Henoch-Schönlein purpura presenting with symptoms mimicking balanoposthitis.

Henoch-Schönlein purpura is a leukocytoclastic vasculitis, characterized with palpable purpuric rush and collection of immunglobuline A (Ig A) around small vessels. Onset of purpuric rush at gluteus and lower extremities is the main symptom of the disease, however it presents with a wide variety of signs and symptoms. Here, we present a two-year-old boy who had presented with penile swelling and color change. Then, purpuric rush was occurred and it was seen spontenous resolution on second day without treatment.

Introduction

Henoch-Schönlein purpura (HSP) is the most common systemic vasculitis in children. The most common clinical manifestations of the HSP are purpuric skin rash typically located on the legs and buttocks, arthralgia and severe abdominal pain. Although the non-renal genitourinary presentations in HSP are rare, ureteritis with associated stenosis, bladder wall hematomas, swelling of scrotum and testis, urethritis and epididymo-orchitis may develop.[1,2] Penile involvement of HSP in children was reported but these cases are extremely rare.[1,3-5]

A two-year-old boy presented with severe penile edema and discoloration which started a few hour earlier. His mother reported that the boy had palpable petechial purpura in the gluteal region and swelling of ankle two-weeks ago and was diagnosed as HSP, but no medication was given. There were no penile trauma and intervention in his history. Physical examination showed hyperemia and edema at whole penis, boy was uncircumcised and preputium was not reducible. No purulent discharge from preputial orifice was seen and his voiding stream was weak and painful. The other systemic findings are normal and no purpuric rash was seen at any part of the body. He hospitalized with the diagnosis of severe balanoposthitis, and was treated with warm water bath. After the first day of conservative therapy, penile hyperemia and edema turned to non-tender and bright red purpuric lesions suggesting the diagnosis of penile involvement of HSP (Figure 1). No specific treatment was given and discharged with routine control program. At the second day of admission, penile edema was resolved with normal voiding stream. At the third day, appearance of preputium was totally normal.

Figure 1

Penile involvement of HenochSchönlein purpura.

Penis involvement of HSP is extremely rare in children and only a few cases were reported.[1,3-5] These reported cases were presented with HSP like purpuric lesions at the preputium and their diagnoses were based on these symptoms. Distinctive feature of our case is that he presented with penile edema and hyperemia looking like balanoposthitis. Therefore, although it is rare, penile involvement of HSP should be kept in mind in children diagnosed with balanoposthitis.

HSP is characterized with accumulation of immune complex in the small vessels and as the penis is an end organ with a complex microvascular structure, there is a potential risk for permanent damage.[2,3] In case of penile involvement steroid therapy is controversial. Although some authors reported that after prednisolone treatment the symptoms resolved, other reports noted that some cases resolved spontaneously without any treatment.[1-6] We did not plan any treatment protocol except warm bath and the appearance of preputium was totally normal at the third day of conservative treatment, which supports that the medication is not necessary in these cases.

As a result, penile involvement of HSP can cause misdiagnosis, since the first symptoms of disease sometimes can mimic balanoposthitis. In addition, we think that no medication is necessary in these cases, since the symptoms would resolve spontaneously.