immune thrombocytopenia

Question 1

ITP define

Answer 1

uncommmon, put most common cause of low platelet count
children present with petechiae, purpura (bruising), sometimes mucosal bleeding
rarely there may be rectal bleeding or haematuria
riks of intracranial heamorrhage is <1%

Question 2

aetiology of ITP

Answer 2

children present between 2-10 years, with peak incidence in preschool years

Question 3

pathophysiology of ITP

Answer 3

immune mediated destruction of platelets often precipitated by viral infections
there are no other coagulation problems

Question 4

ITP can be divided into two clinical syndromes

Answer 4

acute ITP: 90%, these patients present acutely with bruising, ITP resolves within weeks to months
Chhronic ITP: lasts more than 6 months

Question 6

workup for well patient presenting with petechiae or purpura with suspected ITP

Answer 6

take FBC
take coags and G+H if severe bleeding

Question 7

intracranial haemorrhage risk

Answer 7

low but consider increased risk factors such as
- head trauma
- NSAIDs
- haematuria
- history of mucosal bleeding
- bleeding from multiple mucosal sites

Question 8

investigations

Answer 8

urinalysis - haematuria is associated with an increased risk of ICH
FBC shows thrombocytopaenia, normal Hb and WCC
blood film must be reviewed by laboratory haematologist
cerebral imaging in patients with CNS symptoms and signs
coags not required unless dignosis is uncertan or NAI is of concern

Question 9

differential diagnosis

Answer 9

SLE
haematological malignancies eg. leukaemia
aplastic anaemia
infections - virus, meningococcal disease
drug induced thrombocytopaenia
haemolytic uraemic syndrome
coagulatiion disorders
NAI

Question 10

management of ITP

Answer 10

will spontaneously resolve without any treatment within 6 months in most paediatric pateints
treatment decisions should be based on bleeding rather than platelet count

Question 11

management of patients with no/low/moderate risk of severe bleeding

Answer 11

manage conservatively without treatment
outpatient follow up
may be considered for treatment in special circumstances eg. imminent oversease travel, adolescent with self images issues, high risk of trauma

Question 12

management of patients at increase risk of ICH or high-morderate risk

Answer 12

treatment does not influence the natural history but may raise platelet count
should be discussed with haematology/oncology on call
treat with steroids
+- tranexamic acid (contraindicated in hematuria)
+- IVIG
depending on duration of epistaxis/sites of mucosal bleeding

Question 13

what is epistaixs

Answer 13

nose bleed

Question 14

treatment for severe bleeding

Answer 14

Question 15

discharge

Answer 15

if there is no active bleeding and child is well
there is good parental supervision at home wth respect to trauma risk
follow up wth general paediatrics in 1-2 weeks
avoid IM immunisations until resolution
avoid NSAIDs
avoid contact spots

Question 16

referrals and follow up

Answer 16

patients discharged with ITP require review my senior
refer to general paedatrics outpatients
referral to paedatric haematology can be done by general paedatrc team if diagnosis is uncertain