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# Rheumatoid purpura and gastrointestinal obstruction

Florian Martinet-Kosinski, Ophélie Bacoeur-Ouzillou, Géraud Galvaing, Johan Gagnière

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Florian Martinet-Kosinski, Ophélie Bacoeur-Ouzillou, Géraud Galvaing, Johan Gagnière. Rheumatoid purpura and gastrointestinal obstruction. Surgery Open Digestive Advance, 2025, 17, pp.100187. 10.1016/j.soda.2024.100187. hal-05485708

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Submitted on 30 Jan 2026

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Case report

# Rheumatoid purpura and gastrointestinal obstruction

Florian Martinet-Kosinski<sup>a,\*</sup>, Ophélie Bacoeur-Ouzillou<sup>a,b</sup>, Géraud Galvaing<sup>c</sup>, Johan Gagnière<sup>a,d</sup>

<figure><img src="image_3.png" /></figure>

ARTICLE INFO

Article History:

Received 19 September 2024

Revised 5 November 2024

Accepted 17 November 2024

Available online 30 January 2025

Keywords:

Henoch-Schönlein purpura

Digestive obstruction

Case report

Terminal ileitis

ABSTRACT

Purpura rheumatoid, also known as Henoch-Schönlein syndrome (HSP) is a small vessels vasculitis associated with immune complex deposits of IgA. Although it predominantly affects children, it can occur at any age. Gastrointestinal symptoms are frequent, but varying according to clinical series, and may include pain, diarrhea and bleeding. We report the case of a 64-year-old woman who had a relapse of her rheumatoid purpura presenting with terminal ileitis that resulted in an occlusion.

© 2024 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Introduction

Schönlein-Henoch syndrome, also known as rheumatoid purpura, is a systemic vasculitis affecting small blood vessels. Tissue accumulation of IgA-based immune complexes is associated with this illness. Although the disease can occur at any age, it primarily affects young patients (Occurrence of 70 per 100,000 in the 4–7 age group). In adults, incidence is extremely rare, around 1 case per 1 million individuals [1]. This condition affects multiple organs and manifests mainly as flare-ups with combined symptoms: cutaneous (vascular purpura), articular (arthralgia especially of the knees and ankles) and gastrointestinal (spasmodic pain, occult digestive hemorrhage). Gastroenterological complications include terminal ileitis, similar to the Crohn's disease ileitis.

Cas report

A 64-year-old woman presented to the emergency department complaining of dyspnea, respiratory distress, metabolic acidosis, hypotension, and abdominal obstruction linked to vomiting and distension on the abdomen. She reported chronic diarrhea. Informed consent for using clinical data was obtained from the patient.

Her medical history included a Mac Burney appendectomy, a right lobectomy performed in 2013 to treat a bronchial adenocarcinoma, and a left lobectomy performed in 2016 to treat a recurrence without the need of adjuvant therapy. A skin biopsy performed in relation to this neoplasm indicated Henoch-Schönlein purpura, presenting as purpura

on the extremities, joint involvement and gastrointestinal symptoms (edematous mucosal thickening of the jejunal and ileal areas on CT scan). A CT scan ruled out paraneoplastic syndrome. After corticosteroid treatment, the patient experienced a relapse in 2021 with joint and skin involvement, for which she was treated with MYCOPHENOLIC ACID.

When admitted to the emergency department in 2023, she presented with dyspnea, acid-base imbalance and abdominal obstruction. A thoraco-abdominal CT scan identified pulmonary embolism, ileitis and no signs of infection. Terminal ileitis (Fig. 1), resulted in an occlusive syndrome compressing the left colon without any sign of ischemic enteritis. Hypotension was rapidly controlled by fluid infusion. Her abdomen was markedly distended with diffuse tenderness. A new purpura episode had been evolving over twenty days, with concurrent progressive onset of arthralgia, extension of the skin involvement (purpura of the ankles), and intense abdominal pain with profuse diarrhea for 48 h. The metabolic acidosis was attributed to gastrointestinal bicarbonate loss.

Surgery was not indicated in this case. After inserting a nasogastric tube, a bolus of corticosteroids (2 mg/Kg/day) was administered. Antibiotic therapy with CEFTRIAXONE and METRONIDAZOLE was also initiated due to the biological inflammatory syndrome. After 96 h, the obstruction resolved with transit restoration, allowing nasogastric tube removal, resumption of feeding, and reinitiation of MYCOPHENOLIC ACID.

Discussion

Rheumatoid purpura is a rare small-vessel vasculitis according to the Chapel Hill classification. Primary symptoms include

ARTICLE INFO

<footnote><sup>a</sup> Department of Digestive and Hepatobiliary Surgery, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France</footnote>

<footnote><sup>b</sup> Université Clermont Auvergne, INRAe, Unité de Nutrition Humaine, ASMS team, F-63000 Clermont-Ferrand, France</footnote>

<footnote><sup>c</sup> Department of Thoracic Surgery, Centre Jean Perrin Hospital, Clermont-Ferrand, France</footnote>

<footnote><sup>d</sup> U1071 Inserm / UCA, M2iSH, Clermont-Auvergne University, Clermont-Ferrand, France</footnote>

<footnote>* Corresponding author.</footnote>

<footnote>E-mail address: fmartinet@chu-clermontferrand.fr (F. Martinet-Kosinski).</footnote>
<figure><img src="image_4.png" /><figcaption>**Fig. 1.** abdomino-pelvic CTscan with injection of contrast product, showing terminal ileitis (red asterisk) responsible for distension of the upstream small bowel (red arrow-head) compressing the left colon (white arrowhead).</figcaption></figure>

nephrological involvement, arthralgia or arthritis, stomach pain, and palpable cutaneous purpura. Diagnosis is based on palpable purpura with one or more additional clinical lesion (abdominal, nephrological, articular, etc.) (7). We did not perform a skin biopsy in this case, as the clinical history and presentation suggested Henoch-Schönlein purpura.

