Case report: Epstein-Barr virus associated with haemorrhagic
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HSP is the most common vasculitis in children characterised by palpable purpura, arthritis, gastrointestinal symptoms and renal involvement. Typical skin manifestations of HSP are palpable purpura and petechiae, especially on the lower extremities. Haemorrhagic bullous lesions have also been rarely reported.

A 6-year-old boy presented with history of fever and pain in his ankles since 2 days. On initial examination, he had elevated body temperature (38.7°C) and arthritis of both of his ankles. Laboratory examinations revealed elevated CRP (172mg/L) and ESR (77mm/h). On the 7th day of admission, he developed haemorrhagic bullous purpura on his legs, arms and buttocks.

There was no mucosal involvement and rash was not present on the face or trunk. Skin biopsy revealed perivascular neutrophilic infiltration, leukocytoclasia and fibrinoid necrosis. IgM antibody against the viral capsid antigen of Epstein–Barr virus (EBV) and RT-PCR for EBV DNA in serum were found to be positive. These findings led to a diagnosis of EBV associated Henoch–Schonlein purpura (HSP). The rash resolved completely within 3 weeks and there was no recurrence in the following 3 months.

The presence of haemorrhagic bullae might cause diagnostic challenge in HSP patients, because other paediatric diseases such as toxic epidermal necrolysis, bullous impetigo and staphylococcal scalded skin syndrome may present with bullous lesions.

This is the first report of EBV associated haemorrhagic bullous HSP. Deposition of IgA or C3 in skin biopsy materials is diagnostic for HSP. In conclusion, awareness of the various cutaneous presentations of HSP may be helpful for early diagnosis. Although rare, EBV should be considered among the infectious triggers of HSP in children.

Source: https://onlinelibrary.wiley.com/doi/10.1111/jpc.15187
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