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<Provider Id="sundheddkcms"> <Item Id="{0136E5ED-894D-416C-A3C0-7A0B1AE83112}" Name="henoch-sch-nleins-purpura" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{5C6214AB-3203-47F4-81BA-06570358B533}" SortOrder="300" PublishDate="2010-04-27T12:28:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Diagnose<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></h2> <h3>Diagnostiske kriterier</h3> <ul> <li>Stilles på det typiske kliniske billede med tetraden palpabel purpura, mavesmerter, artritis eller ledsmerter og evt. nyrepåvirkning. Samtidig med fravær af trombocytopeni eller koagulopati</li> <li>Hæmatologisk status er normal</li> </ul> <h4>Internationale europæiske konsensuskriterier </h4> <p>Palpabel purpura/petekkier overvejende lokaliseret deklivt til underekstremiteterne samt nærvær af en eller flere af følgende</p> <ul> <li>Diffuse mavesmerter</li> <li>Artritis (akut, ethvert led) eller artralgi</li> <li>Nyreinvolvering (hæmaturi eller proteinuri)</li> <li>Leucocytoklastisk vasculit eller proliferativ glomerulonefrit som viser overvejende immunglobulin A aflejringer</li> </ul> <p>Kriterierne er ikke valideret og Henoch-Schönlein Purpura er ikke den eneste sygdom med disse manifestationer</p> <h3>Sygehistorie</h3> <ul> <li>Patienten har typisk nyligt haft en øvre luftvejsinfektion</li> <li>Akut med flere manifestationer samtidigt eller snigende udvikling over uger eller måneder. Typisk ses dog purpura og ledsymptomer som første tegn over dage til uger</li> <li>Begynder oftest med lyserøde makulopapler som blegner ved tryk og kan ligne nældefeber, men både ledsmerter og gastrointestinale gener kan debutere i ugerne op til udslættet hos op mod 1/4</li> <li>Udslættet progredierer til petecchier eller purpura, symmetrisk og typisk deklivt lokaliseret <ul> <li>Udslættet starter oftest på fødderne og breder sig centralt</li> <li>Ekstremiteternes strækkeflader</li> <li>Nates og perigenitalt</li> <li>Blødningerne kan konfluere til store partier med påfølgende hudnekroser<br> <br> <img alt="Henoch-Schönlein" src="D889E175A0A746778F6FD5D1864B322C-480-193" style="height: 193px; width: 480px;" title="Henoch-Schönlein" height="193" width="480"></li> </ul> </li> <li>Sjældnere debuterende symptomer<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a>: <ul> <li>Ledsmerter og hævelse i led (50-84 %), få store led, hyppigst knæ og ankler. Der er aldrig hæmarthrose <ul> <li>Kan forudgå udslættet hos 15 %</li> <li>Symptomerne er forbigående og efterlader ingen leddeformitet</li> </ul> </li> <li>Mavesmerter med eller uden melæna (50 %); intestinal komplikation (blødning, obstruktion, invagination (0,6-4 %) kan blive livstruende. Evt. blødning er almindeligvis okkult, men 30 % har blodige eller sorte afføringer</li> <li>Mavesmerter forudgår hududslættet hos 15-35 % af tilfældene</li> <li>Smerter og hævelse i scrotum hos 2-38 %</li> </ul> </li> <li>Nyreaffektion<a href="https://www.uptodate.com/" data-type="other-reference" data-value="Niaudet P, Appel GB, Hunder GG. Iga Vasculitis (HSP): Renal Manifestatons. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com/" title="Niaudet P, Appel GB, Hunder GG. Iga Vasculitis (HSP): Renal Manifestatons. www.uptodate.com: Wolters Kluwer; 2022">2</a> <ul> <li>Omtrent 20-55 % af børn med Henoch-Schönlein har nyreaffektion med hæmaturi og/eller proteinuri (30-35 %)</li> <li>Debuterer næsten aldrig før udslættet og kan være forsinket med uger til måneder. Hvis nyrepåvirkning ses det hos 84 % indenfor 4 uger, hos 97 % inden 6 måneder</li> <li>Større børn > 8 år havde en 2,7 gange større risiko for nyrepåvirkning end mindre børn. Kønsrisiko: 2,5 gange større hos piger end hos drenge</li> <li>Makroskopisk hæmaturi hos max 10 % og/eller høj proteinuri sv.t nefrose ligeledes dårlig prognostisk markør </li> <li>Glomerulonefritten er almindeligvis asymptomatisk udover hæmaturi og proteinuri</li> <li>Kan udvikle