THE Henoch-Schonlein syndrome is a welldocumented disease, but the case to be described presented i n an unusual way with apparent torsion of the testicle, and subsequently developed intussusception of the small intestine. Although the pathogenesis of this disease is still not established there is evidence to suggest that it may b e due t o an anaphylactoid process. T h e classical picture is one of purpura, painful joints, abdominal pain, and, infrequently, bleeding per rectum. In a study of 224 cases Sterky and Thilkn (1960) found the peak age of presentation between 2 and 5 years, the majority being males.
CASE REPORT
I. S., aged 28 years, was admitted to the London Hospital on 6 Dec., 1962. Three days before admission he was treated at home for abdominal pain and vomiting which subsided after treatment with kanamycin. Sixteen hours before admission his father noticed that the child was walking awkwardly and found the right testicle to be swollen and tender.
ON ADMISSION.-Temperature 98" F. Pulse 100 per min. Respiration 22 per min. Rather pale but active child. Weight 274 Ib. No lymph-node enlargement. Tongue clean. No evidence of upper respiratory tract infection. The cardiovascular and respiratory systems were normal. Abdomen: no tenderness was found and the liver, spleen, and kidneys were not enlarged. There was redness and oedema of the right side of the scrotum and the right testicle was enlarged and tender. The left testicle was normal. Rectal examination was normal. The urine was sterile with a deposit of epithelial cells. The haemoglobin was 90 per cent, 13.2 g./Ioo ml. A diagnosis of torsion of the right testicle was made.
FIRST OPERATION (D. G. A. E.).-6 Dec. General anaesthesia (nitrous oxide and halothane). An incision was made into the right inguinal region and the testis and cord delivered. The spermatic cord was oedematous and there was evidence of recent haemorrhage into the cord. There was no sign of torsion. The testis was normal. Two large pedunculated hydatids of Morgagni were present but had not undergone torsion. These were both amputated. The epididymis was normal and no hernial sac was seen. The wound was closed without any further interference.
PROGRESS.-Three days after operation numerous purpuric lesions were seen on the extensor surfaces of the lower limbs and forearms. Three days later the patient passed blood and mucus in his stool, with the return of abdominal pain. On examination the abdomen was slightly distended, and a questionable mass was felt in the R.I.F. A diagnosis of Henoch-Schonlein purpura was made. He was treated with naso-oesophageal aspiration and intravenous fluids.
INVESTIGATIONS.-g Dec. Antistreptolysin titrenegative in, all dilutions. Throat swab: no haemolytic streptococci. Normal throat flora. H b 76 per cent, 10.5 g./Ioo ml. Total W.B.C. 12,600: neutrophils 81 per cent, lymphocytes 14 per cent, monocytes 5 per cent. Platelets plentiful. Serum electrolytes : sodium 140 mEq./l., potassium 4.9 mEq./l., chloride 102 mEq./l., bicarbonate 30 mEq./l. Sedimentation rate I mm. per hour.
After 4 days the gastric aspiration and intravenous fluids were discontinued, but that evening he again vomited. On