Cases/Haematology

Purpuric Rash and Abdominal Pain — Free SCA Practice Case

Child with purpuric rash and abdominal pain

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Lily Jenkins

Age

6 years

Consultation Type

Video

Age

Caller

Emma Jenkins (Mother)

Situation

Video Consultation.

Reason for Encounter

"Lily has a rash on her legs that won't go away when I press a glass on it. She’s also complaining of a sore tummy and her knees hurt."

Medical Records

●PMH: Nil significant. Fully vaccinated.
●Medications: None.
●Allergies: NKDA.

Recent Notes

●2 weeks ago: Telephone consult for a mild upper respiratory tract infection (sore throat/coryza). Advised supportive care.

Examination (Visuals provided during consult)

●Photograph: The mother shows a clear photo of Lily’s lower legs and ankles. There is a symmetrical, raised, dark red/purple rash (palpable purpura).

Photograph

Tap to enlarge

Photo sent by the patient's mother: the backs of a child's lower legs and ankles — Lower legs and ankles

Patient Script

For the friend playing the patient role

Character Overview: You are Emma, Lily's mother. You are extremely anxious. You have seen public health campaigns about a "non-fading rash" being a medical emergency. You did the "glass test" this morning, and the spots didn't fade. You are terrified she has meningitis, even though she is currently sitting up and watching cartoons. You will not volunteer this fear unless the doctor explicitly asks what you are worried about or asks if you have done the glass test.

Opening Sentence: "Doctor, thank you for seeing us so quickly. Lily woke up with this dark, spotty rash all over her shins and ankles. I kept her off school because she's also been crying that her tummy aches, and she's limping a bit when she walks."

History if Asked (Data Gathering Phase)

●
Associated Symptoms (The Classic HSP Triad/Tetrad):
- ●Joints: "She says her knees and ankles ache. They look a tiny bit swollen to me."
- ●Abdomen: "She gets these waves of tummy cramps. They last a few minutes and then she is fine again."
- ●Urine/Renal (The Hidden Clue): "Her wee? I haven't noticed any blood, but she went this morning and said it looked a bit dark, I wasn't really paying attention."
●
Systemic Screen (The Reassuring Negatives):
- ●"No, she doesn't have a fever at all today."
- ●"She's eating a little bit, but less than usual because of the cramps."
●
Recent Illness: "She did have a nasty cold and sore throat about two weeks ago, but she completely got over it."

If Asked — Medical History and Medications

●Past medical history: "No, she's never had anything like this before. She's been a healthy little girl, really. Nothing serious — no hospital stays, no operations, nothing."
●Vaccinations: "She's completely up to date with all her jabs. She had her pre-school boosters before she started reception."
●Medications: "She's not on anything. I gave her some Calpol last night because she was grizzly with the tummy pain, but that's it."
●Allergies: "No, no allergies to anything that we know of."
●Recent GP visit: "Yes, I phoned the surgery about two weeks ago because she had a really snotty nose and a sore throat. The doctor said it was just a cold and to keep her comfortable with fluids and paracetamol. She got better within a few days."

Social History and Lifestyle Impact

●Family and daily life: Emma is a teaching assistant at a local primary school. Lily is in Year 1 and usually loves school. She has a younger brother, Oscar, aged 3, who is at nursery. They live with Emma's partner in a semi-detached house.
●Lifestyle impact of the condition: "She was supposed to be at school today but I couldn't send her in looking like this — the school would have called me straight back. She's normally such an active little thing, always running around, but this morning she didn't even want to get off the sofa. She tried to walk to the bathroom and was limping because her ankles hurt so much. She's just sitting there watching cartoons, which is really not like her at all. Honestly, I nearly called 999 last night when I saw the rash didn't fade."

ICE — Ideas, Concerns, Expectations

Only reveal if the doctor directly explores the patient's/parent's perspective.

●Ideas: Emma has no medical explanation for the rash itself — she just knows it doesn't fade under a glass, and from the public health campaigns she has seen, that means something very serious. She has not heard of HSP and has no alternative theory.
●Concerns: She is terrified this is meningitis. The glass test result has frightened her badly, and she is also worried about the combination of symptoms — the rash, the tummy pain, the limping — all appearing at once. She is scared something is being missed.
●Expectations: She wants the doctor to look at Lily properly, explain what is happening, and tell her whether she needs to go straight to A&E. She wants a clear plan and reassurance that she is doing the right thing.

If the doctor asks: "What are you worried this might be?" or "Have you tried pressing on the spots?"