sig til akut nefritis eller nefrotisk syndrom, hvor det histologiske billede varierer fra minimal change til sklerose</li> <li>Risikoen for nyresygdom er højest blandt personer over 8 år med vedvarende purpura, kraftige mavesmerter eller recidiverende episoder</li> <li>Nyresygdommen går spontant væk hos 90-95 %, men hos nogle kan der opstå progressiv glomerulonefritis og evt. kronisk nyreinsufficiens og behov for dialyse på sigt</li> </ul> </li> </ul> <h3>Kliniske fund</h3> <ul> <li>Hæmorrhagisk makulopapuløst, palpabelt udslæt på ekstremiteter, nates og perigenitalt</li> <li>Hævelse og smerter i led</li> <li>Akutte mavesmerter og melæna (sjældent: invagination, ileus)</li> </ul> <h3>Supplerende undersøgelser i almen praksis</h3> <ul> <li>Hb, leukocyttal, SR, CRP, trombocytter, MCV, kreatinin, karbamid, natrium, kalium<br> <ul> <li>Hæmoglobin er normal eller lav på grund af blødning</li> <li>MCV er normal</li> <li>Trombocytter er i normalt antal. I blodudstrygning vil man se trombocytter i alle synsfelter</li> </ul> </li> </ul> <ul> <li>Måling af blodtryk (oftest normalt i starten) </li> <li>Hæmaturi og proteinuri <ul> <li>Kan findes fra starten af eller udvikles under forløbet af sygdommen</li> <li>Urinen bør undersøges ugentligt, så længe sygdommen er aktiv og som minimum de første 4 uger og efterfølgende hver 2 måned i 6 måneder</li> </ul> </li> <li>Svælgpodning til dyrkning for streptokokker </li> <li>Serologi <ul> <li>Der er ingen serologisk test for Henoch-Schönleins purpura</li> <li>Antistreptolysin O titer (ASOT) og antideoxyribonuklease B titer (anti-DNase B) for at bekræfte forudgående streptokokinfektion</li> </ul> </li> </ul> <h3>Andre undersøgelser på sygehus</h3> <ul> <li>Hb, leukocyttal, SR, CRP, trombocyttal, MCV, kreatinin, elektrolytter, karbamid, koagulationsfaktorer (protrombintid, partial tromboplastintid, fibrinogen, fibrin degenerationsprodukter) og IgA, IgM, samt evt. komplement C3 og C4</li> <li>Serum-IgA og -IgM er forhøjede hos 50-70 % af patienterne i akut stadium</li> <li>Urinmikroskopi: Ved nyreaffektion findes røde og hvide blodlegemer samt cylindre</li> <li>Billeddiagnostik <ul> <li>Er ikke rutinemæssigt påkrævet</li> <li>Ved gastrointestinal blødning kan både angiografi og endoskopi være nødvendig</li> <li>Evt. abdominal ultralyd eller CT ved uklare mavesmerter</li> <li>Evt. colonindhældning til at diagnosticere og behandle mistænkt invagination, selv om lokalisationen af invaginationen almindeligvis er ileoileal og mindre tilgængelig for ikke-kirurgisk behandling</li> <li>Evt. ultralyd og dopplerundersøgelse af scrotum, evt. scintigrafi, ved uklar tilstand</li> </ul> </li> <li>Evt. senere i forløbet nyrebiopsi på højt specialiseret enhed <ul> <li>Vil vise IgA-deponering i mesangiet og forandringer, der varierer fra fokal og segmental glomerulonefrit til svær ekstrakapillær proliferation ("halvmånenefritis")<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a><sup>,</sup><a href="EditorPage.aspx?da=core&id=%7B0136E5ED-894D-416C-A3C0-7A0B1AE83112%7D&ed=FIELD7463367708&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7463367768&us=sitecore%5Canvi&mo&pe=0&fbd=1" title="Trnka P, Henoch-Schönlein purpura in children.. J Paediatr Child Health 2013;49: 995-1003" data-pubmedid="24134307" data-value="Trnka P, Henoch-Schönlein purpura in children.. J Paediatr Child Health 2013;49: 995-1003" data-value-piped="Trnka P|Henoch-Schönlein purpura in children.|J Paediatr Child Health|2013|49|995-1003|24134307" data-url="reference-link" data-type="journal-reference">3</a></li> </ul> </li> </ul> <h3>Differentialdiagnoser <a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></h3> <ul> <li>Trombocytopen purpura <ul> <li><a href="~/link.aspx?_id=8E44D0C371024A699D71C581EFA420FF&_z=z">Immunologisk trombocytopenisk purpura</a></li> <li><a href="~/link.aspx?_id=D3C1542A33FC427A8B7A910831EE8D60&_z=z">Hæmolytisk-uræmisk syndrom</a></li> <li><a href="~/link.aspx?