Palpable Purpura in a Boy With Abdominal Pain: Challenge

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An 11-year-old previously healthy boy presented to the Emergency Department on 3 separate occasions over 5 days for diffuse, progressive abdominal pain and vomiting. He was repeatedly diagnosed with constipation by kidney, ureter, and bladder x-ray and treated with laxatives which relieved some stool burden but did not help the severe, colicky abdominal pain. On the third visit, an abdominal computed tomography was concerning for inflammatory or infectious enteritis. He was admitted to the pediatric hospital.
On hospitalization day 2, the patient developed painful palpable purpura of the left cheek as well as scattered purpura and petechiae of bilateral arms. These lesions quickly progressed to symmetrically involve the buttocks, thighs, and ankles, bilaterally (Fig. 1). After this, he had 3 episodes of bloody stool incontinence. Soft-tissue lumbar swelling was also noted. Over subsequent days, he developed joint pain of wrists, low back, knees, and ankles aggravated by ambulation. Oral intake became painful at which point soft palate petechiae were noted.
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