Rheumatol Int

DOI 10.1007/s00296-014-2971-9

Original Article

Establishing hospital admission criteria ofpediatric

HenochSchonlein purpura
KamalMasarweh YosephHorovitz AviAvital
RonenSpiegel

Received: 10 December 2013 / Accepted: 14 February 2014

Springer-Verlag Berlin Heidelberg 2014

AbstractThe current study aimed to define evidencebased admission criteria of pediatric HenochSchonlein
purpura (HSP). In addition, we aimed to better characterize epidemiological and clinical features of pediatric HSP
in Israel. We performed a retrospective cohort study of all
children with HSP admitted during a 15years period to a
single pediatric department. We strictly collected the clinical data of all HSP cases. Each case was categorized as
either necessary admission or unnecessary admission.
We compared the two groups, using initially Chi square
(2) and student t tests, and thereafter, we employed
logistic stepwise regression analysis. One hundred and
sixty-three children with HSP were included. A set of six
clinical criteria of which the presence of minimum one
predicts the need for hospitalization were identified including: orchitis, moderate or severe abdominal pain, arthritis
involving more than two joints, proteinuria, clear evidence
of gastrointestinal bleeding, and inability to ambulate. In
conclusion, we suggest a predictive model for the admission of pediatric patients with acute HSP. The implementation of this model can significantly reduce unnecessary
admissions.

K.Masarweh Y.Horovitz R.Spiegel(*)

Department ofPediatrics A, Emek Medical Center,
18101Afula, Israel
e-mail: spiegelr@zahav.net.il
Y.Horovitz A.Avital R.Spiegel
Rappaport School ofMedicine, Technion, Haifa, Israel

Keywords HenochSchonlein purpura Admission

criteria Retrospective study Arthritis

Introduction
HenochSchonlein purpura (HSP) is the most common form
of systemic vasculitis in children and is often regarded as
a benign disease, with a self-limited course and excellent
prognosis, as opposed to other types of vasculitis. Nevertheless, few patients may manifest severe complications mainly
when involving renal and gastrointestinal manifestations [1].
There is no clear consensus regarding the optimal treatment and follow-up of HSP. Some patients require hospitalization for optimal treatment of disease manifestations,
such as severe arthritis, nephritis, severe abdominal pain,
gastrointestinal bleeding, and intussusception. A recent
study showed substantial variation in the inpatient evaluation and therapy of children admitted with acute HSP to 36
different childrens hospitals in the USA [2]. This variation
strongly encourages the establishment of uniform clinical criteria both for admission and for inpatient treatment
protocols.
In our pediatric department, the policy used in the last
15years was to admit every child with clinical diagnosis
of HSP regardless of its severity. In this study, we took
advantage of this admission strategy. We retrospectively
evaluated the medical files of all HSP cases admitted to our
department in the past 15years in order to define evidencebased statistically significant admission criteria.
Furthermore, our study represents the largest Israeli
cohort of HSP patients. The meticulous analysis of the relevant clinical and epidemiological data, allowed us to establish the most extensive database among the Israeli population so far.

13

Materials andmethods
Patients
This is a retrospective study analyzing the medical files of
all children with HSP admitted to a single pediatric department at Emek Medical Center in Afula, Israel, within the
past 15years (19952010); the cases included in the study
were selected by a computerized search based on the discharge diagnosis of HSP (ICD-10 code 287.0). The charts
of all the cases collected were reviewed by two senior pediatricians (HY & RS). Cases were included in the study only
if they met the EULAR/PReS endorsed consensus criteria
[3].
Data collection
The epidemiological data collected included age, gender,
number of previous HSP episodes (if existed), and number
of days until resolution and discharge.
The clinical data collected included skin manifestations, edema, arthritis/arthralgia, gastrointestinal involvement, renal involvement, and other organs involvement
(central nervous system, scrotum and genitals, heart,
lungs, eyes).
Laboratory data of patients were analyzed, including a
complete blood count (CBC), blood chemistries including renal and liver studies, erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP), coagulation studies,
complement components (C3 and C4), antinuclear antibodies (ANA). Serology studies included EBV, CMV, and
antistreptolysin O (ASLO) tests. Skin and renal biopsies
were documented whenever undertaken.
Data on pharmacological treatment (drug, dosage, duration of treatment) were also reviewed. Clinical outcomes,
including length of stay (LOS), complete remission, and
relapses, were documented.
Necessary versusunnecessary admission
In order to define valid admission criteria for acute HSP,
each case was carefully reviewed by two senior pediatric consultants (RS & YH) and labeled as either necessary admission or unnecessary admission. A necessary
admission is a case in which the hospitalization was needed
in retrospect for optimal assessment and treatment and
would have been difficult to be carried out in an outpatient
setting. The criteria for necessary admission included:
intravenous treatment, studies readily available all day
only at hospitals (imaging studies, etc.), significant pain
requiring close medical observation, and disease complications that can be managed only in hospitals (for example
intussusceptions).

