April 28, 2013

6 years old Girl with Acute ITP

6 Years old girl, immunized, no known medical illness presented with multiple rashes of the bilateral lower limb for two days prior to admission, bruises over the upper limb for 1 day and one episode of epistaxis. Two days prior to the setting of rashes, patient previously have an open wound to the left lateral malleolus secondary to alleged self trauma with coryza symptoms. She was treated by GP with cloxacillin syrup and anti pyretic. She denies history of abdominal pain, diarrhea, fitting or focal neurological symptoms.

On examination, patient is conscious and alert, pink, good hydrational and perfusion status, capillary refilling time < 2 seconds and non toxic looking.

There are numerous number of purpuric rash over the bilateral lower limb from the ankle till the mid thigh region. The rashes are non palpable, non blanching, small in size, no dis unity of the shape and not tender upon palpation.

Apart from that, she also has few bruising about 3X3 cm at bilateral upper limbs. Otherwise, no active bleeding noted upon the examination.

Examination of nervous system, cardiovascular system, respiratory system, and abdominal examination are uneventful

Investigation results are as follow. Hb 12.7, TWBC 8.3, Platelet 9, PCV 40. PT 13.4, PTT 37.7, INR 1.02. Sodium 138, Potassium 3.7, urea 3.0.

A diagnosis of Idiopathic Thrombocytopenic Purpura with underlying viral infection was made and she was treated with platelet transfusion and IV immunoglobulin even though this patient does not have major bleeding disorder. This justification was made based on expert decision and in view of inadequate staff for close observation of possible intracranial bleeding or any other major bleeding complication since the platelet counts were only 9 and presence of bleeding tendency. However, platelet transfusion is no longer the mainstay treatment for ITP except for the major life threatening bleeding and decision for transfusion should be judged accordingly.


Idiopathic thrombocytopenic purpura (ITP), also known as primary immune thrombocytopenic purpura and autoimmune thrombocytopenic purpura, is defined as isolated thrombocytopenia with normal bone marrow and the absence of other causes of thrombocytopenia. The 2 distinct clinical syndromes manifest as an acute condition in children and a chronic condition in adults.[Michael A Silverman]

ITP is a decrease in the number of circulating platelets in the absence of toxic exposure or a disease associated with a low platelet count [Michael A Silverman]

It occurs mostly following the acute infection and may achieve complete resolution within two months. It mainly due to increase in peripheral destruction of platelet as many of the patients develop antibodies to specific platelet membrane glycoprotein. If it persists for more than 6 months without a specific cause, therefore it can be diagnosed as Chronic ITP. 

Atypical presentation of ITP for example in presence of Hepatospleenomegaly, lymphadenopathy or extreme age warrants further diagnostic modalities to exclude other cause of thrombocytopenia like hematological malignancy, autoimmune disorders, primary immunodeficiency syndromes, congenital marrow failure syndromes, neonatal alloimmune or isoimmune. Apart from that, we need to exclude drug induce thrombocytopenia, overwhelming sepsis, HIV, Thrombotic Thrombocytopenic Purpura and Hemolytic Uremic Syndrome.

Full blood count usually shows isolated thrombocytopenia and peripheral blood cell may show normal morphology. Bone marrow aspiration usually not required unless prior to starting steroid therapy in order to safely excludes leukemia, failure to responds to immunoglobulin therapy, recurrence or persistence beyond 6 months

Atypical presentation may be investigate with ANA/DsDNA, Coombs test, CMV serology in patient age less than one year old, coagulation profile, HIV testing and immunoglobulin levels.

Treatment is dependent upon present or absent of major bleeding or not especially intracranial bleeding. Choice of treatment includes oral prednisolone, IV immunoglobulin, selected platelet transfusion and methylprednisolone. Spleenectomy may be considered if failure of treatment occurs.


1) Hussain Imam et al, Paediatric Protocols for Malaysian Hospitals, 3rd edition

2) Michael A Silverman, "Idiopathic Thrombocytopenic Purpura ",

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