Allergic purpura is a systemic vasculitis syndrome with small vasculitis as the main lesion. The main clinical manifestations are skin purpura, gastrointestinal mucosal bleeding, joint pain and kidney damage (hematuria, proteinuria, etc.). The disease can occur throughout the year, but is more frequent in winter and spring. The disease can occur at all ages, but is most common in school-age children, with 3 to 14 years being the most common age. The ratio of male to female is about (1.4~2):1. In ancient medical texts, purpura, purpura wind, grape disease, epistaxis, etc. are similar to this disease.
1. diagnosis
1. 1 Diagnostic points
1) There may be a history of upper respiratory tract infection or consumption of certain foods and drugs before the onset of the disease.
2) The onset of purpura is acute, mostly found in the distal lower limbs and buttocks, symmetrical distribution, varying in shape, higher than the skin surface, and does not fade when pressed. It may be accompanied by urticaria, angioneurotic edema, painful wandering large joints, abdominal pain, blood in stool, hematuria, proteinuria, etc.
3） Platelet count is mostly normal or elevated, and bleeding, clotting time and clot contraction time are normal.
4） Regular urine examination should be noted. There may be signs of kidney injury such as microscopic hematuria and proteinuria. Renal tissue biopsy can determine the nature of renal lesions.
1. 2 Laboratory tests
Routine blood, urine, fecal and occult blood tests, liver and kidney ultrasound, 24-h urine protein quantification, urine immunoassay, urine NAG enzyme, urine red blood cell pattern, capillary fragility test, clot constriction test, coagulation five, liver and kidney function, immunological tests, allergen screening, etc.
1. 3 Differential diagnosis
The disease can be differentiated from idiopathic thrombocytopenic purpura, glomerulonephritis after streptococcal infection, rheumatoid arthritis, acute abdomen, acute nephritis, IgA nephropathy, and other diseases.
2 Identification
2. 1 Allergic purpura
1) Wind-heat injury
The purpura is mostly found on the lower extremities and buttocks, it may be accompanied by urticaria, also seen on the upper extremities, symmetrically distributed, bright red in color, varying in size and shape, may fuse into patches, or itchy; it may also be seen as joint swelling and pain, abdominal pain, blood in stool, blood in urine, etc. The prodromal symptoms are mostly fever, slight wind chill, cough, red throat, epistaxis, general malaise, loss of appetite, etc.; the tongue is red, the fur is thin and yellow, the pulse is floating.
2） Blood-heat delusion evidence
Rapid onset, dense skin petechiae, or even fused into patches, bright red or purple-red; may be accompanied by fever, red face, dry mouth, thirst for cold drinks, distress and insomnia, epistaxis, blood in stool, dry stool, yellow and red urine; red tongue, yellow and slightly dry coating, and strong pulse.
3） Damp-heat paralysis and obstruction
Purple dull skin or sores, mostly around joints, with swollen and painful burning joints, especially in knee and ankle joints, heavy limbs, limited movement of limbs; may be accompanied by abdominal pain, dullness, thirst, inability to drink, irregular stools, blood in stool, blood in urine; red tongue, yellowish greasy coating, smooth or string pulse.
4） Yin deficiency with fire
Slow onset, long duration, skin purpura with intermittent onset, dark red petechiae; may be accompanied by low fever and night sweating, heat in the hands and feet, restlessness, dry mouth and throat, dizziness and tinnitus, blood in urine; red tongue with little fluid, thin pulse.
5) Qi does not take in blood
Long duration of the disease, recurrent purpura, vague and scattered, pale color, emaciation, unpleasant complexion, fatigue, dizziness and palpitations, little food and dullness, loose stools; pale tongue, thin white coating, weak or sunken pulse.
2. 2 Purpura nephritis
1) Wind-heat with stasis evidence
Rapid onset, purple skin patches, mostly on the lower extremities and buttocks, symmetrically distributed, bright red, maculopapular, varying in size and shape, may fuse into patches; may be accompanied by fever, slight wind chill, cough, runny nose, yellow sputum, bright red throat, epistaxis, blood in urine, blood in stool; petechiae on the tongue, thin yellow fur, floating pulse.
