(P38) Idiopathic Thrombocytopenic Purpura in a Pediatric Patient

Chief Complaint : Referral for low platelet count

History of Present Illness : Pt is a 24 month old female born full term with no PMH history, vaccinations up to date, presenting as a referral from her PMDs office for a platelet count of 17,000. Patient went to her Pediatrician the same day for her 2 year old well visit. Blood work noted a Platelet count of 17,000 with no other cell line abnormality. Parents state that for the past week they have noted bruising across the patient's body and yesterday started noting “red marks” on her left upper extremity. This has never happened before, no recent trauma to her body, no recent falls, fevers, cough, cold, congestion, other rashes, diarrhea, or vomiting. They state that she is unable to speak yet, but has been scratching at her left ear. She’s been eating and drinking, has had normal urine output. Denies history of family bleeding disorders, no gross blood per urine or mucosa.

Pertinent Physical Exam: Vital signs are unremarkable with a heart rate of 102, respiratory rate of 26, afebrile through rectal temp, saturating at 100% on RA. Blood pressure not measured
Pt was playing on the stretcher, is well-developed, well-hydrated. Cerumen impacted in b/l ears, unable to visualize TMs b/l. Scattered faint nontender ecchymosis noted on the upper and lower extremities and on the trunk, 2-3 over each extremity and on trunk. Minimal petechiae noted on the right upper extremity over antecubital fossa. No mucosal lesions. No swollen joints, no edema, no cyanosis. No swollen lymph nodes. Alert, normal gait, moving all extremities normally.

Pertinent Laboratory Data: Labs: CBC: Platelet count: 23,000. Reticulocytes: 0.11 Immature reticulocytes: 6.8% BIcarbonate: 20 BUN/Cr: 43 Manual differential: Segmented Neutrophils: 25% Lymphocytes: 65% Anisocytosis: slight . All other cell lines were WNL.
RPP: (+) for Adenovirus (+) Human Rhinovirus/Enterovirus

Case Discussion: Consulted Pediatric Hematology/Oncology Service. Per ASH guidelines, observation was recommended as an outpatient follow for a platelet count of >20k since pt has no bleeding. Spoke to pt’s PMD who would see her in the office in 4 days for repeat blood work, specifically platelet count. In one week the hematology clinic would see her for follow up.
Patient’s working diagnosis is Idiopathic Thrombocytopenic Purpura secondary to viral upper respiratory infections. Parents were given strict precautions with the patient including being cautious of falls, trauma to the body, and return precautions such as increased bruising/active bleeding/decrease in activity level. The expected outcome was slow increase of platelet count with resolution of concomitant adenovirus and human rhinovirus/enterovirus.
At her follow up appointment, parents report that the patient has been well. Her bruising was almost fully resolved. She had no falls, no trauma to the body, mucosal bleeding. She has had normal oral intake and urine output. On a physical exam, upper extremity ecchymosis and petechiae had resolved. Repeat blood work revealed a platelet count of 61,000. Blood smear was reviewed with normal looking platelets consistent with an immune mediated destructive process. The patient did not need treatment, and parents were counseled about results, with follow up in one month for repeat blood work. The diagnosis of ITP in the pediatric population is one of exclusion. Treatment can be inpatient or outpatient, and depends on platelet count +/- evidence of bleeding. Options include: corticosteroids, intravenous immunoglobulin, and anti-d immunoglobulin. If the patient does not have active bleeding and plt count is >20,000, the patient can be managed outpatient without treatment. If a patient has platelet count >20,00 with bleeding present, especially mucosal involvement, the patient should be treated. A platelet count of < 10,000 necessitates treatment with or without the presence of bleeding.

References and Acknowledgements (Optional): “[Diagnosis and Therapy of Immune thrombocytopenia].” PubMed, 30 July 2018, https://pubmed.ncbi.nlm.nih.gov/30060276/. Accessed 30 March 2023.
“ITP-Immune Thrombocytopenic Purpura - StatPearls.” NCBI, https://www.ncbi.nlm.nih.gov/books/NBK537240/. Accessed 30 March 2023.
“Childhood immune thrombocytopenia: Clinical presentation and management.” NCBI, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949815/. Accessed 31 March 2023.
Rice, Damien, and Matt Galbraith. “.,.” ., - YouTube, 16 November 2008, https://ashpublications.org/bloodadvances/article/3/23/3829/429213/American-Society-of-Hematology-2019-guidelines-for. Accessed 31 March 2023.