Acute Idiopathic Thrombocytopenic Purpura
Patient Presentation
M.M., a 6 y/o female presents to the emergency department after what her mother reports as a week of several unusual symptoms. One week prior, the patient experienced fever and vomiting that subsided after 24 hours. The parents believed this was just some sort of 24-hour virus. However, in the days following, the girl experienced several episodes of easy bruising and heavy bleeding. She bit her lip during lunch at school and it bled excessively and was difficult to stop. Later in the week she slipped on the ice after gym class and developed a bruise on her knee the size of a baseball. When her father, a physician, noticed scattered petechiae all over the patient’s body, he called the pediatrician who referred them immediately to the Children’s Hospital ED based on the symptom report.
Differential List
Acute idiopathic thrombocytopenic purpura (ITP), Acute leukemia, Drug induced thrombocytopenia, Bone marrow infiltration, Congenital amegakaryocytic thrombocytopenia
Diagnosis
CBC revealed profound thrombocytopenia (platelets 2,000/μL) and patient was admitted to the pediatric hematology unit with a diagnosis of acute idiopathic thrombocytopenic purpura
Treatment
Intravenous immune globulin infusions were given immediately. The patient was not responding well to the infusions which made the team suspect leukemia. A bone marrow biopsy was performed and the aspirate showed normal levels of megakaryocytes and high levels of reticulated platelets. Leukemia was ruled out and the patient was put on 30mg prednisone daily. Her stay was complicated by anemia secondary to several epistaxis hemorrhages that could not be controlled. ENT was consulted for the nosebleeds and finally was able to control the problem using dissolvable dressings inside the nares. The patient remained hospitalized for one week. She was kept on fall precautions for risk of bleeds and wore a helmet when walking around the unit.
Outcome
The patient recovered well and was discharged on day 7. She was sent home when her platelets reached 90,000/μL. She continued to take 30mg prednisone daily; the dose was tapered down after three months post-hospitalization. She had CBCs drawn every 2 days after returning home for 2 weeks and subsequently every week for the next two months. After 2 months her platelet levels had stabilized around 100,000/μL. She made a full recovery and experiences no problems today.