_id=C7CF5C6B14864D8F8A6E93F35C2DC1A0&_z=z">Polyarteritis nodosa</a></li> <li><a href="~/link.aspx?_id=7820A4D99B6E40138285EE2E25F6E86E&_z=z">Wegeners granulomatose</a></li> </ul> </li> <li>Andre vaskulære årsager til hudblødninger <ul> <li>Avitaminosis C</li> <li>Hereditær hæmorrhagisk teleangiectasi</li> <li><a href="~/link.aspx?_id=2D4CDBE1B76E431588CBAFF59A7341F6&_z=z">Ehlers-Danlos' sygdom</a></li> <li><a href="~/link.aspx?_id=87413D29E5E14A01BBF5078535C3F251&_z=z">Kawasakis syndrom</a></li> </ul> </li> <li>Infektioner som meningokoksepsis/meningitis </li> <li>Akut abdomen <ul> <li><a href="~/link.aspx?_id=353878CED09B4855B7D5BAF24D31361B&_z=z">Invagination</a> (Henoch-Schønlein disponerer)</li> <li><a href="~/link.aspx?_id=8DA1D6A63D0D4EBF984D7071FB1080A9&_z=z">Appendicitis</a></li> <li><a href="~/link.aspx?_id=2A906C7D4F544FF9A538DC818B9A5304&_z=z">Mesenterial adenitis</a></li> <li><a href="~/link.aspx?_id=6587E1B25CD148388BA16FC240116AB2&_z=z">Meckels divertikulitis</a></li> </ul> </li> </ul> <h2>Behandling <a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a><sup>,</sup><a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022">4</a></h2> <h3>Behandlingsmål</h3> <ul> <li>Symptomlindring indtil sygdommen klinger af</li> <li>Behandling af potentielt udløsende årsag, f.eks ved verificeret streptokoktonsillitis, behandling med p.o penicillin i rekommanderede doser</li> </ul> <h3>Generelt om behandlingen</h3> <ul> <li>Tilstanden er i de fleste tilfælde selvbegrænsende, varer i gennemsnit ca. 4 uger og behøver ingen behandling udover reduceret aktivitetsniveau</li> <li>En tredjedel af patienterne har recidiverende symptomer med tilbagefald indenfor 4 måneder</li> <li>Behandlingen er rettet mod, at patienten er velhydreret, at lindre smerter og monitorere udvikling af evt. komplikationer</li> </ul> <h4>Nefritis</h4> <ul> <li>Nefritis er en af komplikationerne til HSP, som kan have kroniske konsekvenser. Langtidsprognosen afhænger af sværhedsgraden af nefritis</li> <li>30-50 % har vedvarende urinfund i måneder og år, men < 1 % progredierer til terminalt nyresvigt</li> <li>Patienter med mikroskopisk hæmaturi og minimal proteinuri har en god prognose</li> <li>Nefritis kompliceret med nefrotisk syndrom har dårlig prognose</li> </ul> <h3>Håndtering i almen praksis</h3> <ul> <li>Ved mistanke om diagnosen skal der henvises til Børne- og ungeafdeling</li> </ul> <h3>Råd til patienten</h3> <ul> <li>Sengeleje og forsigtig adfærd mindsker udbredelsen af purpura</li> <li>Patienten bør informeres om, at purpura kan opstå igen, når aktivitetsniveauet øges igen</li> </ul> <h3>Medicinsk behandling<a href="EditorPage.aspx?da=core&id=%7B0136E5ED-894D-416C-A3C0-7A0B1AE83112%7D&ed=FIELD7463367708&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7463367768&us=sitecore%5Canvi&mo&pe=0&fbd=1" title="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-pubmedid="26258874" data-value="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-value-piped="Hahn D, Hodson EM, Willis NS, Craig JC|Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).|Cochrane Database Syst Rev|2015||CD005128|26258874" data-url="reference-link" data-type="journal-reference">5</a><sup>,</sup><a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022">4</a></h3> <h4>I almen praksis</h4> <ul> <li>Smertestillende ved behov, f.eks. [DliActiveSubstance;6381;paracetamol] eller <a href="http://pro.medicin.dk/Laegemiddelgrupper/grupper/213010">NSAID</a> <ul> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/grupper/213010">NSAID</a> bør undgås ved gastrointestinale symptomer og hos patienter med kendt nyreaffektion</li> </ul> </li> </ul> <h4>På sygehus/hos specialist</h4> <ul> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/171030">Kortikosteroider</a>?