Allergic purpura is a disease with systemic small blood vessel damage as the main pathological basis, its onset may be related to capillary metaplasia caused by infection, toxin, food, insect bite and other factors, clinical mainly characterized by skin purpura, hemorrhagic gastroenteritis, arthritis and kidney damage as a syndrome. The kidney damage caused by allergic purpura is called purpura nephritis, which can occur at any age, but is mostly seen in children under 10 years old. This disease mostly belongs to the category of blood evidence, edema, deficiency labor, back pain and blood in urine in Chinese medicine. About the treatment of allergic purpura nephritis can be consulted and contacted by phone. The following is a brief introduction to this disease from several aspects.
[Western medical etiology]
First, the cause of allergic purpura is not clear, it may be related to infection and allergic reaction. Although more than 1/3 of patients had symptoms of upper respiratory tract infection before the onset of the disease, there is a lack of evidence of ß-hemolytic streptococcal infection. It is generally believed that it may be related to various infections, vaccinations, insect bites, cold stimuli, drug and food allergies, etc.
Second, the deposition of granular immune complexes such as IgA in the glomerular tract area of patients with allergic purpura nephritis suggests that the disease is an immune complex disease, and the deposition of IgA and C3 in the skin, intestinal vessel wall and glomerular tract area suggests that the pathogenesis of the disease is systemic. In contrast, the decrease in CH50 and preparedin suggests that the immune damage is produced by activation of complement through the bypass pathway. Activation of the complement system produces a series of inflammatory mediators, leading to local inflammatory changes, followed by disorders of the coagulation and fibrinolytic systems, intracellular thrombosis and deposition of fibrin, which leads to glomerular injury.
[Western pathology]
The pathological changes of allergic purpura nephritis must be clarified by renal biopsy. The basic pathological changes are proliferation of thylakoid cells and stroma with crescent formation, and the lesion may be accompanied by necrosis. Segmental thrombosis may be associated with necrosis and crescentic bodies. The degree of tubular atrophy, interstitial cell infiltration and fibrosis may reflect the severity of glomerular injury.
I. Light microscopy
(A) The morphologic classification of the light microscopic pathology of allergic purpura nephritis by the International Society for the Study of the Kidney in Children (ISKDC). Type I: microscopic lesions. Type II: (a) focal and (b) diffuse thylakoid hyperplasia. Type III: (a) focal and (b) diffuse thylakoid hyperplasia with crescent formation or segmental glomerular damage <50%. Grade IV: (a) focal and (b) diffuse thylakoid hyperplasia with crescent formation or segmental glomerular injury <50-75%. Grade V: (a) focal and (b) diffuse thylakoid hyperplasia with crescentic or segmental glomerular injury >75%. Grade VI: pseudotethered thylakoid capillary glomerulonephritis.
(B) The grading method of the World Health Organization (WHO). Grade I: including microscopic lesions with focal segmental significant, focal proliferative glomerulonephritis mild. Grade II: including diffuse proliferative glomerulonephritis mild, diffuse proliferative glomerulonephritis mild with focal segmental significant. Grade III: including focal proliferative glomerulonephritis moderate, diffuse proliferative glomerulonephritis moderate. Grade IV: including diffuse proliferative glomerulonephritis severe, end-stage renal failure. This classification method is less commonly used clinically.
Immunofluorescence
Immunofluorescence shows predominantly clumped IgA deposits in the thylakoid region, which may be accompanied by C3, IgG and preparedin, but the fluorescence intensity is weaker than that of IgA. The deposits are diffusely distributed. IgA deposits were also seen in the subcutaneous and intestinal vessel walls.
III. Electron microscopy
Focal thylakoid hyperplasia with increased thylakoid stroma and deposition of fine granular electron dense material of varying sizes in the thylakoid region and also in the subendothelium, mainly containing IgA and small amounts of C3 and IgG.