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Rheumatol Int

A clinical comparison was then carried out between the

two groups. Based on the differences identified between the
two categories, the final stage consisted on implementing
a statistically relevant set of criteria that will assist the primary pediatrician in deciding whether to admit a child with
an acute HSP episode or to continue treatment and surveillance in an outpatient setting.
Statistical analysis
Initially, the prevalence of all categorical and continuous variables was computed, including clinical and laboratory data collected from the cases files. Thereafter, all
cases were categorized either as necessary admissions or
unnecessary admissions. Accordingly, a comparison of
categorical variables (such as gender, presence of joint disease, etc.) between the 2 groups was made using Chi square
(2) tests. Comparison of continuous variables (such as
age, LOS, etc.) between the two groups was made by independent sample t tests. Finally, a logistic stepwise regression analysis was performed using all univariate variables
with p<0.05 as potential predictors in order to define a set
of criteria for necessary admissions.
The statistical analyses were performed using the SPSS
software package (SPSS 17.0; Chicago, IL). A P value
of<0.05 (two-tailed test) was considered statistically
significant.
Ethics
The study was approved by the local ethics committee.

Results
Epidemiological features
Between January 1995 and December 2010, 163 cases
of acute HSP fulfilling the inclusion criteria as described
above were admitted to our pediatric department, suggesting an average of 11 patients/year. Males were affected
slightly more than females (57 vs. 43%, respectively).
The patients ranged in age from 1year to 17years (median
6.8years), while most patients were between 3 and
10years (126 patients). Although seasonality was not dominant, HSP occurred more commonly in the winter (31%)
than in the summer (17%).
Clinical manifestations
The main clinical manifestations are shown in Table1.
All patients developed non-thrombocytopenic palpable
purpura during the course of the disease. Edema developed

Rheumatol Int
Table1Comparison of necessary and unnecessary admission data

Age
MeanSD
Age range
Median
Gender
Males
Females
Length of stay (LOS)
Skin involvementPurpura
Joints involvementArthritis
Numbers of joints involved (mean)
Monoarthritis
Pauciarthritis
Polyarthritis
Patient refuses to ambulate
Gastrointestinal involvement
Abdominal pain
Mild
Moderate
Severe
Positive blood occult tests
Clear bleeding
Renal involvement
Microhematuria
Macrohematuria
Proteinuria
Hypertension
Acute renal failure (mild)
Genitals involvement
Pain/tenderness
Orchitis
Epididymitis
CNS involvementconvulsions
Laboratory studies: leukocytes
CRP
ESR
Hemoglobin (gr%)
Treatment
NSAIDSMean treatment duration
CorticosteroidsMean treatment duration
Oral drugs
Parenteral drugs

All cases (%)

Necessary
admissions (%)

Unnecessary
admissions (%)

2/t

df

P value

6.863.32
17.3
6.3

6.703.4
15.2
6.4

6.943.29
17.3
6.3

<1

161

0.66

92 (57%)
71 (43%)
7.25.9
163 (100%)
118 (72%)
1.61.3
33 (20%)
70 (43%)
14 (9%)
18 (11%)
60 (37%)
54 (33%)
25 (15%)

37 (64.9%)
20 (35.1%)
11.67.7
57 (100%)
45 (79%)
2.141.5
6 (11%)
27 (47%)
12 (21%)
15 (26%)
35 (61%)
32 (56%)
10 (18%)

55 (51.9%)
51 (48.1%)
4.82.2
106 (100%)
77 (69%)
1.261
27 (25%)
43 (41%)
2 (2%)
3 (3%)
25 (24%)
22 (21%)
15 (14%)

2.71

0.1

6.536

32.69
3.73
5.12
0.87
17.34
20.81
11.34
20.95
0.329

61

1
82
1
1
1
1
1
1
1

0.0001

0.0001
0.0001
0.024
0.35
0.0005
0.0001
0.001
0.0001
0.566

29 (18%)
2 (1%)
9 (6%)
8 (5%)
25 (15%)
20 (12%)
2 (4%)
9 (6%)
4 (2%)
2 (1%)
15 (9%)
12 (7%)
2 (1%)
4 (2%)
1 (1%)
12.16
22
41.27
12.83

