A 4-year-old girl is brought to the emergency department for evaluation of a rash. This morning, the family noticed "lots of little spots on her arms and legs" that have now spread to her chest and trunk. Her mother also noticed several bruises over the lower extremities and says, "She had a nosebleed this morning but it stopped after a few minutes." The patient and her family do not recall any preceding trauma. She has no fever, vomiting, diarrhea, or decrease in appetite, but did have a "cough and runny nose a few weeks ago." The patient has mild, intermittent asthma for which she takes albuterol as needed. Immunizations are up to date. Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 100/min, and respirations are 20/min. Physical examination shows a well-appearing, smiling girl. Scattered petechiae and ecchymoses are noted over the upper and lower extremities, chest, and trunk. There are 3 small hematomas on the buccal mucosa, and there is dry, crusted blood in the left nostril. Cardiac, abdominal, and lymphatic examinations are normal. Laboratory results are as follows: Which of the following is the most appropriate management for this patient?

Question

A 4-year-old girl is brought to the emergency department for evaluation of a rash.  This morning, the family noticed "lots of little spots on her arms and legs" that have now spread to her chest and trunk.  Her mother also noticed several bruises over the lower extremities and says, "She had a nosebleed this morning but it stopped after a few minutes."  The patient and her family do not recall any preceding trauma.  She has no fever, vomiting, diarrhea, or decrease in appetite, but did have a "cough and runny nose a few weeks ago."  The patient has mild, intermittent asthma for which she takes albuterol as needed.  Immunizations are up to date.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 100/min, and respirations are 20/min.  Physical examination shows a well-appearing, smiling girl.  Scattered petechiae and ecchymoses are noted over the upper and lower extremities, chest, and trunk.  There are 3 small hematomas on the buccal mucosa, and there is dry, crusted blood in the left nostril.  Cardiac, abdominal, and lymphatic examinations are normal.  Laboratory results are as follows:  Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf62_1813_8f63_7f3fee588544_MD0005_00 This patient has immune thrombocytopenia (ITP), which occurs due to autoimmune platelet-specific autoantibodies. ITP is a diagnosis of exclusion that presents in children with a platelet count <100,000/mm³, often with sudden onset of bleeding. Patients frequently report a recent viral infection but have no evidence of systemic disease (eg, fever, malar rash, joint stiffness) or additional laboratory abnormalities. The severity of the patient's bleeding symptoms is graded as follows (based on the likelihood of progression to uncontrolled bleeding): Mild - asymptomatic or cutaneous bleeding (eg, petechiae, purpura) Moderate/severe - mucosal bleeding (eg, gingival bleeding, epistaxis), internal hemorrhage (eg, hematochezia, intracranial hemorrhage) Patients with mild or no bleeding do not require pharmacotherapy and can be managed with observation and monitoring of platelet counts (Choice D). Those with an increased bleeding risk, such as this patient (eg, mucosal bleeding, platelet count <30,000/mm³), are treated with intravenous immune globulin. Approximately 50% of children with ITP have spontaneous remission within a few years after diagnosis. (Choice A) Patients requiring bone marrow biopsy have atypical features, including bone pain, fevers, weight loss, lymphadenopathy, splenomegaly, neutropenia, and anemia without hemorrhage. (Choice B) Splenectomy is indicated in patients with chronic ITP who have recurrent bleeding or are unresponsive to pharmacotherapy; it is not indicated in the treatment of acute symptoms. In addition, this patient's response to pharmacotherapy has not been established. (Choice E) Transfusion of packed red blood cells is indicated in patients with severe hemorrhage and hemodynamic instability. This patient is hemodynamically stable and has no findings suggestive of hemorrhage; therefore, she does not require a transfusion. Educational objective: Immune thrombocytopenia is an autoimmune condition that causes thrombocytopenia with no other laboratory abnormalities. Patients at a high risk of bleeding are treated with intravenous immune globulin. References: International consensus report on the investigation and management of primary immune thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/19846889) The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/21325604) Diagnosis and management of autoimmune cytopenias in childhood. (http://www.ncbi.nlm.nih.gov/pubmed/24237984)

A 4-Year-Old Girl Is Brought to the Emergency Department for Evaluation