[Chinese medicine etiology and pathogenesis]
I. Insufficient endowment
Deficiency of lung qi, deficiency of external function of the guard, inability to resist external evil, the evil of the six obscenities take advantage of the deficiency and enter, damaging the blood channels of the kidneys; deficiency of kidney yin, yin deficiency and fire, damaging the kidney channels, forcing the blood to travel delicately and thus blood in urine; injury to both qi and yin, or deficiency of spleen and kidney qi, qi deficiency is unable to take in blood, blood travels externally and blood in urine is seen.
Second, wind-heat and dampness invasion
The invasion of wind-heat and dampness due to eating foreign substances or allergic to drugs, resulting in internal injury to the blood channels and blood overflowing to the skin, resulting in purple spots; internal disturbance of the kidneys and damage to the kidney channels, resulting in more than blood in urine; wind-heat and dampness, resulting in swelling and pain in the joints; damage to the blood channels of the stomach and intestines, resulting in blood in the stool.
Blood stasis blocking the ligaments
Blood stasis is caused by the accumulation of blood within the meridian, and blood stasis blocks the kidney ligaments; or blood stasis is caused by the weakness of blood flow due to Qi deficiency.
[Clinical symptoms]
I. Extra-renal symptoms
(a) Rash The rash of allergic diesel purpura is characterized by hemorrhagic and symmetrical distribution in both lower limbs, mostly in the ankle and knee joints, also seen in the temple and upper limbs, and the rash can appear repeatedly.
(B) Joint symptoms About half of the cases have wandering, multiple arthralgia, some of them can show joint swelling and restricted movement, often involving knee, ankle and hand joints. No joint deformity remains, but recurrent episodes may occur.
（Clinical symptoms are often abdominal pain with paroxysmal colic, which may be complicated by intussusception, intestinal obstruction and intestinal perforation in children.
（Other symptoms: enlargement of liver, spleen, lymph nodes, hemoptysis due to pulmonary hemorrhage, etc.
Renal manifestations
(A) nephritis syndrome type persistent microscopic hematuria, often accompanied by mild proteinuria, edema, hypertension or slowly progressive renal impairment, this type accounts for about 10% to 15%.
(2) Recurrent botrythematous hematuria This type often appears during upper respiratory tract infection or intestinal infection, and then becomes microscopic hematuria after 2 to 3 days, and so on repeatedly. When the botryoidal hematuria disappears, the urine protein is reduced or disappears. Patients usually do not have edema and hypertension, but they often have back pain, which may be unilateral or bilateral, and there is no obvious percussion pain in the kidney area on physical examination. This type is most often seen in children and accounts for about 20% of the disease.
(iii) Asymptomatic microscopic hematuria Microscopic hematuria often persists, and the red blood cells in the urine are mainly abnormal red blood cells (more than 80%). It may be accompanied by mild proteinuria (24-hour urine protein quantification of 1g or less), which is clinically asymptomatic and mostly found during physical examination. This type is the most common, accounting for about 50%.
(iv) Nephrotic syndrome type manifesting as massive proteinuria, hypoproteinemia and microscopic hematuria, accounting for about 7%-16% of allergic purpura nephritis. If accompanied by hypertension and renal function impairment, the prognosis is poor.
(E) Other types such as acute nephritis syndrome, acute renal failure. About 5% of the cases. It is less common clinically and has a poor prognosis.
Patients with doctor’s symptoms, please go to the regular hospital as soon as possible, inconvenient to come to the hospital can be and I telephone consultation, for your specific situation to give appropriate guidance and advice.
[Diagnostic points]
Symptoms
History and manifestations of allergic purpura, such as hemorrhagic rash, abdominal pain, intestinal bleeding; manifestations of concurrent renal damage, such as edema, hypertension, hematuria, proteinuria, nephrotic syndrome and renal insufficiency, etc., and thylakoid proliferative lesions with IgA deposition as the main pathological examination of the kidney. It can be diagnosed as purpura nephritis.
Physical signs
No significant specificity.