22 (39%)
2 (4%)
7 (12%)
8 (14%)
18 (32%)
14 (25%)
3.766
8 (14%)
4 (7%)
2 (4%)
13 (23%)
12 (21%)
2 (4%)
4 (7%)
1 (2%)
12.47
29.04
41.17
13.95

8 (8%)
0
2 (2%)
0
7 (7%)
6 (6%)
0
1 (1%)
0
0
2 (2%)
0
0
0
0
11.9
16.86
41.33
12.22

23.79
3.766
7.676
15.64
78.33
12.30
2 (1%)
12.18
7.626
155.1
19.41
24.09
3.76
7.63
1.87
0.33
1.34
0.02
3.50

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
154
41
31
48

0.0001
0.052
0.006
0.0001
0.0001
0.0001
0.052
0.0001
0.006
0.0001
0.0001
0.0001
0.052
0.006
0.171
0.742
0.187
0.986
0.034

4.522.4
5.514.8
43 (83%)

5.863
6.335.2
30 (53%)

3.51
3.071.4
13 (12%)

4.59
3.50
56.80

44
46
2

0.0001
0.034
0.0001

9 (17%)

9 (16%)

56.80

0.0001

in almost half of the cases, mostly in the feet (72 cases). Joint
manifestations, in particular arthritis, were very common
during the course of the disease. One hundred and eighteen
(72%) developed joint involvement, mostly monoarthritis

(70 cases43%) or pauciarthritis (24 joints) (33 cases

20%), and only 14 cases (9%) developed polyarthritis (more
than 4 joints). Joint inflammation was more common in the
lower extremities mainly the ankles and knees (93 cases).

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Gastrointestinal disease occurred in 60 children

(37%). The majority (54) suffered from abdominal pain,
most cases were mild (VAS score3) or moderate (VAS
score 47), and only in 2 (1%) cases, the abdominal
pain was severe (VAS score8) and accompanied by
peritoneal signs. Nine children (6%) had gastrointestinal bleeding. Eight children (5%) had clear bleeding,
while one child (1%) had massive hemorrhage. None of
the children suffered from intussusception or abdominal
perforation.
Renal manifestations were observed in 25 (15%) children. Twenty (12%) children had microscopic hematuria,
2 (1%) children had macroscopic hematuria, and 9 (6%)
had isolated asymptomatic proteinuria. Two (1%) children suffered from nephrotic range proteinuria, and one of
them developed full blown nephrotic syndrome. Hypertension was observed in 4 (3%) children. Two children (1%)
developed acute renal failure.
Involvement of other systems was less common.
Only one child suffered from seizures. Genital involvement (mainly orchitis) occurred in 15 (16% of male children). None of our patients had cardiac or ophthalmologic
manifestations.
Treatment
Most of the patients (90 children 55%) were treated with
oral non-steroid anti-inflammatory drugs (NSAIDS) such
as ibuprofen and naproxen. The mean duration of treatment
was 4.52days. Fifty-two (32%) children were treated with
steroids. In most cases, the treatment was given by oral
route, and only nine children (6%) required parenteral steroids. The mean duration of treatment was 5.51days.
Laboratory findings
The main laboratory data are shown in Table1. Twentythree cases (16%) had leukocytosis, defined as a leukocytes count over 15,000/ml. ESR was increased (above
25mm/h) in 20 of 33 cases tested. CRP was significantly
elevated (above 30mg/ml) in 7 children (16%). A high
antistreptolysin O (ASLO) titer was detected in 11 of
26 cases studied (42%), suggesting post-streptococcal
infection as the most common etiology of HSP in our
cohort.

