Vol 74, No 2 (2023)
Case report
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Lambliasis-associated Schönlein-Henoch purpura in an Italian traveller: first case report in Italy

Antonio Mastroianni1, Sonia Greco1, Valeria Vangeli1, Maria Vittoria Mauro2, Francesca Greco2, Roberto Manfredi3
Pubmed: 37417841
IMH 2023;74(2):89-91.

Abstract

A unique report of Schönlein-Henoch purpura (SHP) associated with a recent Giardia lamblia enteric infection
is described and discussed on the ground of the available literature. Tinidazole plus an appropriate
probiotic therapy, including Lactobacillus reuteri and vitamin D, proved to be effective in the condition.
SHP is an immunocomplex-mediated disorder characterised by a number of differently associated signs
and symptoms, leading to the possible involvement of the skin, joints, abdomen and kidneys. Recent
bacterial, viral, or protozoan infections may trigger the disease onset in patients of all ages. The paper describes
the first case of SHP triggered by a giardiasis. Tinidazole plus an appropriate probiotic therapy, i.e.
L. reuteri and vitamin D proved to be effective in this condition. To our knowledge, this is the first reported
case of lambliasis-associated SHP described in an international traveller.

CASE REPORT

Int Marit Health
202
3; 74, 2: 8991
10.5603/IMH.2023.0013
www.intmarhealth.pl
Copyright © 202
3 PSMTTM
ISSN 1641-9251
eISSN 2081-3252

Lambliasis-associated Schönlein-Henoch purpura in an Italian traveller: first case report in Italy

Antonio Mastroianni1Sonia Greco1Valeria Vangeli1Maria Vittoria Mauro2Francesca Greco2Roberto Manfredi3
1Infectious and Tropical Diseases Unit, “Annunziata” Hub Hospital, Azienda Ospedaliera di Cosenza, Cosenza, Italy
2Microbiology and Virology Unit, “Annunziata” Hub Hospital, Azienda Ospedaliera di Cosenza, Cosenza, Italy
3Infectious Diseases Institute, Alma Mater Studiorum University of Bologna, Bologna, Italy
ABSTRACT
A unique report of Schönlein-Henoch purpura (SHP) associated with a recent Giardia lamblia enteric infection is described and discussed on the ground of the available literature. Tinidazole plus an appropriate probiotic therapy, including Lactobacillus reuteri and vitamin D, proved to be effective in the condition. SHP is an immunocomplex-mediated disorder characterised by a number of differently associated signs and symptoms, leading to the possible involvement of the skin, joints, abdomen and kidneys. Recent bacterial, viral, or protozoan infections may trigger the disease onset in patients of all ages. The paper describes the first case of SHP triggered by a giardiasis. Tinidazole plus an appropriate probiotic therapy, i.e. L. reuteri and vitamin D proved to be effective in this condition. To our knowledge, this is the first reported case of lambliasis-associated SHP described in an international traveller.
(Int Marit Health 2023; 74, 2: 89–91)
Key words: Giardia lamblia, giardiasis, Schönlein-Henoch purpura, travel medicine

Dr. Antonio Mastroianni, MD, Infectious and Tropical Diseases Unit, “Annunziata” Hub Hospital, Azienda Ospedaliera di Cosenza, Viale della Repubblica s.n.c., I-87100, Cosenza, Italy, tel: +39 0984 68.18.33, +39 349 – 54.44.330 (mobile), e-mail: antoniomastroianni@yahoo.it

Received: 24.01.2023 Accepted: 2.05.2023

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

A 34-year-old otherwise healthy immunocompetent woman, was seen 2 weeks after coming back from a 3-month stay in a small village located in Tanzania, where she participated in a volunteer humanitarian programme. The patient presented with watery, foul-smelling diarrhoea, associated with asthenia, dyspepsia, abdominal cramps/pain, mild arthralgia predominantly involving the upper and lower limbs, and a diffuse symmetric pompho-erythemato-petechial cutaneous vasculitis-like rash initially localized on the buttocks and trunk, and later spreading to the upper and lower limbs, characterised by small non-itching but palpable papules (Fig. 1). After skin biopsy, histopathologic studies confirmed IgA vasculitis. The patient denied contact with water from uncontrolled sources; however, during her stay in Africa, the patient worked as a health care professional and had contact with paediatric patients. Also, the patient reported having unprotected sex while in Africa. Before leaving Italy for Africa, the patient had been immunised against hepatitis A, typhoid fever and yellow fever, and received antimalarial prophylaxis as well.