Laboratory tests
(1) Platelets, bleeding and clotting times, and prothrombin time are all within normal limits, and capillary fragility tests may be positive in some patients in the acute phase; (2) serum complement levels are usually within normal limits, C3 is normal, CH50 and preparedin levels are mildly decreased, and serum IgA is elevated in about half of the patients; (3) routine urinalysis may be mild to severe hematuria, proteinuria, and tubularity.
[Differential diagnosis]
It is difficult to differentiate from IgA nephropathy based on renal pathology and immunofluorescence changes. The degree of glomerular capillary loop necrosis and fibrin deposition is more severe in this disease. In those who present with rash and nephritis syndrome (even acute renal failure), care should be taken to differentiate them from other primary or secondary small-vessel vasculitis. IgA predominates in the immunofluorescence of the small vessels of the skin and glomeruli in this disease, whereas immunoglobulin deposition is often absent in primary small-vessel vasculitis and IgG and IgM deposition in other secondary small-vessel vasculitis. When the rash and other extrarenal manifestations are not obvious, it should be differentiated from acute post-streptococcal nephritis. The serum C3 and anti-streptococcal “O” titers are normal in this disease, but IgA and circulating immune complexes containing IgA components are often elevated.
[Therapeutic measures]
I. Occurrence of the disease
It is often associated with food, drugs, insect bites and other triggering factors. Therefore, community doctors should strengthen publicity and education and health guidance, instruct patients to actively exercise and pay attention to prevent various triggering factors.
II. Treatment
(1) General treatment: Patients with allergic purpura should rest in bed during the acute period and pay attention to keep warm. Those who are allergic to food or drugs should try to find the antigen and stop or avoid contact with the related allergen. Severe arthralgia and abdominal pain can be treated with appropriate analgesics, and those with severe gastrointestinal bleeding can be treated with appropriate blood transfusion. Early application of glucocorticoids has good effect on edema, gastrointestinal symptoms and skin purpura. (2) Antihistamines: such as paracetamol, orally, 4mg each time, 3 times a day; benadryl, orally, 25-50mg once, 2-3 times a day. Intramuscular injection, 20mg once, 1 to 2 times a day. (3) Hemostatic drugs: no major bleeding, generally do not use hemostatic drugs, serious bleeding, can be used such as hemostatic min, oral, each 0.5 ~ 1g, 3 times a day. Intramuscular injection, 0.25~0.75g each time, 2~3 times a day. Vitamin K4, 4mg each time, 3 times a day. (4) Glucocorticoids and cytotoxic drugs: glucocorticoids are effective in controlling rash, abdominal pain and arthritis, and glucocorticoids plus cyclophosphamide can be used for the treatment of purpura nephritis manifesting as nephrotic syndrome. Generally, prednisone 1 mg/(kg.d) for 6-12 months; cyclophosphamide 2-3 mg/(kg.d) for 6-8 g. (5) Shock therapy: For those with crescentic bodies over 50% and clinical manifestations of acute nephritis, methylprednisolone and phosphoramidate shock therapy can be given, and if shock therapy is ineffective for 3-4 courses, plasma replacement can be added. (6) Dialysis and kidney transplantation: Patients with end-stage renal failure can be considered for dialysis or kidney transplantation treatment.
Chinese medicine treatment
(1) Identification and treatment ① Wind-heat wrestling evidence: sudden onset, fever and sore throat, skin purpura, joint pain, microscopic or naked eye hematuria, red tongue, yellow coating, slippery pulse.
Treatment: dispel wind-heat, cool the blood and stop bleeding Main formula: Yin Qiao San (Yin Hua, Lian Qiao, pale leaf, bitter orchid, peppermint, raw licorice, thorny spike, tempeh, burdock) plus or minus: for dry mouth and desire to drink, add Sheng Di, Dan Pi, Huang Jing; for abdominal pain and blood in the stool, add Bai Shao, Sheng Di Yu; for obvious blood in the urine, add Bai Mao Root, lotus root, large and small thistle, Verbascum, Phellodendron.
