A 10-Year-Old Girl with Gastrointestinal Hemorrhage

Abstract

A 10-year-old girl presented to our hospital with arthralgia in the lower extremities and abdominal pain. Laboratory tests were normal. Urinalysis was negative for hematuria and proteinuria. Stool for occult blood test was negative. She was given oral ibuprofen for joint pain. On the same day she also presented with fever and sore throat, so she was given oral clavulanic-amoxicillin. After a few days she presented to our hospital with advanced polyarthralgias (affecting her wrists and ankles in particular) and two episodes of vomiting.She was admitted to our unit, at which point she suddenly presented with severe abdominal pain localized in the epigastric and the lower quadrant of her abdomen, leading to hematemesis and melena. On physical examination there were discreet general conditions, the abdomen was soft, and only deep palpation evoked diffuse moderate pain. Cardiac and lung findings were normal. The girl also presented with swollen and painful wrists and ankles, and a few purpuric lesions appeared on her lower extremities and eyelid.We suspended anti-inflammatory oral therapy and began omeprazole intravenously. We positioned nasogastric and rectal tubes. Laboratory tests revealed normal values of hemoglobin and coagulation parameters, C-reactive protein of 2.1 mg/dL (normal value <.5 mg/ dL), and normal renal and liver function. Urinalysis was negative for hematuria and proteinuria. Abdominal ultrasound showed thickening of the duodenal wall (Figure 1). Esophagogastroduodenoscopy showed multiple erosions in the duodenum with hyperemic gastric mucosa, and the biopsies were compatible with leukocytoclastic vasculitis (Figure 2). Steroid therapy with intravenous methylprednisolone at 2 mg/kg was started. The patient showed progressive improvement of her general condition in the first 24 hours, and 2 days later we removed the nasogastic tube and she began a liquid diet and then began to eat lighter foods. The patient was discharged from the hospital, and her laboratory and radiological follow-up results showed complete regression of the lesions after 3 weeks of steroid therapy (Figure 3).