Clinical Gastroenterology and Hepatology image challenge: A 61-year-old man presented with a history of general malaise, abdominal pain without diarrhea, nausea and vomiting for the last several days. He noted a rash on the torso and extremities (figure A). There was no arthralgia. On physical examination he was nonfebrile, and blood pressure was 128/79 mm Hg. Diffuse abdominal tenderness without guarding was noted. Laboratory results were leukocytes 24.0 × 109/L (normal = 4–10) and C-reactive protein 48 mg/L (normal < 5 mg/mL); urine analysis showed erythrocyturia of 19 U/L (normal < 15) without proteinuria. A computed tomography scan of the abdomen showed small bowel wall thickening (figure B, white arrows). An oral enteroscopy was performed. A sharp delineation from normal mucosa in the duodenum to deep ulcerations in the jejunum (figure C) was seen. Biopsies were taken from both the jejunum and the skin. Histologic examination of the jejunum showed erythrocyte extravasation, fibrinoid necrosis of vessel walls (arrow), neutrophils and nuclear dust (figure D). Biopsy of the skin showed leukocytoclastic vasculitis with immunoglobulin A and C3 deposits in the vascular walls. This combination of findings led to the diagnosis of immunoglobulin A vasculitis (formerly known as Henoch-Schönlein’s disease).
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