●Reaction (The Reveal): Your voice shakes. "Well, I did that glass test they show on the news. I pressed a tumbler against her leg, and the spots didn't fade. Not even a bit. Doesn't that mean it's meningitis? I'm absolutely terrified, Doctor."

If Asked — Associated Symptoms

●If asked about a rash anywhere else on the body: "I've checked her all over — it's mainly on her shins and ankles, and there are a few spots on her bottom as well. Nothing on her face or chest."
●If asked about blood in the stool: "No, I haven't noticed any blood when she goes to the toilet. Her poos have been normal."
●If asked about headache: "No, she hasn't mentioned a headache at all."
●If asked about neck stiffness: "No, she can move her neck fine. She was looking around at the telly without any problem."
●If asked about sensitivity to light: "No, the lights haven't bothered her at all."
●If asked about vomiting: "She hasn't been sick, no. Just the cramps."
●If asked about how the rash started or progressed: "I first noticed a couple of spots on her ankles yesterday evening, but there were only a few and I thought it might be insect bites. By this morning it had spread all the way up her shins and there were loads more."
●If asked about bruising or bleeding: "No, she hasn't had any unusual bruising. No nosebleeds or bleeding gums or anything like that."
●If asked about recent travel: "No, we haven't been away anywhere. Just normal school and home."
●If asked about contact with anyone unwell: "A few kids in her class had colds around the same time she did, but nothing serious that I know of."
●If asked about weight loss: "No, she's been eating normally until the last day or two with the cramps."
●If asked about swelling of hands or feet: "Her ankles look a little puffy, but I haven't noticed her hands being swollen."
●If asked about any skin conditions or eczema: "No, she's never had any skin problems before this."
●If asked about testicular pain (if relevant): "She's a girl, so no — but she hasn't mentioned any pain down below."

Responses to Management (The Negotiation Phase)

●
If the Doctor dismisses the meningitis fear quickly without explaining:
- ●Reaction: Defensive. "But the glass test didn't work! Why isn't it fading if it's not meningitis?" (Doctor needs to explain that any bleeding under the skin is non-blanching, not just meningitis).
●
If the Doctor diagnoses Henoch-Schönlein Purpura (HSP):
- ●Reaction: "Henoch-what? Is it contagious? Her brother is 3, can he catch it?"
●
If the Doctor asks you to bring her in for a urine test/blood pressure check:
- ●Reaction: "Of course, I can bring her down right now. Why do you need to check her wee if the rash is on her legs?"
●
If the Doctor prescribes Ibuprofen for the joint pain:
- ●Reaction: "I can give her Nurofen, but doesn't that upset the tummy? She already has cramps." (Note: Ibuprofen should ideally be avoided or used with extreme caution if there is abdominal pain or suspected renal involvement).

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 28 indicators checked+0−0

Positive (0/14)

Negative (0/14)

Domain 3: Relating to Others

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Clinical Learning Points

Diagnosis: Henoch-Schönlein Purpura (IgA Vasculitis)

●HSP (IgA vasculitis) is the most common small vessel vasculitis in children, typically affecting those aged 3–15. It is caused by IgA immune complex deposition in small vessel walls, most commonly triggered by a preceding upper respiratory tract infection — usually appearing 1–3 weeks after the infection resolves.
●The classic tetrad is: palpable purpura (non-blanching, gravity-dependent rash) + colicky abdominal pain + arthralgia or arthritis (large joints — knees and ankles most commonly) + renal involvement (haematuria and/or proteinuria).
●The rash is palpable (raised) because it represents true vasculitis — not thrombocytopenic purpura. It is symmetrically distributed on the buttocks and lower limbs, sparing the face and upper body in most cases.
●HSP is not contagious. It is an immune-mediated inflammatory response, not a transmissible infection. Siblings are not at risk of catching it.
●HSP can recur in approximately one-third of cases, typically within four months of the initial episode. Recurrent episodes are usually milder and self-limiting.

Distinguishing HSP from Meningococcal Septicaemia

●Both conditions produce a non-blanching rash. The mechanism matters: in meningococcal septicaemia, widespread intravascular coagulation causes petechiae and purpura anywhere on the body. In HSP, IgA-mediated vessel inflammation in gravity-dependent areas causes localised extravasation of red cells — the blood cannot be pressed away under a glass for the same physical reason, but the underlying pathology is entirely different.
●The key clinical differentiator is the child's systemic state. In meningococcal disease: the child is typically toxic, lethargic, feverish, and deteriorating rapidly; the rash may be widespread and rapidly evolving. In HSP: the child is alert and often well-appearing, is typically afebrile, and the rash is confined to dependent areas.
●Do not assume that a non-blanching rash in a well child can be observed at home without assessment. The diagnosis of HSP still requires formal face-to-face evaluation — the clinical state of the child determines urgency, not the rash morphology alone.
●A structured screen for meningococcal disease is mandatory in any non-blanching rash: fever, neck stiffness, photophobia, headache, altered consciousness, and rapidly spreading petechiae must all be specifically asked about and documented.

