Small and large bowel manifestation of leukocytoclastic vasculitis

Leukocytoclastic vasculitis is a disease mostly limited to the skin. Extracutaneous manifestations that include visceral involvement are normally self-limiting and not life-threatening. We describe a 44-year-old man with palpable purpura, polyarthritis and microhematuria who developed severe vasculitis of the small and large bowel. Initial laboratory tests confirmed leukocytosis, slightly elevated C-reactive protein and mildly increased erythrocyte sedimentation rate. Skin biopsy revealed histological features typical of leukocytoclastic vasculitis. The search for trigger factors revealed urogenital infection with Ureaplasma urealyticum. Severe abdominal pain followed cutaneous symptoms eight days after admission. Abdominal x-ray showed several air-fluid levels in the lower right abdomen and an abdominal CT scan revealed thickening of the intestinal wall in several segments of jejunum, ileum and colon. C-reactive protein rose from 32 mg/l to 107 mg/l. Methylprednisolone pulse therapy rapidly improved gastrointestinal, cutaneous and articular symptoms. The aim of this report is to show the unpredictability of vasculitic disease and the difficulties in its classification. The report emphasizes the importance of adapting diagnosis and treatment according to disease severity rather than to the type of vasculitis. The specific etiological trigger remains unknown in this case, although a causal relationship with U. urealyticum infection is speculated.