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Rash and acute nephritic syndrome due to candesartan

BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7430.25 (Published 01 January 2004) Cite this as: BMJ 2004;328:25

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Rash and acute nephritic syndrome in Henoch-Schonlein purpura

Sir,

We read with interest an article on Rash and acute nephritic syndrome due
to candesartan by Morton et al. [1] Their patient was 73 years old, and
showed non-palpable purpura, no abdominal pain or arthralgia, but
haematuria with proteinuria and lymphocytic vasculitis were present.

To fulfill classification criteria for Henoch-Schonlein purpura (HSP) by
the American College of Rheumatology (ACR), two of the following are
required: age <20 years, palpable purpura, abdominal pain and vessel
wall granulocytes on biopsy.[2] Recently, the ACR criteria were revised by
the European League against Rheumatism (EULAR), which deleted the age
criterion, included predominant IgA deposition, and added arthritis and
renal involvement to the group of criteria.[3] Therefore, at least one of
the following four should be present in the presence of palpable purpura:
diffuse abdominal pain, any biopsy showing predominant IgA deposition,
arthritis or arthralgia, and renal involvement (any haematuria and/or
proteinuria). In both criteria, palpable purpura is a mandatory criterion.

The skin manifestations of HSP are mainly palpable purpuric eruption,
while cutaneous allergic vasculitis shows various eruptions which include
purpura, papules, nodules, ulcers and necrosis.[4] Because this patient
presented with non-palpable purpruric eruption with pruritus and oedema,
the typical characteristics of palpable purpura seen in HSP are lacking.

Therefore, we would like to recommend skin biopsy to differentiate HSP
from other vasculitis such as hypersensitivity vasculitis if the rash is
not typical and there is no abdominal pain or arthralgia, because
predominant IgA deposition has recently been one of the important findings
in diagnosing HSP.

Also, the definition of acute nephritic syndrome is wrong in this patient.
Nephritis is often defined by the presence of macroscopic or microscopic
hematuria with or without proteinuria.[5], while acute nephritic syndrome
refers to haematuria with at least 2 conditions among hypertension, raised
serum urea or creatinine and oliguria.[6] Therefore, it would be
appropriate to consider that this patient had nephritis or renal
involvement of vasculitis rather than acute nephritic syndrome.

References

1. Morton A, Muir J, Lim D. Rash and acute nephritic syndrome due to
candesartan. BMJ 2004;328:25.

2. Mills JA, Michel BA, Bloch DA, Calabrese LH, Hunder GG, Arend WP, et
al. The American College of Rheumatology 1990 criteria for the
classification of Henoch-Schonlein purpura. Arthritis Rheum 1990;33:1114-
21.

3. Ozen S, Ruperto N, Dillon M, Bagga A, Barron K, Davin JC, et al.
EULAR/PRES Endorsed Consensus Criteria for the Classification of Childhood
Vasculitides under review by the ACR. Ann Rheum Dis 2005 Dec 1; [Epub
ahead of print]

4. Ruiter M. A case of allergic cutaneous vasculitis (arteriolitis
allergica). Br J Dermatol 1953;65:77-83.

5. Kaku Y, Nohara K, Honda S. Renal involvement in Henoch-Schonlein
purpura: a multivariate analysis of prognostic factors. Kidney Int
1998;53:1755-9.

6. Meadow SR, Glasgow EF, White RH, Moncrieff MW, Cameron JS, Ogg CS.
Schonlein-Henoch nephritis. Q J Med 1972;41:241-58.

Competing interests:
None declared

Competing interests: No competing interests

23 January 2006
Jae Seung Lee
Paediatric Nephrologist, Professor
Jae Il Shin, and Jae Seung Lee
Department of Paediatrics, Yonsei University College of Medicine, Seoul, Korea