2） Blood heat with stasis evidence
The onset of the disease is rapid, with dense petechiae on the skin, one after another, deep purple-red in color, or even fused into patches; it may be accompanied by heart trouble, dry mouth and desire to drink, epistaxis, epistaxis, blood in stool, constipation, and short red urine; the tongue is red and vivid or with mangoes, the veins under the tongue are tortuous, the moss is thin yellow or yellow thick, and the pulse is counted and strong.
3) Yin deficiency with stasis evidence
The onset of the disease is slow, the duration of the disease is long, the purpura is sporadic, the color is dark red, or the purpura has faded, low fever, hot flashes and night sweats, heat in the hands and feet, dry mouth and drinking, restless sleep at night, dark red throat, dry stool; the tongue is red and less fluid, the tongue is petechiae, little or no moss, and the pulse is fine.
4） Qi and Yin deficiency with stasis
The onset of the disease is slow, the duration of the disease is long, the purpura is sporadic, the color is dark red, or the purpura has faded, spontaneous sweating and night sweating, dry throat and lips, thirsty and thirsty for drinks, five hearts are troubled and hot, the face is flushed, hot flashes in the afternoon, easy to catch a cold on weekdays, tiredness and fatigue, little breath and lazy speech, poor appetite; tongue body petechiae, tongue red and less fluid, less moss, thin and weak pulse.
3 Treatment
3. 1 Treatment principles (Recommendation level: E)
The treatment of this disease is not only to eliminate the cause and eliminate the spots, but also to treat both the symptoms and the causes. In the early stage, the main treatment is to eliminate the evil, and in the later stage, the main treatment is to protect the qi and yin and eliminate the purpura. The actual evidence is to clear the heat and cool the blood, with the help of dispelling the wind and clearing the ligaments, slowing down the emergency and harmonizing the middle; the deficiency evidence is to nourish the yin and lower the fire, benefit the qi and take in the blood. The blood of purpura is stagnant blood, so it is important to activate the blood and remove stasis throughout.
The most important thing is that the patient should be able to get the best out of the situation. The child should avoid contact with allergens; restrict activities when there is a lot of bleeding; avoid hot and spicy diet; abstain from food when there is gastrointestinal bleeding; and prevent and control infections and get rid of internal parasites.
3. 2 Treatment by evidence
3. 2. 1 Allergic purpura
(1) Wind-heat injury to the ligament (Recommendation: D)
Treatment: Expel wind and heat, cool the blood and calm the ligament. Main formula: Yin Qiao San plus reduction. Commonly used drugs: honeysuckle, forsythia, burdock, peppermint, thorny mustard, comfrey, cyperus, raw earth, peony bark, etc. If the skin is itchy, add Bai Xian Pi, Burdock Root, Botrytis, Fucus, Cicada; for cough, add Mulberry Leaf, Chrysanthemum, Qian Hu; for blood in stool, add Bitter Ginseng, Sophora charcoal; for abdominal pain, add Magnolia, Red Peony; for blood in urine, add Rootstalk charcoal, White Fleece Root, Artichoke, Little Thistle, Dry Lotus Grass; for joint swelling and pain, add Gentiana, Antibiotics, Huai Niu Kne.
(2) Blood-heat delusional evidence (Recommended grade: D)
Treatment: Clearing heat and detoxifying toxins, cooling the blood and resolving blemishes. Main formula: Rhizoma Rhizoma Dihuang Tang with added flavor. Commonly used herbs: Rhinoceros horn, Radix et Rhizoma, Mudanpi, Red peony, etc. Add and subtract: If there are many purple spots on the skin, add Salvia miltiorrhiza, Thornbush, Lonicera japonica; if there is blood in the stool, add Sheng Di Yu, Blood Yu Char, Sambucus Flower Char; if there is abdominal pain, add Guang Mu Xiang, White Peony; if there is blood in the urine, add Da Thistle, Xiao Thistle, Bai Mao Root, Dry Lotus Grass; if there is swelling and pain in the joints, add Lonicera japonica, Hai Feng Vine, Huai Niu Kne; if there is constipation, add Sheng Da Huang (later); if there is redness in the eyes, add Qing Dai, Chrysanthemum.
