Diagnostic approach to a patient with atypical Henoch-Schönlein purpura

We read with great interest the recent contribution by Uza et al. [1]. They reported an 81-year-old man who presented with hematochezia and hemorrhagic ascites, but with no abdominal pain or skin rash. Initial duodenoscopy and colonoscopy demonstrated multiple ulcers and nonspecific inflammation. Palpable purpura developed 8 days later, and hematochezia and renal function rapidly worsened and did not respond to methylprednisolone pulse therapy (MPT), leading to death. IgA depositions on the small vessels of the duodenum and ileum were demonstrated on the autopsy specimens. The authors regarded this patient as having atypical Henoch-Schönlein purpura (HSP) due to old age at onset, delayed appearance of characteristic purpura, an absence of abdominal pain, and the presence of hemorrhagic ascites; they wondered why the jejunum could be spared despite systemic vasculitis.