Guest guest Posted September 22, 2004 Report Share Posted September 22, 2004 Hi Chris > I've posted the NYT article under the file " Case Studies " on the > site, in two formats :20040921_NYT_Connect_Sx.doc -- > MS Word 97 (from Windows/NT OS) and 20040921_NYT_Connect_Sx.txt -- > in " flat-text " format, readable in any word-processor. Very interesting case!, Chris Have you a TCM Dx / explanation for it? The full urls for the article are: MS Word 97 version: http://tinyurl.com/6d3rr flat-text version: http://tinyurl.com/5o7mz The text version is: Connecting the Symptoms, From Skin to Joints to Abdomen By PERRI KLASS, M.D. Published: September 21, 2004 [New York Times] It sounds like the beginning of a teaching case for medical students: A 14-year-old girl with a chief complaint of abdominal pain. How the story unfolds could turn out to be a lesson in the difficulty of diagnosing appendicitis, or a reminder that there are many different organs that can cause pain in the general region of the abdomen - the digestive system, the urinary tract and, of course, the reproductive system. Abdominal pain in an adolescent girl can have a simple common explanation - chronic constipation, say, or acute gastroenteritis - but it cannot be taken for granted as a simple question. So, a 14-year-old girl who had never been to my health center before walked in one day, complaining that her stomach had been hurting since the night before, with the pain right in the middle, around her belly button. She had vomited twice, but she had not had any fever or any pain with urination. In the past, she had occasionally been troubled by constipation. When the doctor examined her and pressed on her belly, it hurt her, both in the middle, and also on the left side. But the pain was not terribly severe, her abdomen was not swollen or distended, and there didn't seem to be any swelling of her liver or her spleen. When her urine was tested, it was mostly notable for a lot of red blood cells - not surprising, since she had her menstrual period. But there weren't any white blood cells, the way there would be if she had a urinary infection, or even if she was developing appendicitis. So the best guess, that first day, was constipation: no fever, no evidence of infection, mild pain on the wrong side for appendicitis, normal urine. The teenager was given a prescription for a laxative to take over the next three days and sent home, after extensive discussion, via an interpreter because the family spoke only Vietnamese, about what to do if the pain got worse. The pain did get worse, and her parents brought her to an emergency room, where a new set of doctors examined her all over again, and did an ultrasound of her abdomen, which looked normal. When the surgeons were convinced that she had " nothing surgical " going on, no appendicitis or intestinal compromise or peritonitis, they admitted her and gave her intravenous fluids and morphine. Initially, she seemed to be doing better, but the doctors taking care of her weren't satisfied. On a CT scan of her abdomen, they saw what looked like inflammatory disease of her bowel. So the community hospital transferred her to a big teaching hospital. Pediatric gastroenterologists planned an upper endoscopy and a colonoscopy. And then the rash on her legs developed. She hadn't had a rash when she first came into the health center. The only thing notable about her skin exam had been the marks left by the common Vietnamese practice of coining, rubbing a sick person's skin with a coin [gwa-sha! (note by C.Macie)]: marks on her neck and around her belly button, regular, recognizable linear striations. But in the hospital she developed strange new marks, four to six small lesions on each ankle. And the endoscopy showed petechiae in her small intestine, small dark red marks that suggest damage to the blood vessels. This confirmed the diagnosis: Henoch-Schonlein purpura. Purpura is the medical term for a particular, and particularly alarming, type of skin lesion, red or purple patches that reflect not the redness of inflammation or infection, like most rashes, but the weakening and leaking of small blood vessels in the skin. You can check whether a rash is purpura by pressing on it - most rashes blanch white, as you press the blood out of the vessels, then turn pink again when you take your finger away and the blood rushes back. Purpura stay red - or purple - when pressed; the blood has already leaked out of the vessels and infiltrated the skin. Purpural lesions are alarming because they suggest the possibility of serious diseases - overwhelming infection, which can turn blood vessels leaky and prevent blood from clotting properly, or inflammations of the circulatory system, like Henoch-Schonlein purpura. Though this syndrome is not an infection, it sometimes follows an infection, usually a sore throat or a cold. It seems to