<a href="EditorPage.aspx?da=core&id=%7B0136E5ED-894D-416C-A3C0-7A0B1AE83112%7D&ed=FIELD7463367708&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7463367768&us=sitecore%5Canvi&mo&pe=0&fbd=1" title="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-pubmedid="26258874" data-value="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-value-piped="Hahn D, Hodson EM, Willis NS, Craig JC|Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).|Cochrane Database Syst Rev|2015||CD005128|26258874" data-url="reference-link" data-type="journal-reference">5</a><br> <ul> <li>Er alene indiceret ved og har overvejende effekt på akutte mavesmerter og/eller CNS- symptomer</li> <li>Indikationen er ellers kontroversiel </li> <li>Benyttes kun i de alvorligste tilfælde og har kun akut effekt på nyre-, abdominal-, led- og hudsymptomer, men det ændrer ikke ved patofysiologien af sygdommen</li> <li>Patienter med plagsomme symptomer kan have nytte af tidlig behandling, fordi [DliActiveSubstance;5894;prednison] reducerer de ekstrarenale symptomer, men ikke ændrer langtidsprognosen af nyreinvolveringen</li> <li>Der anbefales ved f.eks. kraftige mavesmerter en dosis på 1 mg/kg per dag (max 60-80 mg) til 2 dage efter symptomerne er ophørt - typisk 1 uge, hvis længere da nedtrapning over -12 uger</li> <li>Ved tegn til nefrotisk syndrom opstartes steroid jvf. den gældende vejledning sv.t 60 mg/m2</li> </ul> </li> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/65000">Antifibrinolytika</a>, <a href="http://min.medicin.dk/Medicin/Indholdsstoffer/1011">tranexamsyre</a> ved tarmblødning</li> </ul> <h3>Anden behandling</h3> <ul> <li>Plasmaferese og/eller <a href="https://pro.medicin.dk/Laegemiddelgrupper/Grupper/317707">immunosuppressiv behandling</a> ved progredierende nyreaffektion</li> </ul> <h3>Forebyggende behandling</h3> <ul> <li>Det er i dag ingen intervention, som kan forhindre nyresygdom hos børn med HSP<a href="EditorPage.aspx?da=core&id=%7B0136E5ED-894D-416C-A3C0-7A0B1AE83112%7D&ed=FIELD7463367708&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7463367768&us=sitecore%5Canvi&mo&pe=0&fbd=1" title="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-pubmedid="26258874" data-value="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-value-piped="Hahn D, Hodson EM, Willis NS, Craig JC|Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).|Cochrane Database Syst Rev|2015||CD005128|26258874" data-url="reference-link" data-type="journal-reference">5</a></li> </ul> <h2>Henvisning</h2> <ul> <li>Ved petecchier/ekkymoser og mistanke om Henoch-Schönlein purpura - bør der henvises akut for at vurdere og udrede for differentialdiagnoser samt evt. steroidbehandling</li> <li>Indlæggelse kan være nødvendig ved utilfredsstillende opfølgning, moderat til alvorlig dehydrering, gastrointestinal blødning, kraftige mavesmerter, stærke ledsymptomer der forhindrer mobilitet, tegn til nyresygdom<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> </ul> <h2>Opfølgning</h2> <h3>Plan</h3> <ul> <li>Patienter med nyreskade eller hæmaturi/proteinuri længe efter sygdomsudbruddet bør følges op</li> <li>I en meta-analyse fandt man ingen nyreskade, efter at der forelå normal urinprøve. Men selv om urinprøven er normal, anbefales det, at opfølgningen fortsætter i seks måneder. Der er ikke behov for opfølgning udover de første seks måneder, hvis urinprøverne er normale<a href="EditorPage.aspx?da=core&id=%7B0136E5ED-894D-416C-A3C0-7A0B1AE83112%7D&ed=FIELD7463367708&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7463367768&us=sitecore%5Canvi&mo&pe=0&fbd=1" title="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-pubmedid="26258874" data-value="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-value-piped="Hahn D, Hodson EM, Willis NS, Craig JC|Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).