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Erythema multiforme in a 14‐year‐old girl with Henoch‐Schönlein purpura and pancolitis: a relationship with mesalazine?

The most common vasculitis in childhood is Henoch-Schönlein purpura (HSp), a type of small vessel inflammation leading to leukocyte rupture mediated by immunoglobulin A-dominant immune complexes, mostly involving the skin, gastrointestinal tract, joints and kidneys [1, 2]. Due to the variety of clinical manifestations, management of HSp represents a special challenge requiring interdisciplinary collaboration [3, 4]. Mesalazine (5-aminosalicylic acid) can be useful in managing specifically abdominal distress with HSp due to its anti-inflammatory role in the treatment of chronic inflammatory bowel disease [5]. A fourteen-year-old girl developed small reddish-purple lesions on her lower and upper extremities associated with nonspecific joint pain in Macedonia, where she lived. Ten days later the girl was transferred to Italy and admitted to another hospital: her skin lesions were compatible with a clinical diagnosis of HSp. Abdominal pain was also present. Hematological tests, urinalysis, serum electrolytes, renal and liver function tests, immunoglobulins and abdominal ultrasonography were all normal. Skin biopsy, carried out on her left leg, revealed a “leukocytoclastic vasculitis” with fibrinoid necrosis of vessels and neutrophil infiltration. Corticosteroid therapy was accordingly started at full dosage. Six days later the girl had rectal bleeding and arrived at our polyclinic for further investigation. A complete blood count showed leukocytosis (white blood cells 25,120/mm3, normal 4000–10,000, neutrophils 86 %), C-reactive protein was increased (24.1 mg/l; normal < 5), clotting test and complement were normal, while the results of anti-Saccharomyces cerevisiae antibodies, anti-neutrophil cytoplasmic antibodies and microbiological stool cultures were negative. Gas distension and segmental thickening in the large intestine were noted on plain abdominal radiographs and ultrasonography. Intestinal bleeding persisted for 48 hours after admission. Parenteral nutrition, metronidazole, ciprofloxacin and intravenous methylprednisolone were started, but abdominal distress with bloody diarrhea reappeared. A transient intussusception of the ileum was noted on ultrasonography, while colonoscopy revealed a severe pancolitis with extensive inflammation from the cecum to rectum associated with scattered targetoid ulcers in the descending colon. Because of Clinical Letter