(3) Damp-heat paralysis and obstruction (Recommended grade: D)
Treatment: Clearing heat and relieving dampness, resolving blood stasis and promoting circulation. Main formula: Si Miao Pill with added flavor. Commonly used drugs: Phellodendron, Atractylodes, Atractylodes, Coix Seed, Atractylodes, Papaya, Comfrey, Mulberry, Doklam, etc. If the joints are swollen and painful, with restricted movement, add Radix Paeoniae Alba, Radix Rehmanniae, Radix Lonicerae, Rhizoma Polygonati, Radix Bupleurum, Radix Bupleurum; for diarrhea, add Radix Puerariae, Rhizoma Huanglian, Radix Verbascum; for blood in urine, add Radix Thistle, Radix Shivei, Radix Bupleurum; for abdominal pain, add Radix Paeoniae Glycyrrhizae to relieve pain.
4) Yin deficiency and fire (Recommended grade: D)
Treatment: Nourishing Yin and clearing heat, cooling blood and resolving blood stasis. Main formula: Tai Tonic Yin Pill plus reduction. Commonly used drugs: Radix Rehmanniae Praeparata, Tortoise Plate, Phellodendron Bark, Zhi Mu, Mudanpi, Niu Knee, Honey, etc. If the blood in the urine is red, swallow amber powder and panax ginseng powder; if the blood is low, add silver bupleurum and ground bones to clear deficiency heat; if the sweating is night, add calcined oyster, calcined dragon bones and wu wei zi to stop sweating.
(5) Qi does not take in blood (Recommended grade: D)
Treatment: Strengthening the spleen and benefiting Qi, harmonizing the Ying and regulating Blood. Main formula: Gui Shen Tang with addition and subtraction. Commonly used herbs: Radix et Rhizoma Ginseng, Radix Astragali, Rhizoma Atractylodis Macrocephalae, Radix Angelicae Sinensis, Radix Longan, Fu Shen, Radix Ziziphi, etc. If there is blood in the abdominal pain and blood in the stool, add Wu Mei, Bai Shao, Fang Feng Char, Sheng Di Yu; if the bleeding does not stop, add Chicken Blood Vine, Blood Yu Char, Agaricus; if there are also superficial evidence of wind, add Thornbush, Fang Feng, Burdock, etc. to relieve wind and relieve superficial symptoms, but the dosage should not be large, in order to prevent dryness and injury to yin.
3. 2. 2 purpura nephritis
(1) Wind-heat with stasis (Recommended level: E)
Treatment: Expel wind-heat and clear heat, invigorate blood circulation and remove blood stasis. Main formula: Radix Angelicae Sinensis plus reduction. Commonly used drugs: Radix Angelicae Sinensis, Radix Angelicae Sinensis, Scutellariae Sinensis, Radix et Rhizoma Macrocephala, Radix et Rhizoma Chai Hu, Radix et Rhizoma Qian Hu, Radix et Rhizoma Sheng Di Huang, Radix et Rhizoma Huang Lian, Radix et Rhizoma Glycyrrhiza Uralensis. If the skin is itchy, add Bai Xian Pi and Di Shen Zi; if the abdomen is painful, add Mu Xiang and Peony; if the blood is in the stool, add Sheng Di Yu, Bitter Ginseng and Sophora charcoal; if the blood is in the urine, add Rootstalk charcoal, Bai Mao Root, Da Thistle, Xiao Thistle and Dry Lotus Grass.
(2) Blood-heat with stasis evidence (Recommended grade: D)
Treatment: Clearing heat and removing toxins, activating blood circulation and resolving blood stasis. Main formula: Rhizoma Rhizoma Dihuang Tang with Addition. Commonly used herbs: water hyacinth, Radix et Rhizoma, Radix Paeoniae Alba, Peony Skin, Radix et Rhizoma Ginseng, Gardenia, Radix Scutellariae, Radix et Rhizoma Zizyphus, Radix et Rhizoma Glycyrrhizae. For epistaxis, add Zhi Mu, Gardenia, Rootstalk charcoal, Xi Cao Charcoal, and Xian He Cao; for epistaxis, add Bai Mao Root, Fried Pu Huang (decoction), Xian He Cao, and San Qi Powder (swallowed); for epistaxis, add Rootstalk charcoal; for blood in urine, add Da Thistle and Xiao Thistle; for blood in stool, add Sheng Di Yu and Yi Mao Cao.
