Liam and HSP

In the spring of 2009, Liam was a healthy, active, 8.5 year old boy. After completing a season of ice hockey, he decided to play a spring season of lacrosse. He did well throughout the tryouts and was looking forward to his first team session.

Day 1 - Saturday April 18 2009
Liam at last stages of a cold, outside playing street hockey in the evening. Came in the house complaining of pain in leg joints, ankles and back of knees. Could not walk. Noticed minor rash, very small sporadic red dots, thought maybe pricks from crawling through bushes to find Easter eggs the previous weekend. Assumed he was overtired.

Day 2 - Sunday April 19 2009 (Emergency visit # 1)
Feeling better, well enough to watch first lacrosse practice but not well enough to participate. Played with a friend in the afternoon. Began complaining of joint pain again towards evening, could not walk. Pain increasing, more joints throughout body – wrists, back... By 3:00am pain so intense all over body decided to go to emergency. Exam, urine and blood work all negative. Noted rash but did not consider significant. Dr suggested cold virus affected joints and/or muscles. Prescribed codeine and discharged.

Day 3 - Monday April 20
Missed school, feeling pain. Codeine results in drowsiness, slept lots during day.

Day 4 - Tuesday April 21
Increasing pain and nausea, decreasing apatite and thirst. Began vomiting near midnight.

Day 5/6
Ongoing pain, nausea, little food and water, increasing dehydration, decreasing energy. Vomiting every 4 – 5 hours.

Day 7 - Thursday April 23 (Emergency visit # 2)
Called Healthlink with concern that ‘flu’ is continuing for so long, although spirits slightly better. Encouraged to see paediatrician. Saw doctor mid afternoon, concerned about potential pneumonia, directed back to emergency. Joint swelling increasing. Appearance of bruise and pain in hand while in emerge waiting room. Physical exam revealed small cluster rash on ankle, confirming diagnosis of HSP. Started I.V. and more urine / blood testing. Showed decreased kidney efficiency. Sent home at 12:00am told to come back to Nephrology clinic in the morning for a 9:00am appointment.

Day 8 - Friday April 24 (Hospital Admission # 1)
9:00am Nephrology appointment; Liam very dehydrated and in pain. Admitted to hospital for more monitoring, pain control and intravenous hydration. Stomach pain and nausea lessened and focus was on monitoring his kidneys. Towards end of the weekend his kidney functioning improved, although his joints, swelling and foot pain made it hard to walk.

Day 10 - Sunday April 26
Discharged from hospital, with appointment at kidney clinic on 28th.

Day 11 - Monday April 27
Increased pain in toe, can’t walk. Left eye swollen, pain in neck. Increasing rash on feet and lower legs, evening rash increasing to bum/penis

Day 12 - Tuesday April 28 (Hospital Admission # 2)
Increasing rash on ankles, lower legs, feet. Decreased apatite, decreased spirits. Increasing abdominal pain.
Examination at kidney clinic shows poor kidney function, increasing pain, nausea, vomiting. Admitted to hospital from clinic

Day 13 - Wednesday April 29
Increasing abdominal pain, vomiting bile, some rash (purpura) on face, bruising around eyes, more vomiting with some blood. Controlling pain with codeine.

Day 14 - Thursday April 30
Abdominal pain increasing, ultrasound and x-ray detect bowel intussusceptions, surgeon alerted, bowel recovered with enema prior to needing surgery. Pain gone.

Day 15 - Friday May 1
Discharged from hospital. To see paediatrician again, kidney clinic again. Starting prednisone therapy.

Day 15-30
General improvement, rash decreasing, energy level increasing, not back at full strength, attended some school. Cancelled participation with lacrosse team. Slight puffiness in face, increasing weight, slight increase mood swings (all related to prednisone)

Day 30 - Saturday May 16
Abdominal pain return in evening. Vomited near midnight. Slept through night.

Day 31 - Sunday May 17 (Emergency visit # 3, Hospital admission #3)
Woke with increased pain, nausea. Return to Emergency. Ultrasound showed not bowel intussusceptions but kidney stone. Admitted to hospital, restricted from food and drink, waiting to see urologist. By 5pm, no urologist coming so allowed to eat and drink again until midnight.

Day 31, 32
On emergency waitlist to remove stone, managing pain with various pain killers intravenously and orally. Throwing up bile, pain and nausea increase, long nights.

Day 33 - May 20
No food or drink while on waitlist. Admitted to O.R. mid day to have stone removed. Removal successful. Post Op reaction to anaesthetic and morphine, follows with 40 min psychotic episode, requires restraining, finally conks out, sleeps, wakes up couple hours later. Great deal of pain before, during and after urinating. Stent in urinary tract between bladder and into kidney - to be pulled out in 4-5 days.

Day 34 - May 21
Discharged from hospital. Lots of pain, especially upon urination

Day 35-38
Ongoing pain management, slow improvement, no school

Day 39 - May 26
Appointment at kidney clinic. Urologist removed stent, Nephrologist gave exam. In evening at home, most dramatic display of pain yet. Called Dr who advised to take to hospital if this level of pain continued. Took extra dose of prednisone. Perhaps pain is from swelling and spasms of kidney.

Day 40 - May 27 (Emergency visit #4)
3:00am took to emergency to manage pain. Given dose of ketoralak - seemed to help, filled prescription and returned home by 7am. Continued meds and pain management.

Day 41, 42
Ongoing pain management, easing off on meds, attends some school

Day 43 - May 30
Intense itchiness all over body in evening. Beside himself with itchiness. Walked around block to try to help – very anxious and hyper. Call to Healthlink and poison/med hotline. Not sure if sign of drug reaction or withdrawal.

Day 44 – 52
Itchiness every evening continues, slowly decreasing intensity. Continuing urine and blood testing, monitoring high blood pressure by paediatrician.

Day 54 - May 28
Appointment with paediatrician, blood pressure good, protein and blood still in urine. No more itchiness in the evenings. No rash, swelling, pain or other symptoms associated with HSP. Will continue with urine and blood testing for months.

October 2009
No reoccurrence. Has had cold and insect bites since initial occurrence. Back to full strength, enrolled in another season of hockey, fully active at school –life back to normal. Continues monitoring by Nephrology. Conclusion about kidney stone is that the HSP likely created conditions conducive to growth of stones (dehydration, swelling, etc) and that HSP was not a direct cause of the stones.

November 2009
Had a urinary ultrasound, with negative results. Will continue with urine tests every two months and another visit to Nephrology in 6 – 9 months.