Rheumatol Int

Comparison betweennecessary andunnecessary

admissions
A total of 57 cases, representing 35% of the study cohort,
were defined as necessary admission and the rest 106
(65%) cases where defined as an unnecessary admission
based on patients file review as explained above.
Categorical and continuous parameters of the two
groups were compared statistically as described previously,
and the results are shown in detail in Table1.
There was no statistically significant difference in the
patients gender and age between the two groups. The mean
LOS in the necessary admission group was significantly
longer (11.6days) than the unnecessary admission group
(4.8day) [t (61)=6.53, p<0.0001].
Joint involvement was more common in the necessary group [2(1) =32.69, p<0.0001]. In addition,
more joints were involved in this group [t (82)=3.734,
p<0.0001]. Likewise, gastrointestinal disease was
more common in the necessary group [2(1) =11.34,
p<0.001]. Moreover, this group was characterized by
more cases who suffered from moderate to severe abdominal pain [2(1)=23.796, p<0.0001]. Additionally, in this
group, there were more cases with positive fecal occult
blood studies ([2(1)=7.676, p<0.006]) and more cases
with clear gastrointestinal bleeding ([2(1) =15.645,
p<0.0001]).
Renal involvement was also more common significantly in the necessary admission group [2(1)=78.33,
p<0.0001]. Specifically, microscopic hematuria
[2(1)=12.302, p<0.0001], proteinuria [2(1)=12.179,
p<0.0001], hypertension [2(1)=7.626, p<0.006], and
acute renal failure [2(1)=155.0.9, p<0.0001] were more
common in this regard.
Genital involvement [2(1)=19.415, p<0.0001], especially testicular pain (a milder form of orchitis) in male
patients [2(1)=24.089, p<0.0001], was more common
in the necessary group. In regard with laboratory studies
performed, we found no statistically significant difference
between the two groups.
As expected the necessary group required longer
duration of treatment both when NSAIDS were given
(5.863days compared with 3.51days [t (44)=4.593,
p<0.0001]) and when glucocorticoid drugs were used
(6.335.2 treatment days compared with 3.071.4days
[t (46)=4.593, p<0.034]).

Outcome
Establishing hospital admission criteria
The mean LOS in our study population was 7.2days
(SD5.9days). Of 163 cases included in the study, 7 children (4.2%) have had a recurrence (defined as a new episode of HSP, following complete resolution of disease for
at least 3months).

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The final step was to establish valid admission criteria by

a logistic stepwise regression analysis using all univariate variables with p<0.05 as potential predictors. Table2
presents a predictive model with statistical significance

Rheumatol Int
Table2A predictive model for
hospital admission criteria

Variable

R2

R2 change

Standardized

Statistical
significance

Pain and tenderness in testicles

0.151

0.15

0.45

0.25

p<000.1

Moderate to severe abdominal pain

0.26

0.11

0.33

0.27

p<000.1

Number of joints involved

0.34

0.08

0.08

0.22

p<0.001

Asymptomatic proteinuria

0.41

0.07

0.58

0.28

p<000.1

Patient refuses to ambulate

0.45

0.04

0.34

0.21

p<0.001

Evidence of gastrointestinal bleeding

0.48

0.03

0.41

0.12

p<0.003

established when using the stepwise regression: [F

(6,155) =24.154, p<0.0001]. Of note, all the criteria in
this model are categorical (Yes/No), except for one criterion (number of joints involved), which is a continuous
parameter. In order to make this parameter practical, we
reviewed again all the cases focusing on the number of
joints involved and conclude that the presence of three or
more inflamed joints reflects a disease severity that justifies
admission.

Discussion
Our study presents the epidemiological and clinical data of
163 HSP pediatric patients admitted in a 15years period
(19952010) to a single pediatric department. As such our
study reflects the most extensive Israeli HSP clinical database, providing a better delineation of the disease in Israel,
and one of the largest cohorts of HSP published worldwide.
Similar to previous studies conducted in other countries
[48], the majority of our patients (77%) ranged between
3 and 10years, and seasonal distribution was noted where
most cases occurred in the winter and autumn months, thus
supporting the post-infection pathogenesis theory suggested to underlie HSP [4, 610].
We compared the clinical features of our cohort with
previous studies from five different countries including the
USA, Spain, Czech Republic, Japan, Italy, and Saudi Arabia. The incidence of joint involvement in our study was
similar to that reported in the other studies. Likewise, most
cases were either monoarticular or pauciarticular, involving
mainly the knees or ankles [4, 6]. Gastrointestinal involvement manifested by abdominal pain and mild gastrointestinal bleeding was less common in our study compared with
its incidence in studies from the USA [6], Spain [7], Italy
[4], Japan [10], and Saudi Arabia [12], but it was similar to
the data of the study from the Czech Republic [11].
Renal involvement in HSP is highly variable in different
parts of the world ranging between 10 and 60% [4, 6, 7,
10, 13, 14]. Nevertheless, it has major importance as renal
complications constitute most of the long-term morbidity [13, 14]. In our study, renal involvement was found in