3) Yin deficiency with stasis (Recommended grade: D)
Treatment: Nourishing Yin and clearing heat, activating blood circulation and resolving blood stasis. Main formula: Zhi Bai Di Huang Tang with addition and subtraction. Commonly used herbs: Radix Rehmanniae Praeparata, Radix Mudanpi, Cornus Officinalis, Poria Cocos, Phellodendron Bark, Radix et Rhizoma Polygonati, Radix et Rhizoma Drynariae, Radix Achyranthes Bidentatae, Radix Zeleniae. Addition and subtraction: If there is low fever, add Yin Chai Hu, Artemisia annua, Di Bone Bark; if there is night sweating, add Calcined Oyster, Calcined Dragon Bone, Wu Wei Zi; if there is blood in urine, add White Fleece, Small Thistle, Large Thistle, Xian He Cao; if there is blood in stool, add Raw Earth Elm, Sophora charcoal.
4) Qi and Yin deficiency with stasis (Recommended level: E)
Treatment: Benefiting Qi and nourishing Yin, activating blood circulation and resolving blood stasis. Main formula: Ginseng, Astragalus, Dihuang Tang plus reduction. Commonly used drugs: ginseng, astragalus, poria, raw earth, yam, dogwood, peony bark, zedoary, etc. If the mouth is dry and throat is dry, add Ginseng, Dendrobium, Yu Zhu, etc.; if the blood is in urine, add fried Pu Huang (decoction), lotus root charcoal, small thistle, large thistle; if the blood is in stool, add raw Di Yu, Sophora charcoal, etc.
3. 3. 3 Prepared Chinese medicines
3. 3. 1 Oral Chinese patent medicines
1) Leigongtang Polyglucoside Tablets: 1~1.5 mg/(kg?d), divided into 2~3 times orally. It is suitable for recurrent allergic purpura and all types of purpura nephritis. The course of treatment is 2 to 3 months for simple skin purpura and 3 to 6 months for purpura nephritis. (Recommended level: D)
(2) GUIZEN WAN (Radix Codonopsis Pilosulae, Atractylodes Macrocephalae, Radix Astragali, Radix Glycyrrhiza Uralensis, Poria, Radix Fructus Yuanzhi, Radix Ziziphi, Longan Flesh, Radix Angelicae Sinensis, Muxiang, Jujube): 1 /3 pills for 3-6 years old, 1 /2 pills for 6-9 years old, 1 pill for 9 years old and above, 2-3 times a day. Used for the evidence of Qi not taking in blood. (Recommended level: E)
(3) Lotus Leaf Pill (Lotus Leaf, Lotus Root, Artichoke Charcoal, Little Thistle Charcoal, Zhi Mu, Scutellaria Baicalensis Charcoal, Di Huang Charcoal, Palm Charcoal, Jiao Yuan Zi, Bai Mao Root, Xuan Shen, Bai Shao, Angelica Sinensis, Xiang Mo): 4.5 g per dose for children above 7 years old, 2 to 3 times a day with warm water on an empty stomach. For the evidence of blood-heat delusion. (Recommended level: E)
4) Nephrolithiasis Rehabilitation Tablets (Radix et Rhizoma Ginseng, Radix Ginseng, Rhizoma Dioscoreae, Fried Eucommiae, Rhizoma Yam, Rhizoma Alba, Rhizoma Polygonati, Rhizoma Polygonati, Rhizoma Polygonati, Rhizoma Polygonati, Radix Eucommiae): 5 tablets each time, 3 times a day. Indicated for purpura nephritis with deficiency of both qi and yin. (Recommended grade: D)
3. 3. 2 Chinese medicine injections
1) Qingkailing injection (bile acid, mother-of-pearl, porcine deoxycholic acid, gardenia, water hyacinth powder, panax quinquefolium, baicalin, gold silver flower. (Excipients are disodium edetate, sodium thiosulfate, glycerol): 0.5 mL/(kg?d), add 5% glucose injection 100-250 mL intravenously, 1 time a day, 4 weeks. For blood-heat delusion. (Recommended Grade: D)
(2) Compound Salvia injection (Danshen): 0.5 mL/(kg?d), add 5% glucose injection 100-250 mL intravenously, once a day, for 4 weeks. It is used for allergic purpura with blood-heat delusion and all types of purpura nephritis. (Recommended level: D)
①Recommendation level or strength is divided into 5 levels: A, B, C, D, E. The strength of A is the highest. The intensity of A level is the highest, and decreasing in order.
②The so-called recommendation level or recommendation strength only refers to the degree of support in the literature, and does not represent a special recommendation.