Diagnosis and management of ITP Flashcards
What can trigger ITP?
Viral infection or immune phenomenon
What does ITP stand for?
Primary Immune Thrombocytopenia
Who does ITP affect?
5 in 100 000 children
Usually between 2-5 years of age
What is the natural history of ITP?
Usually self resolving within 6 months for 75-80% of cases
- Remaining children usually resolve within the year
How do most children present with ITP?
Bruising and petechiae
- 3% will have a more severe presentation* including bleeding nose, mucosa, or GI tract
What is the most serious complication of ITP? What is the incidence of this?
- Intracranial hemorrhage
- 0.17-0.6% of cases
What are red flags on history for a child with suspected ITP?
Constitutional symptoms (fevers, weight loss, night sweats) Bone pain
Recurrent thrombocytopenia
Poor treatment response
What are red flags on physical exam for a child with suspected ITP?
Lymphadenopathy Hepatomegaly Splenomegaly Child is “unwell” Signs of chronic disease
What are red flags with investigations for a child with suspected ITP?
Low Hb (unless mildly low and explained by bleeding history)
High mean corpuscular volume (MCV)
Abnormal white blood cell (WBC) and/or neutrophil count Abnormal cellular morphology on smear
What should be done if red flags are present?
Urgent referral to Hematology
What is the definition of ITP?
Platelet count <100 x 10^9/L
Most patients will have <20 x 10^9/L
Is a bone marrow necessary for children with ITP?
No* if there are no red flag features present
What are secondary causes of ITP to consider?
Drug induced SLE Infections Immunodeficiencies Malignancy
How to do pharmacologic treatments for ITP work?
What are some disadvantages to consider?
- Increase platelet count and reduce perceived bleeding risk
- Downsides include possible hospitalization and side effects from exposure to medication
What are treatment options for ITP?
- Observation (+/- treatment)
- Corticosteriods
- IVIG
- Anti-D immunoglobulin (Anti-D) for patients that are Rh-positive children
Who can the American Hematology Society guidelines be applied to?
Any child between 90 days to 17 years of age
Newly diagnosed primary ITP (up to three months post diagnosis)
*not meant to be applied to chronic, secondary or persistent ITP
Is treatment for ITP curative?
NO!
Based on the new (2011) guidelines, what is the goal of treatment with ITP?
Achieve a platelet count associated with adequate hemostasis ie: no active bleeding, no epistaxis, no menorrhagia or blood within the stool
no absolute platelet number as target
What is considered mild bleeding with ITP? What percentage of children have mild symptoms?
No bleeding; or (at most) bruising, petechiae or occasional, mild epistaxis
No or very little interference with daily living
May include non- oozing petechiae on oral mucosa or resolved mild epistaxis
- 77% of cases
What is the goal of treatment with ITP?
To raise platelet level high enough to obtain hemostasis
What is considered moderate bleeding with ITP? What percentage of children have moderate symptoms?
More severe skin manifestations
- some mucosal lesions and more troublesome epistaxis or menorrhagia
Seen in 20% of cases
What is considered severe bleeding with ITP? What percentage of children have severe symptoms?
Bleeding episodes (epistaxis, melena, menorrhagia and/or intracranial hemorrhage) requiring hospital admission
Seen in 3% of cases
What is the treatment for mild ITP?
1) Observation
2) Second line treatment can include IVIG or corticosteroid course
What is the treatment for moderate ITP?
1) IVIG (0.8 to 1 g/kg)
2) Short course of steroids
3) Anti-D immunoglobulin for those who are Rh-positive*
* not considered first line due to rare but serious side effects that can occur