|Cochrane Database Syst Rev|2015||CD005128|26258874" data-url="reference-link" data-type="journal-reference">5</a><sup>,</sup><a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022">4</a></li> </ul> <h3>Hvad bør man kontrollere</h3> <ul> <li>Urinundersøgelse for protein, blod</li> <li>Blodtryk</li> </ul> <h2>Sygdomsforløb, komplikationer og prognose<a href="EditorPage.aspx?da=core&id=%7B0136E5ED-894D-416C-A3C0-7A0B1AE83112%7D&ed=FIELD7463367708&vs&la=da&fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&di=0&hdl=H7463367768&us=sitecore%5Canvi&mo&pe=0&fbd=1" title="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-pubmedid="26258874" data-value="Hahn D, Hodson EM, Willis NS, Craig JC, Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).. Cochrane Database Syst Rev 2015;: CD005128" data-value-piped="Hahn D, Hodson EM, Willis NS, Craig JC|Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).|Cochrane Database Syst Rev|2015||CD005128|26258874" data-url="reference-link" data-type="journal-reference">5</a><sup>,</sup><a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (HSP): Management. www.uptodate.com: Wolters Kluwer; 2022">4</a></h2> <h3>Sygdomsforløb</h3> <ul> <li>Hos de fleste patienter er sygdomsforløbet godartet og af kort varighed. Patienten helbredes i løbet af få uger</li> <li>Hos enkelte vil spor af purpura og hæmaturi vedvare i flere måneder</li> </ul> <h3>Komplikationer</h3> <ul> <li>Nyrer <ul> <li>Involvering af nyrer i form af nefritis, nefritisk og nefrotisk syndrom sker i mindre end 5-10 % af tilfældene. Manifest nyresvigt hos < 1% er den hyppigste alvorlige komplikation og kan følge patienten i flere år efter sygdommen</li> </ul> </li> <li>Scrotum <ul> <li>Orkitis og skrotal hævelse kan forekomme hos op til 2-38 % af drenge med HSP</li> <li>Testis-torsion på grund af skrotalt ødem</li> </ul> </li> <li>Andre livstruende tilstande, som gastrointestinal blødning og tarmperforation, kan også forekomme omend sjældent</li> </ul> <h3>Prognose</h3> <ul> <li>Stort set god; sygdommen helbredes som regel spontant i løbet af ca. 4 uger</li> <li>HSP har en udpræget tendens til recidiv. Gælder ca. 1/3 i løbet af de første 4 måneder efter akutfasen og er hyppigere blandt dem med nyreaffektion</li> <li>Efter alvorlig nyreaffektion, langvarig sygdom og/eller flere recidiver ser man nogle gange (1-5 %) kronisk affektion af nyrerne <ul> <li>Hvis nyrepåvirkning ses det hos 84 % indenfor 4 uger, hos 97 % inden 6 måneder</li> </ul> </li> </ul> <h2>Baggrundsoplysninger</h2> <h3>Definition</h3> <ul> <li>Henoch-Schönleins purpura er en systemisk IgA immunmedieret vaskulitis, som afficerer hud, tarm, nyrer og led med et udtalt typisk klinisk billede. Symptomerne fra huden er obligat<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>I den angelsachsiske litteratur kaldes tilstanden også IgA vaskulitis<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Den hyppigste vaskulitis i barnealderen<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Har sit navn efter en tysk læge og hans student, som beskrev tilstanden i 1837 </li> <li>Kaldes også "mindre korrekt" for anafylaktoid purpura, omend anafylaksi ikke spiller nogen patogenetisk rolle for tilstanden<a href="%20" title="Trnka P, Henoch-Schönlein purpura in children.. J Paediatr Child Health 2013;49: 995-1003" data-pubmedid="24134307" data-value="Trnka P, Henoch-Schönlein purpura in children.. J Paediatr Child Health 2013;49: 995-1003" data-value-piped="Trnka P|Henoch-Schönlein purpura in children.|J Paediatr Child Health|2013|49|995-1003|24134307" data-url="reference-link" data-type="journal-reference">3</a> </li> </ul> <h3>Forekomst</h3> <ul> <li>Sygdommen debuterer hovedsageligt i barneårene (3-15 år), noget oftere blandt drenge end piger<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Incidens <ul> <li>10-20 per 100.000 børn 0-17 per år<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Børn under 10 år udgør mere end 90 % af tilfældene, og incidensen er højest hos børn mellem 4 og 6 år (ca. 70 per 100.000)<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> </ul> </li> <li>Det kliniske forløb er mildere hos spædbørn og børn under 2 år</li> <li>Forekomsten er højest i vinterhalvåret, og HSP følger