Sir,

We report on severe gastrointestinal bleeding that was successfully treated with four sessions of plasmapheresis.

In a 13-year-old girl, Henoch-Schönlein purpura (HSP) was diagnosed 5 year earlier following a vaccination against hepatitis B [1]. This time, 2 days after hepatitis B revaccination, necrotizing purpura started on lower extremities and spread throughout the body, including the face. Urinary protein excretion was 4.2 mg/m2/h, but serum creatinine was not elevated. A skin biopsy showed perivascular deposits of immunoglobulin A (IgA) when using direct immunofluorescence. After three pulses of methylprednisolone (30 mg/kg), 2 mg/kg prednisolone treatment was given because of necrotizing purpuric lesions. Although she was using steroids, in next 15 days, she twice had severe gastrointestinal bleeding. Her hemoglobin dropped from 14.3 to 10.2 g/dl. As she had repeated gastrointestinal bleedings 800 mg/m2 intravenous immunoglobulin was infused, but necrotizing purpura at the lower limbs and gastrointestinal hemorrhage recurred after 5 days of well-being. Treatment with 500 mg/m2 cyclophosphamide at day 25 of the disease did not stop gastrointestinal bleeding. Therefore, we started four sessions of plasmapheresis. A total of 800 ml of human plasma was exchanged per cycle on alternate days. Cutaneous lesions were resolved 48 h after the start of plasmapheresis, and no gastrointestinal bleeding was noted thereafter. After the plasmapheresis, low-dose steroid treatment was given in alternate-day cycle during the second month of the disease. Two months after discharge, she had no complaints, physical examination was normal, and laboratory parameters were in the normal range. In conclusion, we feel that plasma exchange might be an effective therapy in patients with HSP presenting severe symptoms, including severe gastrointestinal symptoms [2–4].