A 6-year-old boy presents with a 2-week history of symmetric, non-blanching purpura over his lower limbs and buttocks following a sore throat. On examination, he has palpable purpura, mild ankle swelling, and colicky abdominal pain. Platelet count is 250,000/μL. The condition marked **C** in the diagram is suspected. Which of the following is the MOST IMPORTANT long-term complication that requires surveillance in this child?
A. Permanent joint deformities from erosive arthritis
B. Thrombocytopenia developing over months leading to bleeding diathesis
C. Recurrent episodes of abdominal pain requiring surgical intervention
D. Renal involvement with potential progression to end-stage renal disease
Explanation
Why "Renal involvement with potential progression to end-stage renal disease" is right
The condition marked C (Henoch-Schönlein purpura / IgA vasculitis) is a systemic small vessel vasculitis characterized by IgA1 immune complex deposition affecting skin, joints, GI tract, and kidneys. While most cases are self-limited and resolve within 4–6 weeks, renal involvement (occurring in 20–55% of children) is the MOST IMPORTANT long-term complication and the primary determinant of prognosis. HSP nephritis can range from mild glomerulonephritis to rapidly progressive crescentic disease, with 1–3% progressing to end-stage renal disease (ESRD). The Nelson Textbook and EULAR/PRINTO/PRES criteria emphasize that urinalysis surveillance for at least 6–12 months is mandatory, as renal disease may develop silently and late in the course. This is why long-term follow-up with urinalysis and blood pressure monitoring is the cornerstone of management.
Why each distractor is wrong
Recurrent episodes of abdominal pain requiring surgical intervention: While abdominal pain occurs in 50–75% of HSP cases and intussusception (ileoileal) is a recognized acute complication, it is not the MOST IMPORTANT long-term complication. Most abdominal symptoms resolve with supportive care; surgical intervention is rare and not a defining long-term sequela.
Thrombocytopenia developing over months leading to bleeding diathesis: HSP is explicitly characterized by NORMAL platelet count, which distinguishes it from ITP. Thrombocytopenia is NOT a feature of HSP and does not develop over time.
Permanent joint deformities from erosive arthritis: HSP arthritis is non-erosive, oligoarticular, affecting large joints (ankles, knees), and transient (resolves within <1 week). It does NOT cause permanent deformities or erosions, unlike rheumatoid arthritis.
High-YieldNEET PG
HSP is the most common small vessel vasculitis of childhood; normal platelets + palpable purpura + systemic involvement = think HSP. Renal surveillance (urinalysis + BP) for ≥6 months is the most important follow-up — silent hematuria/proteinuria can herald late nephritis.
Nelson Textbook of Pediatrics 22e; EULAR/PRINTO/PRES Criteria 2010
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