During admission, patient developed melena and there was coffee-ground material per NGT, he MG-132 datasheet was referred to gastroenterology service for co-management. His medical history was unremarkable except for a history of previously treated pulmonary tuberculosis in 2012. Physical examination revealed direct tenderness on the epigastric area and there was left lower quadrant rebound tenderness and multiple purpuric rashes on the gluteal area up to the dorso-medial aspect of both lower extremities. The initial leukocyte count was 17000/mm3,

and the C-reactive protein was elevated to more than 16 mg/dL. Urinalysis showed hematuria with trace albuminuria. Serum creatinine and liver function was normal and a plain abdominal film did not show pneumoperitoneum or obstruction. A repeat fecalysis and stool culture was negative for enteric pathogens, and no ova or parasites were found. Results: An Opaganib chemical structure upper endoscopy showed patchy to linear erythematous areas following the rugal

folds and edematous mucosa from the cardia up to the antral area there was note of stellate to linear ulcers at the second part of the duodenum. Colonoscopy was done which showed patches of erythema, with mucosal and submucosal hemorrhages at the rectum up to the sigmoid area. The skin biopsy of the purpuric lesions showed evolving leukocytoclastic vasculitis compatible with Henoch-Schonlein purpura. Patient was started on IV Hydrocortisone and was eventually shifted to oral prednisone. Abdominal pain improved remarkedly during the course of the steroid therapy. We only maintained the patient on oral proton-pump inhibitor while on prednisone. Conclusion: The American College of Rheumatology has defined four diagnostic criteria, two of which are necessary Cyclooxygenase (COX) to distinguish HSP from other forms of vasculitis. These criteria are (a) age of 20 years or younger at onset, (b)

palpable purpura, (c) gastrointestinal bleeding, and (d) biopsy evidence of granulocytes around small arteriolar and venular walls. The clinical presentation of HSP is more severe among adults and tends to be atypical where there is higher rate of severe and atypical gastrointestinal & renal complications. Gastrointestinal pain was the first manifestation in 11% of patients with HSP. Massive GI hemorrhage and grossly bloody or melenic stools are respectively reported in 2% and 30% of the patients 3 Mucosal lesions develop anywhere within the GI tract. Diffuse mucosal redness, small ring-like petechiae and hemorrhagic erosions are characteristic endoscopic findings. As seen in our patient, the small intestine is considered to be the most frequently affected site with the duodenal being the most commonly affected site especially the second part of the duodenum than in the bulb. 3 In most cases, HSP spontaneously disappears without treatment. The use of corticosteroids is controversial and usually reserved for severe systemic manifestations4.