A 4-year-old boy is brought to the office for evaluation of a rash. His mother states that "pinpoint" bruises have appeared all over his body during the past 24 hours. The patient has had no bleeding or recent trauma. Three weeks ago, he had an upper respiratory tract infection that resolved uneventfully. The patient takes no medications, he has no allergies, and his immunizations are up to date. There is no family history of bleeding or clotting disorders. Vital signs are normal for age. Physical examination shows a cooperative, well-appearing child with scattered petechiae on the trunk and extremities. Oral mucosa appears normal. There is no lymphadenopathy or splenomegaly. Laboratory results are as follows: Peripheral smear shows few platelets; the platelets are of normal size and morphology. Which of the following is the best next step in management of this patient?

Question

A 4-year-old boy is brought to the office for evaluation of a rash.  His mother states that "pinpoint" bruises have appeared all over his body during the past 24 hours.  The patient has had no bleeding or recent trauma.  Three weeks ago, he had an upper respiratory tract infection that resolved uneventfully.  The patient takes no medications, he has no allergies, and his immunizations are up to date.  There is no family history of bleeding or clotting disorders.  Vital signs are normal for age.  Physical examination shows a cooperative, well-appearing child with scattered petechiae on the trunk and extremities.  Oral mucosa appears normal.  There is no lymphadenopathy or splenomegaly.  Laboratory results are as follows:  Peripheral smear shows few platelets; the platelets are of normal size and morphology.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d6a5_ce68_bc81_89e03c808a44_MD0003_00 Immune thrombocytopenia (ITP), most common in children age 2-5, is characterized by an abnormally low platelet count (<100,000/mm³) that results in an increased propensity for bruising and bleeding. In ITP, autoantibodies are directed against platelet membrane antigens, leading to destruction of antibody-platelet complexes in the spleen. ITP is usually preceded by a viral infection, as in this case, and presents with petechiae and purpura. In severe cases, patients may experience mucosal bleeding (eg, epistaxis, hematuria, gastrointestinal bleeding). Laboratory studies show isolated thrombocytopenia, and a few variably sized (normal to large) platelets may be present on peripheral smear due to increased platelet turnover. Observation alone is recommended for children with only cutaneous symptoms (eg, petechiae), regardless of platelet count. The course is usually self-limited with spontaneous recovery within 3 months. Glucocorticoids, anti-D immune globulin (if Rh-positive and Coombs-negative), or intravenous immunoglobulin is first-line treatment in children with mucosal bleeding (Choice C). (Choice A) Bone marrow evaluation is performed if the presentation is concerning for leukemia (eg, fever, leukopenia/leukocytosis, anemia). Biopsy is not typically indicated for isolated thrombocytopenia. (Choice B) Antibiotics treat sepsis, which can lead to bleeding and thrombocytopenia from disseminated intravascular coagulation (DIC). However, patients with DIC are ill-appearing and often have schistocytes on peripheral smear. Antibiotics are not indicated for ITP. (Choice E) Platelet transfusion is the treatment for congenital platelet abnormalities, such as Bernard-Soulier syndrome, which presents with very large platelets on peripheral smear. Platelet transfusion is considered in severe cases of ITP (eg, intracranial bleeding) but is typically avoided as it can lead to further platelet destruction. (Choice F) Splenectomy can increase the life span and quantity of platelets because the spleen is the site of platelet destruction. Splenectomy is a last resort, reserved for catastrophic bleeding or chronic ITP refractory to intravenous immunoglobulin and glucocorticoids. Educational objective: Immune thrombocytopenia typically presents with isolated thrombocytopenia after a viral infection. Children with isolated cutaneous symptoms (eg, petechiae) usually recover spontaneously and require observation alone, regardless of platelet count. Those with bleeding should receive glucocorticoids, anti-D, or intravenous immunoglobulin. References: The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. (http://www.ncbi.nlm.nih.gov/pubmed/21325604)

A 4-Year-Old Boy Is Brought to the Office for Evaluation