Figure 1. Lambliasis-associated Schönlein-Henoch purpura

Laboratory examinations showed that a platelet count and coagulation tests results were within normal limits. The tests demonstrated mild leukocytosis and eosinophilia (12.000 and 900 cells/µL, respectively). Microhaematuria and mild albuminuria, together with mild serum aspartate aminotransferase (AST/GOT, 110 U/L, normal value: 550) and alanine aminotransferase (ALT/GPT, 160 U/L, normal value: 550) indicated limited but present kidney and liver involvement, respectively. Serum C2-C3 complement fraction consumption and moderately reduced serum IgA levels were fully consistent with the diagnosis of Schönlein-Henoch purpura (SHP). As for the microbiological tests results, all cultures for bacteria, mycobacteria and fungi tested negative, as well as all serological examinations for bacterial or viral diseases, malaria tests, and all parasite tests performed on blood/urine/stool specimens, when trying to detect Giardia lamblia by both direct methods and DNA immunoenzymatic assay on multiple consecutive stool specimens. The typical clinical and laboratory picture associated with parasitological findings confirmed the diagnosis. The administration of a full dose of oral tinidazole, and of an oral probiotic including Lactobacillus reuteri and vitamin D, plus supportive rehydration therapy led to a complete resolution of signs and symptoms, with negative stool test results within 3 weeks of treatment. Follow-up tests performed 3 months and again 6 months post treatment revealed no abnormalities.

Schönlein-Henoch purpura is a form of vasculitis which is common in children, but is rare among adults. Typical manifestations include palpable purpura, abdominal pain, arthritis, and haematuria. It frequently occurs following an infectious trigger and involves IgA and C3 deposition in the walls of the small vessels. Many infectious agents were proposed as a potential trigger for SHP, particularly B-haemolytic Streptococci. Other bacterial agents that have been suggested as possible triggers of SHP include Salmonella, Mycoplasma pneumonia, Staphylococcus aureus, Helicobacter pylori and Bartonella henselae [1–11]. Many reports suggest that several viruses and vaccine inoculations should be included in the list of differentials responsible for triggering SHP. SHP, however, is rarely reported in association with parasitic infections [1–11]. Only 43 cases of SHP in association with parasites have been found in a MEDLINE search; they are summarised in Table 1 [1–11]. The analysis of the data retrieved suggests that, although it is an infrequent combination, clinicians should not underestimate this possibility. Parasitic diseases less frequently reported as triggers of SHP include intestinal giardiasis, amoebiasis, and toxocariasis. It was frequently responsible for the development of SHP nephritis in the cases described. Although representing an extremely rare condition, which was proved by our literature search [1–11], clinicians should be aware of the infrequent, but possible role of giardiasis in prompting SHP at any age and in the absence of underlying comorbidities.

Table 1. Reported cases of Henoch-Schönlein purpura and parasitic infections

References, year, country

Patient, age/
/sex

Parasitic infection

Kidney disease

Treatment

Clinical course

Janković et al., 2016, Serbia

A 14-year-old girl

Strongyloides stercoralis
infection

HSP nephritis

Mebendazole; prednisone + azathioprine + enalapril

Recovery

Tutanç et al., 2013, Turkey

A 30-month-boy

Blastocystis hominis

Renal function tests remained normal

Systemic steroid
+ co-trimoxazole

Recovery

Thapa et al., 2010, India

A 9-year-old otherwise
healthy boy

Plasmodium falciparum,
cerebral malaria

Renal function tests remained normal

Parenteral artesunate.
He was discharged with primaquine

Recovery

Hamidou et al., 1999, France

A 17-year-old boy

Toxocara canis infection

Renal function tests remained normal

No anthelmintic

treatment

Recovery

Bellanger et al., 2011, Canada

A 28-year-old woman

Toxocara canis infection

HSP nephritis

An anthelmintic treatment with diethylcarbamazine together with the corticosteroid treatment

Recovery

Ergür et al.,
1999, Turkey

35 cases of HSP (25 males, 10 females), aged between 2 and 15 years

Giardia intestinalis 14 cases, Trichomonas hominis 6 cases, Entamoeba histolytica 3 cases, Ascaris lumbricoides 2 cases

Renal involvement 8 cases

NR

NR

Kim et al., 2010, Korea

An 8-year-old girl

Entamoeba histolytica

Renal function tests remained normal

Empirical antibiotic (metronidazole), methylprednisolone /oral prednisolone

Recovery

Demiricin et al., 1998, Turkey

An 11-year-old boy

Entamoeba histolytica

HSP nephritis

Metronidazole, prednisolone

Recovery

Reitano, Fondacaro, 1950, Italy

Data not available

Ascarids

Data not available

Data not available

Data not available

Conflict of interest: None declared

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