almindeligvis efter en luftvejsinfektion<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> </ul> <h3>Ætiologi og patogenese</h3> <ul> <li>Tilstanden har ingen klar ætiologi, men forekommer i op mod 50 % af tilfældene efter øvre luftvejsinfektioner, ofte streptokokker, men også andre både bakterielle og virale infektioner. Desuden efter insektstik, allergier, eksponering for kulde samt ved brug af en række forskellige medikamenter, inkl. antibiotika og vaccination<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Eksponering for et antigen fra f.eks. en infektiøs agens, medikament eller andre miljøfaktorer kan udløse dannelse af antistof og immunkomplekser<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Af alle patogener er gruppe A beta-hæmolytiske streptokokker mest studeret. Positive tonsilpodninger findes hos 10-30 % af patienterne og titer til anti-streptolysin O er øget hos 20-50 %</li> <li>IgA og komponenter i den alternative komplementreaktionsskæde antages at være involveret i patogenesen. Samtidig antages en defekt glykosylering af dele af IgA-molekylet som en årsag til immunkomplekserne ikke udvaskes så hurtigt som vanligt. Der er tale om aflejring af immunkomplekser i de små blodkars vægge og giver anledning til en non-granulomatøs leukocytoklastisk vaskulitis<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a> <ul> <li>Kun IgA1-immunkomplekser er involveret, og aflejret i kapillærer forårsager de petekkier og palpabel purpura<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Når immunkomplekserne forekommer i små blodkar i tarmvæggen, fører det til gastrointestinal blødning<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> <li>Hvis immunkomplekset afficerer det renale mesangium, kan det føre til glomerulonefritis<a href="https://www.uptodate.com" data-type="other-reference" data-value="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022" data-url="https://www.uptodate.com" title="Dedeoglu F, Kim S. IgA vasculitis (Henoch-Schönlein purpura): Clinical Manifestations and diagnosis. www.uptodate.com: Wolters Kluwer; 2022">1</a></li> </ul> </li> <li>Betændelsesreaktionen resulterer i øget vaskulær permeabilitet, eksudation og blødning, hvilket giver symptomer i forskellige organsystemer</li> </ul> <h3>Disponerende faktorer</h3> <ul> <li>Forudgående infektion </li> <li>Arv og miljøeksposition </li> <li>Unge drenge synes at være mest udsat for at få sygdommen</li> </ul> <h3>ICPC-2</h3> <p>[ICPC]</p> <h3>ICD-10/SKS-koder</h3> <p>[ICD10]</p> <h2>Patientinformation</h2> <h3>Link til patientinformation</h3> <ul> <li><a href="~/link.aspx?_id=DFF634B15C904F29A71A3A1A60B5EF8A&_z=z">Henoch-Schönleins purpura</a></li> </ul> <h2>Link til vejledninger</h2> <ul> <li>Forløbsbeskrivelser og pakkeforløb [ICPC]</li> </ul>]]></HtmlField> <HtmlField Name="Resume"><![CDATA[<h2>Resumé</h2> <h3>Diagnose</h3> <ul> <li>Klassisk udslæt med palpabel purpura deklivt, smerter fra led og evt. mavesmerter</li> <li>Fravær af trombocytopeni eller koagulopati</li> <li>Evt. nyrepåvirkning med proteinuri</li> </ul> <h3>Behandling</h3> <ul> <li>Ro og evt. reduceret aktivitetsniveau </li> <li>Smertestillende behandling i form af NSAID og paracetamol</li> <li>Ved vedvarende mavesmerter kan overvejes kortikosteroid</li> <li>Ved nefrotisk syndrom kortikosteroid jvf vejledning for dette</li> <li>Ved tarmblødning kan der gives antifibrinolytika</li> </ul> <h3>Henvisning</h3> <ul> <li>Ved mistanke om diagnosen skal der henvises til Børne- og ungeafdeling</li> <li>Ved mistanke om recidiv, forværring eller nyrepåvirkning med blodtryksforhøjelse i efterforløbet</li> </ul>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">2905</TextField> <TextField Name="PageTitle">Henoch-Schönleins purpura</TextField> <TextField Name="NavigationTitle">Henoch-Schönleins purpura</TextField> 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]]></Media> 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