be an autoimmune problem, in which, for some unknown reason, the body attacks itself, leading to inflammation of the blood vessels, or vasculitis. Most types of vasculitis affect some particular set of blood vessels, and Henoch-Schonlein goes for the small vessels, the arterioles and capillaries - in the skin and often in the kidneys. Most commonly, the illness starts with the rash, raised symmetrical marks usually over the buttocks and on the legs, along with joint pain and, yes, abdominal pain. When the blood vessels in the kidney are affected, blood and protein may show up in the urine, so perhaps those red blood cells in that initial urine test were more than just menstruation. The abdominal pain can be so severe that people have been taken to the operating room for appendectomies - especially if, as in this case, the rash was slow to emerge. Most of the time, this is a self-limited disease, though occasionally major abdominal problems can develop - serious bleeding or even perforation. The inflammation in the kidneys usually gets better, but there is a risk of lasting kidney damage. This 14-year-old girl was treated with corticosteroids to help decrease the inflammation faster, and her abdominal pain got better. She did have blood in her urine, and specialists will continue to check her. And thanks to careful diagnostic attention and thoughtful surgeons - and perhaps to the timely appearance of her purpura - she didn't have to undergo abdominal surgery. So who were Henoch and Schonlein? Johann Lukas Schonlein was a German physician-scientist in the 19th century, and personal physician to King Frederick William IV of Prussia. He was well- known as a teacher, and he described Schonlein's purpura, the association between the skin rash and the joint problems. Eduard Heinrich Henoch was a German pediatrician who lived from 1820 to 1910, studied under Schonlein and described the skin lesions associated with abdominal pain. He called it, in that 1868 description, Schonlein-Henoch purpura, crediting his teacher with the initial description. You will still find the two eponyms used separately - Schonlein's purpura for skin and joint symptoms, Henoch's purpura for skin and abdominal symptoms - but in the most common term now used for the syndrome, the two names have switched position. Or you can dispense with the eponyms and call it anaphylactoid purpura. Still, the two names, with the history they imply of piecing together the connections among a complex set of symptoms and tracing them to a common pathology, seem very appropriate for a disease that can still puzzle as it challenges us to connect the spots. Best regards, Email: < WORK : Teagasc Research Management, Sandymount Ave., Dublin 4, Ireland Mobile: 353-; [in the Republic: 0] HOME : 1 Esker Lawns, Lucan, Dublin, Ireland Tel : 353-; [in the Republic: 0] WWW : http://homepage.eircom.net/~progers/searchap.htm Chinese Proverb: " Man who says it can't be done, should not interrupt man doing it " Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 23, 2004 Report Share Posted September 23, 2004 Phil- I have a friend in Boston who came across a young boy who had the purple blotches on his skin from H-S purpura. He did laser acup on this boy, and concentrated on SP 1 and SP 6. The boy's mother was frantic that, while medications would in time heal the infection causing the purpura, there is still a danger of the " port wine " stains remaining on the boy. The boy feared needles, so just SP 1 and SP 6 were zapped. The blotches cleared up in 2-3 txs. Spleen controlling the vessels. John Garbarini --- < wrote: > Hi Chris > > > I've posted the NYT article under the file " Case > Studies " on the > > site, in two formats > :20040921_NYT_Connect_Sx.doc -- > > MS Word 97 (from Windows/NT OS) and > 20040921_NYT_Connect_Sx.txt -- > > in " flat-text " format, readable in any > word-processor. > > Very interesting case!, Chris Have you a TCM Dx / > explanation for > it? > > The full urls for the article are: > MS Word 97 version: http://tinyurl.com/6d3rr > flat-text version: http://tinyurl.com/5o7mz > > The text version is: > > Connecting the Symptoms, From Skin to Joints to > Abdomen > By PERRI KLASS, M.D. Published: September 21, 2004 > [New > York Times] > > It sounds like the beginning of a teaching case for > medical > students: A 14-year-old girl with a chief complaint > of abdominal > pain. > > How the story unfolds could turn out to be a lesson > in the difficulty > of diagnosing appendicitis, or a reminder that there > are many > different organs that can cause pain in the general > region of the > abdomen - the digestive system, the urinary tract > and, of course, > the reproductive system. Abdominal pain in an > adolescent girl can > have a simple common explanation - chronic > constipation, say, or > acute gastroenteritis - but it cannot be taken for > granted as a > simple question. > > So, a 14-year-old girl who had never been to my > health center > before walked in one day, complaining that her > stomach had been > hurting since the night before, with the pain right > in the middle, > around her belly button. She had vomited twice, but > she had not > had any fever or any pain with urination. In the > past, she had > occasionally been troubled by constipation. > > When the doctor examined her and pressed on her > belly, it hurt > her, both in the middle, and also on the left side. > But the pain was > not terribly severe, her abdomen was not swollen or > distended, and > there didn't seem to be any swelling of her liver or > her spleen. > When her urine was tested, it was mostly notable for > a lot of red > blood cells - not surprising, since she had her > menstrual period. > But there weren't any white blood cells, the way > there would be if > she had a urinary infection, or even if she was > developing > appendicitis. > > So the best guess, that first day, was constipation: > no fever, no > evidence of infection, mild pain on the wrong side > for appendicitis, > normal urine. > > The teenager was given a prescription for a laxative > to take over the > next three days and sent home, after extensive > discussion, via an > interpreter because the family spoke only > Vietnamese, about what > to do if the pain got worse. > > The pain did get worse, and her parents brought her > to an > emergency room, where a new set of doctors examined > her all over > again, and did an ultrasound of her abdomen, which > looked normal. > When the surgeons were convinced that she had > " nothing surgical " > going on, no appendicitis or intestinal compromise > or peritonitis, > they admitted her and gave her intravenous fluids > and morphine. > > Initially, she seemed to be doing better, but the > doctors taking care > of her weren't satisfied. On a CT scan of her > abdomen, they saw > what looked like inflammatory disease of her bowel. > So the > community hospital transferred her to a big teaching > hospital. > Pediatric gastroenterologists planned an upper > endoscopy and a > colonoscopy. > > And then the rash on her legs developed. She hadn't > had a rash > when she first came into the health center. The only > thing notable > about her skin exam had been the marks left by the > common > Vietnamese practice of coining, rubbing a sick > person's skin with a > coin [gwa-sha! (note by C.Macie)]: marks on her neck > and around > her belly button, regular, recognizable linear > striations. But in the > hospital she developed strange new marks, four to > six small > lesions on each ankle. And the endoscopy showed > petechiae in > her small intestine, small dark red marks that > suggest damage to > the blood vessels. This confirmed the diagnosis: > Henoch-Schonlein > purpura. > > Purpura is the medical term for a particular, and > particularly > alarming, type of skin lesion, red or purple patches > that reflect not > the redness of inflammation or infection, like most > rashes, but the > weakening and leaking of small blood vessels in the > skin. > > You can check whether a rash is purpura by pressing > on it - most > rashes blanch white, as you press the blood out of > the vessels, > then turn pink again when you take your finger away > and the blood > rushes back. Purpura stay red - or purple - when > pressed; the > blood has already leaked out of the vessels and > infiltrated the skin. > > Purpural lesions are alarming because they suggest > the possibility > of serious diseases - overwhelming infection, which > can turn blood > vessels leaky and prevent blood from clotting > properly, or > inflammations of the circulatory system, like > Henoch-Schonlein > purpura. > > Though this syndrome is not an infection, it > sometimes follows an > infection, usually a sore throat or a cold. It seems > to be an > autoimmune problem, in which, for some unknown > reason, the > body attacks itself, leading to inflammation of the > blood vessels, or > vasculitis. > > Most types of vasculitis affect some particular set > of blood vessels, > and Henoch-Schonlein goes for the small vessels, the > arterioles > and capillaries - in the skin and often in the > kidneys. Most > commonly, the illness starts with the rash, raised > symmetrical > marks usually over the buttocks and on the legs, > along with joint > pain and, yes, abdominal pain. > > When the blood vessels in the kidney are affected, > blood and > protein may show up in the urine, so perhaps those > red blood cells > in that initial urine test were more than just > menstruation. The > abdominal pain can be so severe that people have > been taken to > the operating room for appendectomies - especially > if, === message truncated === Quote Link to comment Share on other sites More sharing options...
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