② Heat and compulsion of blood evidence: fever at night, thirst for drink, purpura of the skin, hematuria under the mirror or the naked eye, red tongue, less coating, pulse number.
Treatment: Nourish Yin and clear heat, cool the blood and stop bleeding Main formula: Rhizoma Dihuang Tang (water hyacinth, raw groundnut, red peony, peony bark) plus or minus: for dry throat and sore throat, add silver flower, forsythia, xuan shen; for hematuria, add white foxglove, root of lotus root, cyperus.
(③) Damp-heat internalized evidence: swelling of both lower limbs, dry mouth, bitter mouth, yellow urine, red tongue, yellow greasy coating, slippery pulse.
Treatment: Nourish Yin and clear heat, invigorate blood and promote water.
Spleen and kidney Qi deficiency evidence: lumbar soreness and weakness, withered face, loose abdomen and stool, or edema, pale tongue with teeth marks, white greasy moss, thin and smooth pulse.
Treatment: Strengthen the spleen and benefit the kidney.
Main formula: Shengqi Dihuang Tang (Radix Astragali, Radix Codonopsis, Rhizoma Atractylodis Macrocephalae, Poria, Radix Rehmanniae, Cornu Cervi Pantotrichum, Salviae Miltiorrhizae) plus or minus: for oedema and abdominal distension, add Dagastrodiae, Chen Pi, Winter Claw Skin; for pale tongue, add Angelicae Sinensis, Radix et Rhizoma, Radix Paeoniae Alba, Radix et Rhizoma, Salviae Miltiorrhizae.
⑤ Qi and Yin deficiency evidence: soreness and weakness of the waist and knees, fatigue, heat in the hands and feet, dry mouth, dry throat, dark red throat, red tongue with yellow or less moss, and thin pulse.
Treatment: Benefit Qi and nourish Yin.
Main formula: Liu Wei Di Huang Tang (Radix et Rhizoma Atractylodis Macrocephalae, Poria, Radix et Rhizoma Rehmanniae, Cornu Cervi Pantotrichum, Salviae Miltiorrhizae) plus or minus: for Qi deficiency, add Radix Astragali, Radix et Rhizoma Polygonatum; for Yin deficiency, add Radix et Rhizoma Polygonatum, Radix et Rhizoma Sagittatum; for Yin deficiency and fire, add Radix et Rhizoma, Radix et Rhizoma Polygonatum, Radix et Rhizoma Glabra.
(6) Liver and kidney yin deficiency evidence: soreness and weakness of the waist and knees, dizziness, blurred vision, dry mouth and throat, heat in the heart of the hands and feet, red tongue with little coating, thin and slightly counted pulse.
Treatment: Nourish the liver and kidney. Main formula: Qiju Dihuang Wan (Fructus Lycii, Chrysanthemum, Radix et Rhizoma Atractylodis Macrocephalae, Poria, Radix et Rhizoma Rehmanniae, Cornu Cervi Pantotrichum, Salviae Miltiorrhizae) plus or minus: for insomnia and dreaminess, add Chicken Seed Yellow, Sour Jujube Seed, Cypress Seed; for dry mouth and throat, add Salviae Miltiorrhizae, Medlar.
(2) Traditional Chinese medicine treatment
(1) Compound Salvia injection (main ingredient Salvia). Add 10-20ml of compound salvia injection into 5% glucose injection, and then administer the injection once a day for 14 days. It is mainly used in the stable stage of allergic purpura nephritis with stasis of blood. ②Yu Ping Feng San Punch. Take orally, 5g each time, 3 times a day, for those who are prone to cold in this disease. ③Legendan Polyglucoside Tablets (the main ingredient is leigendan polyglucoside). Take by mouth in 3 doses at 1~1.5mg/kg.d, after meals. It is applicable to the nephrotic type of allergic purpura nephritis.
About the specific methods of Chinese medicine treatment can contact me by telephone consultation, combined with your own situation dialectical treatment.