In this case, a patient with recurrent rheumatoid purpura presented with terminal ileitis resulting in abdominal obstruction. She was well-managed on MYCOPHENOLIC ACID and we were unable to identify any factor that would have contributed to a relapse. Triggers are found in about half of cases, requiring further investigations (e.g. viral, bacterial and parasitic infections, drugs, toxins, systemic diseases or cancer) [2]. The most likely explanation for this patient's condition is a lung cancer recurrence, which will be further investigated by bronchoscopy and PET-CT.

Gastrointestinal and renal disorders are the main causes of morbidity and mortality in adults. In 46 % of individuals, intestinal complications are prevalent [2]. These digestive symptoms are dominated by abdominal pain, diarrhea and intraluminal bleeding. The small intestine and descending duodenum are the primary sites of gastrointestinal involvement [3]. Terminal ileitis is rarely reported in the literature as a manifestation of the disease. In a review by Sampat et al. [4], only 11 cases of terminal ileitis associated with a diagnosis of rheumatoid purpura were documented and obstruction is generally not reported in these cases. Most cases involve young patients under 26 years. Terminal ileitis shares radiological similarities with Crohn's disease with age, sex, and ethnicity as possible distinguishing clinical characteristics [4].

Histologic confirmation may be helpful in atypical presentations. Pathological findings typically include neutrophil infiltration around and within vessel walls, IgA and C3 deposits in small vessel walls or in the intestinal wall chorion. In the acute stage of the disease, increased serum levels of IgA and pro-inflammatory cytokines have been described (10). As part of the investigation of digestive disorders, imaging, particularly CT scans, may reveal thickening of the intestinal wall in the form of haematomas or inflammation.

Digestive manifestations may sometimes require surgery, particularly for intussusception, which is a frequent complication in children. Older studies report surgical intervention rate between 5 and 22 % in children [5]. In adults, a surgical management seems to be less common and generally reserved for intestinal perforation or mesenteric ischemia [6].

Long term corticosteroid therapy alleviate abdominal pain and arthralgia but is less effective for skin lesions. In this case, corticosteroids relieved the obstruction, treated terminal ileitis and prevented a potential digestive resection. In particular, corticosteroids help to reduce monocyte-macrophage activation and lower pro-inflammatory prostaglandins and leukotrienes production. In this case, corticosteroids were administered at 2 mg/Kg/day for 96 h, after which the patient's usual treatment with MYCOPHENOLIC ACID was resumed.

## Conclusion

This case exemplifies how rheumatoid purpura may lead to digestive occlusions associated with terminal ileitis, similar to Crohn's disease, a condition that is best understood by digestive surgeons. High-dose corticosteroid treatment may alleviate obstruction and potentially prevent digestive resection, provided there are no signs of gastrointestinal distress on imaging.

## Authors' contribution statements

* FMK: analysis, writing, proofreading

* OBO: proofreading

* GG: proofreading

* JG: proofreading

## Ethics declarations

- No funding

- The authors declare no conflicts of interest

- This research does not involve Human Participants and/or Animals

- Informed consent from the patient

- No Ethics approval required

- No availability of data, hardware and/or code

## Declaration of competing interest

None

## CRediT authorship contribution statement

**Florian Martinet-Kosinski:** Writing – original draft, Investigation, Funding acquisition, Conceptualization. **Ophélie Bacoeur-Ouzillou:** Writing – review & editing. **Géraud Galvaing:** Writing – review & editing. **Johan Gagnière:** Supervision.

## References

[1] Watts RA, Lane S, Scott DGI. What is known about the epidemiology of the vasculitides? Best Pract Res Clin Rheumatol 2005;19:191–207.
[2] Rostoker G. Schönlein-henoch purpura in children and adults: diagnosis, pathophysiology and management. *BioDrugs* 2001;15:99-138.

[3] Ebert EC. Gastrointestinal manifestations of Henoch-Schonlein Purpura. *Dig Dis Sci* 2008;53:2011-9.

[4] Sampat HN, McAllister BP, Gaines DD, Ostrov B. Terminal Ileitis as a Feature of Henoch-Schönlein Purpura Masquerading as Crohn Disease in Adults. *J Clin Rheumatol* 2016;22:82-5.

[5] Harvey JG, Colditz PB. Henoch-Schönlein purpura—a surgical review. *Aust Paediatr J* 1984;20:13-6.

[6] Audemard-Verger A, Pillebout E, Amoura Z, Cacoub P, Jourde-Chiche N, Lioger B, et al. Gastrointestinal involvement in adult IgA vasculitis (Henoch-Schönlein purpura): updated picture from a French multicentre and retrospective series of 260 cases. *Rheumatology (Oxford)* 2020;59:3050-7.

Further readings

[1] Yang YH, Yu HH, Chiang BL. The diagnosis and classification of Henoch-Schönlein purpura: an updated review. *Autoimmun Rev* 2014;13:355-8.

[2] Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, et al. EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis. *Ankara* 2008. Part II: Final classification criteria. *Ann Rheum Dis* 2010;69:798-806.

[3] Yang Y.H., Chuang Y.H., Wang L-C, Huang H.Y., Gershwin M.E. Chiang B-L. The immunobiology of Henoch-Schönlein purpura. *Autoimmun Rev* 2008;7:179-184.

[4] Touchard G, Maire P, Beauchant M, Doeuvre P, Babin P, Pecheur H, et al. Vascular IgA and C3 deposition in gastrointestinal tract of patients with Henoch-Schoenlein purpura. *Lancet* 1983;1:771-2.