Renal Involvement: The Priority Complication

●IgA nephropathy is the most clinically significant complication of HSP. IgA complexes deposit in the glomerular mesangium, causing haematuria, proteinuria, hypertension, and — in a minority — progressive renal impairment. It is the leading cause of long-term morbidity in HSP.
●Renal involvement occurs in approximately 20–50% of children with HSP. Most cases are mild and self-resolving, but up to 1–2% develop end-stage renal disease.
●A urine dipstick and blood pressure are mandatory at first presentation — even if the child appears well and the urine appears normal to the parent. Microscopic haematuria and proteinuria are often clinically silent. A video consultation alone is insufficient; a face-to-face appointment or referral to a paediatric assessment unit must be arranged the same day.
●Crucially, renal involvement can develop or worsen weeks to months after the initial presentation, even when the initial urinalysis is normal. A single normal urine at diagnosis is not adequate reassurance.
●Standard follow-up monitoring protocol (NICE CKS / RCPCH guidance): urine dipstick and blood pressure at weeks 1, 2, 4, 6, 8, and 12, then at months 6 and 12 from diagnosis. This schedule should be clearly communicated to the family and arranged with the GP practice.

Abdominal Complications: Screening for Intussusception

●Colicky abdominal pain in HSP is caused by inflammation and oedema of the bowel wall, which can act as a lead point for intussusception — where a segment of bowel telescopes into the adjacent segment. This is a recognised serious complication, occurring in approximately 2–3% of HSP cases.
●Warning features that should prompt urgent paediatric referral: abdominal pain that is severe, escalating, or no longer colicky in character; bilious vomiting; blood in the stools ('redcurrant jelly' stool); or a palpable abdominal mass.
●Episodic, intermittent colicky pain that resolves between episodes (as in this case) is typical of bowel wall vasculitis and can be managed with analgesia and monitoring — but it must be distinguished from the worsening, continuous pain pattern of intussusception.

Analgesia: Paracetamol First, NSAIDs with Caution

●Paracetamol is the recommended first-line analgesia for joint and abdominal pain in HSP.
●NSAIDs (including ibuprofen) should be avoided or used with extreme caution in the acute phase for two reasons: they may exacerbate gastrointestinal symptoms (the bowel wall is already inflamed), and they carry a risk of worsening renal function in the context of possible nephritis. NSAID use is contraindicated if there is active abdominal pain, suspected GI bleeding, or any evidence of renal involvement.
●This is a common candidate error: ibuprofen feels intuitively appropriate for joint pain and is familiar to parents as an anti-inflammatory, but the abdominal pain and unknown renal status in this case make it the wrong choice at first presentation.

Referral Criteria

Refer to paediatrics (same day or emergency) if any of the following are present:

●Abdominal: severe, worsening, or constant pain; GI bleeding; bilious vomiting; features of intussusception
●Renal: macroscopic haematuria; significant proteinuria on dipstick; elevated blood pressure; oedema
●Systemic: fever and systemic upset raising concern for an alternative diagnosis (e.g. meningococcal disease)
●Neurological or other organ involvement (rare but recognised)
●Diagnostic uncertainty — particularly if the rash distribution is atypical or the child is unwell in a way that does not fit the HSP pattern

If initial urine and blood pressure are normal and the child is well, management in primary care is appropriate with close monitoring follow-up.

Safety-Netting: What to Watch For

Specific return criteria to provide to the family:

●Urine becomes pink, red, or tea-coloured (macroscopic haematuria)
●Abdominal pain becomes severe, constant, or is associated with vomiting or rectal bleeding
●Swelling of the face, ankles, or generalised (suggesting nephrotic-range proteinuria)
●Rash spreads to the face, upper body, or becomes more extensive
●Fever develops or the child becomes systemically unwell, lethargic, or difficult to rouse
●Reduced urine output over 24 hours

Emphasise that the next scheduled urine and blood pressure check must not be skipped even if Lily appears completely well — silent renal involvement is the key risk.

Mapped to the RCGP curriculum topic: Haematology.

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