Understand the toxic side effects of drugs, and go to the hospital for examination if you have similar symptoms.
[Home care]
Keep the air in the room fresh, ventilate regularly, eliminate filthy air and prevent cold; pay attention to personal hygiene, keep the mouth and skin clean, bathe regularly and pay attention to skin care; avoid straining, rest in bed during the acute period, and move appropriately after the condition is stabilized.
[Prevention and rehabilitation]
Allergic purpura nephritis is closely related to respiratory and intestinal infections, therefore, you should actively exercise, enhance physical fitness, pay attention to timely increase and decrease clothing, prevent cold and keep warm, pay attention to dietary hygiene, prevent respiratory and intestinal infections. The occurrence of this disease is related to food, drugs, insect bites and other triggers, so the diet is rich in nutrients, easy to digest food, eat more fresh vegetables, fruits, avoid seafood hair, spicy and dry products, quit smoking and alcohol. For those who have clear allergens, they should pay more attention to avoid contact with such allergens again. Regulate the spirit, maintain physical strength, and moderate sexual life. Women should not get pregnant in the short term after the disease, and if they do, they should closely monitor the changes in kidney function and blood pressure. To improve autoimmune function, you can often take Yu Ping Feng Punch and Fang Feng Tong Sheng Wan.
[Family Medicine Celosia]
I. Western medicine
(1) Glucocorticoids: ① Prednisone (prednisone, dehydrocortisone), 5mg per tablet, 5~80mg per time, 1 oral dose in the morning. Caution: Do not abuse it without authorization, and use it strictly under the guidance of a doctor. Prednisone needs to be activated to hydrogenated prednisone by the liver to be effective, so it should not be used in patients with poor liver function. Prednisolone can be used in patients with hepatic impairment. (2) Immunosuppressants: ①Cyclophosphonamide, 50mg per tablet, 50-100mg per time, twice daily. (2) Azelaic acid benzoate, 2mg per tablet, 2-4mg per time, 3 times a day. Azathioprine, 50mg per tablet, 50-100mg per dose, 2 times daily by mouth. ④Mortimerol (MMF, primaquine), 250mg per tablet, 250-750mg per time, 2 times daily. Caution: These drugs should be administered strictly under the guidance of a physician and are contraindicated in patients with abnormal liver function and peripheral blood leukopenia. (3) Antihistamines: ①Paracetamol, 4mg per tablet, 1 tablet each time, 3 times a day orally. ②Pheniramine, 25mg per tablet, 1~2 tablets per time, 2~3 times a day orally. Caution: These drugs have side effects such as dizziness, headache and drowsiness.
II. Proprietary Chinese medicine
(1) The occurrence of this disease is closely related to the cold, so you should always have some Chinese medicines to relieve the symptoms. (1) Zheng Chai Hu drink punch, granules, 1 bag of 3g, 1 box of 10 bags, 1 time 3g, 3 times a day orally. ②Yin Qiao Jie Toxin Granules, granules, 1 sachet of 2.5g, 1 box of 12 sachets, 2.5g once, 3 times a day orally. ③Yu Ping Feng San Punch, granules, 1 sachet of 5g, 1 box of 12 sachets, 5g once, 3 times a day orally. ④Feng Feng Tong Sheng Wan, water pills, 1 bag of 6g, 1 pack of 10 bags, 6g once, 2 to 3 times a day. (2) Hemostatic agents: Yunnan Baiyao capsule, capsule, 1 capsule 2.5g, 1 box of 16 capsules, 2.5g once, 3 times a day orally. (3) Wind and dampness dispelling agent: Leigongtang Polysaccharide Tablets, tablet, 1 tablet 10mg, 1 box of 50 tablets, 1 time 20mg, 3 times a day, taken after meals.
The instructions should be read carefully before taking various drugs and should be used strictly under the guidance of a doctor, especially glucocorticoids and immunosuppressants, etc. Do not abuse them.