature. A search of the PubMed, Embase, Ovid, Scopus and Cochrane databases was conducted using a combination of the following search terms: intercostal lung hernia in children, lung herniation in children, traumatic intercostal lung hernia in children. Two authors independently extracted data, reviewed the abstracts, and assessed them for inclusion in the review. Results: All reported cases were single case reports, with total of 16 including our patient. All ILH were unilateral. The most common etiology was bicycle handle bar injury 10 (63%). Herniation was found on the anterior chest wall in 13 (81%) patients, and in 3 (19%) was on the anterolateral chest wall. To confirm the diagnosis chest x-ray was used in 14 (88%) patients, CT chest in 7 (44)%, fluoroscopy in 1 (6%), chest ultrasound in 3 (19%), and in 1 patient there was no imaging documented. Management was surgical in 10 patients (63%) including thoracotomy with primary closure in 8 patients and thoracoscopic repair in 2 patients. Six patients (37%) had nonsurgical management by chest strapping, with complete resolution of herniation within 2â6 weeks. There was no reported complications or recurrence following either type of management. Conclusions: Postraumatic intercostal lung herniation in children is a rare condition. Including our case reported here, there are only 16 reported cases. In children ILH is mostly seen after blunt chest trauma caused by bicycle handle bar injury. Given the rarity of the condition, the pediatric literature on this subject is scarce, with no published guidelines or evidence based recommendations for imaging and management approaches (surgical vs. nonsurgical). Although rare, the pediatric surgeon should be familiar with this condition in order to avoid potentially harmful, invasive or unnecessary diagnostic and therapeutic approaches that are extrapolated from experience in adult patients. Noninvasive imaging modalities including chest radiographs and ultrasound, and nonsurgical management of posttraumatic intercostal lung herniation should be considered as an initial treatment option in the management of asymptomatic patients

Free intestinal perforation in children with Crohn's disease

Background: Free intestinal perforation in children with Crohn's disease (CD) is a rare, but serious complication that requires urgent surgical management. The incidence, contributing risk factors, diagnostic workup, and management strategies for these complex pediatric patients are not well established. Methods: We present a recent case of free intestinal perforation in a patient with CD. In addition, a systematic review of the literature was conducted by searching the PubMed, Embase, Ovid, Scopus and Cochrane databases. Two authors independently extracted data, reviewed the abstracts, and assessed them for inclusion in the review. Results: The literature review identified 21 pediatric patients documented in 14 publications; including our case, there are a total of 22 pediatric patients reported. The majority of patients presented with features of peritonitis. Perforation occurred early in the disease course (median 6.5 months), and was most commonly a single perforation in the ileum with active Crohn's disease (82%). Colonic perforation occurred in 18% of patients. All patients underwent urgent surgical management. Surgical approaches included resection of the diseased bowel segment with proximal diversion in eleven patients (50%), resection with primary anastomosis in 9 (41%) or direct suture repair in two (9%). Both patients who underwent simple primary repair developed post-operative complications. Conclusions: Free intestinal perforation may occur at any age and stage of Crohn's disease. Three-dimensional imaging may be required to confirm the diagnosis. The management of free intestinal perforation in CD is surgical. This should involve resection of the involved segment with proximal diversion or resection with primary anastomosis in selected cases. Primary suture closure of the perforation is discouraged. Keywords: Free intraperitoneal perforation, Pediatric Crohn's diseas