only 15% of cases, similar to the data found in the study

from the Czech Republic [11]. Moreover, regardless of
its prevalence, when occurred, renal involvement in our
patients tended to be milder with self-limited microscopic
hematuria and proteinuria being the most common presentations. This is in contrast with other reports, where renal
disease was associated with significant long-term morbidity [15, 16]. A possible explanation for the relatively lower
incidence of gastrointestinal and renal involvement in our
study relies on our patient cohort which as a rule included
milder cases that may not necessarily be admitted.
Interestingly, an earlier study performed on HSP Israeli
patients with a smaller cohort of only 45 affected children
[17] demonstrated higher renal and gastrointestinal involvement, similar to the studies detailed above, thus supporting
our assumption relating these changes to the differences in
admission criteria.
So far, only a few studies have been published on the
epidemiological and clinical characteristics of HSP in
Israel. Prais etal. [18] reported on 260 Israeli children
admitted with HSP in a single medical center. Similar to
our findings, most children were males (56.7%), and the
mean age was 5.72.6years. Joint involvement was present in 68% of cases, similar to their rate in our study, but
gastrointestinal (68%) and renal (35%) manifestations
were higher most probably reflecting different admission
criteria with bias selection favoring the more severe cases.
In their study, Prais etal. focused primarily on the clinical and epidemiological features of patients with recurrent
HSP. They claimed to report a rather surprising high recurrence rate of 2.7%. In our study, we had 7 (4.2%) cases of
recurrent HSP that is in line with the previous Israeli study
of Prais etal., but in contrast with other studies worldwide.
One possible explanation for this high recurrence rate in the
Israeli population could be a genetic predisposition to HSP.
One of the proven genetic factors predisposing to HSP is
patients with Familial Mediterranean fever (FMF) disease
[19, 20]. Several studies have shown a higher tendency to
develop HSP in patients with FMF compared with the general population. Interestingly, a carrier state of FMF is also
associated with a higher incidence of HSP. Since, the carrier rate of FMF in the Israeli population is relatively high

13

(up to 1:5 in certain ethnic origins [21], one may expect

higher frequency of HSP as well as higher recurrence rate
of HSP in the Israeli population. Other genetic and environmental factors predisposing to higher recurrence are yet to
be discovered.
As of today, no consensus consists regarding the optimal treatment and follow-up of HSP patients. There are no
clear admission criteria for acute HSP, and the approach to
admission varies widely among different medical institutions and is mostly based on the clinical judgment of the
primary pediatrician. In our opinion, a significant number
of children diagnosed with HSP do not require hospitalization, and the follow-up can be done safely in an outpatient
setting. On the other hand, we believe that there is a sincere
need to better define evidence-based admission criteria that
will help primary pediatricians in this decision.
The unlimited admission policy of HSP patients to our
pediatric department regardless of their disease severity
served as a platform for such retrospective study. After extensive evaluation of the medical files of all children included in
the study, we found that most cases (65%) could have benefited equally if they were treated in an outpatient setting.
By dividing the patients into two groups of necessary
and unnecessary admission and employing multivariate
regression analysis, we were able to define six statistically
significant admission criteria including:
1. Pain and tenderness in testicles. This criterion actually
reflects the milder cases of orchitis.
2. Moderate to severe abdominal pain.
3. Arthritis in three or more joints.
4. Proteinuria.
5. Inability to ambulate independently.
6. Evidence of gastrointestinal bleeding, including positive occult fecal blood.
The presence of at least one of the following clinical
findings should serve an admission criterion by itself, predicting a more severe disease course. Furthermore, if none
of the six criteria is present, clinical evaluation should be
performed on a regular daily basis by the community-based
pediatrician in an outpatient setting and if one or more of
these clinical parameters develops during the course of the
disease the patient should be admitted at that stage.
Hospital admission is a complex decision. It is a joint
result of pure medical issues and other concerns including the availability of appropriate outpatient medical personnel, laboratory and imaging resources, the ability of
the patients parents to understand and follow medical
instructions given, etc. Therefore, our suggested admission guidelines are not absolute ones and should undergo
required adaptations in agreement with local health systems and organizations. Nevertheless, we believe that

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Rheumatol Int

implementation of this predictive model in daily practice is a safe, simple, and elegant tool for the pediatrician
both in the emergency room setting and in the community
clinic. Additionally, the implementation of such predictive
model can significantly reduce the number of unnecessary
admissions of children diagnosed with HSP, making this
model cost effective in terms of health services.
Finally, the findings of the current study may serve as
the basis for a future prospective study, which will assess
the effectiveness and validity of the suggested model in
various hospitals.

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