Acute Idiopathic Thrombocytopenic Purpura of Childhood ... - sepeap

Panepinto and Brousseau Pediatric Emergency Care Volume 21, Number 10, October 2005
secondary to the immune-mediated removal of decoded
erythrocytes. This results in a decrease in the hemoglobin,
on average, from 1 to 2 g/dL. 52 Anti-D has also been shown in
rare circumstances to result in hemoglobinemia and/or
hemoglobinuria and renal insufficiency. 53 Like IVIg, anti-D
is a blood product and thus has the potential to transmit
pathogens despite viral inactivation steps that are used.
Treatment of Life-threatening Bleeding
Serious bleeding that may be life-threatening, such as an
intracranial hemorrhage, is rare in children with acute ITP but
requires emergent treatment when it occurs. The treatment
should not be delayed for computed tomography scanning if a
computed tomography scan is not immediately available and
the suspicion for bleeding is high. This treatment should
consist of corticosteroids in high doses (30 mg/kg per day
of IV methylprednisolone for 3 days), IVIg, and platelet
transfusions. 16,21 In addition, a splenectomy, which results
in an immediate rapid rise in the platelet count, should
strongly be considered in situations such as an intracranial
hemorrhage. Although platelet transfusions are not routinely
used in acute ITP because circulating antibody will also bind
transfused platelets, transfused platelets can be helpful
temporarily to gain control of bleeding even in the absence
of a concomitant rise in the platelet count. Other sites of
bleeding that may become life-threatening are gastrointestinal
or genitourinary bleeding or severe mucocutaneous bleeding.
In addition, a packed red blood cell transfusion should be
given to children who experience significant bleeding that
results in a decrease in their hemoglobin concentration.
Prognosis
Prognosis for acute ITP is excellent, especially for those
children younger than 10 years. In addition to having a 75%
chance of resolution of the acute ITP within the first 6 months
of presentation, serious bleeding complications are uncommon
in children with acute ITP. 1,13,54 One study reported that
only 17% of patients had enough bleeding with ITP to result in
a drop in hemoglobin or to require intervention such as nasal
packing or cautery for epistaxis. 54 The incidence of the most
severe complication, intracranial hemorrhage, is very rare and
estimated to be between 0.1% and 0.9%. 1,24–26 In the majority
of patients who developed an intracranial bleed, the platelet
count was less than 20 10 9 /L, and they had received some
form of treatment before developing the bleed. 24–26 The
mortality rate in the studies reporting intracranial hemorrhage
varied from 0% to 55%. 1,24–26
CONCLUSIONS
Acute ITP is generally a benign diagnosis that can be
approached with careful observation and education of patient
and family. For children with more serious bleeding
symptoms, there are effective treatment options that will
cause an increase in the platelet count within 1 to 2 days. The
majority of children diagnosed with acute ITP will go on to
complete resolution of the disease within 6 months with no
further sequelae. Further work using clinical grading scales
for bleeding to predict outcome, direct treatment, and
promote the development of new therapies will continue to
advance the care of children with acute ITP.
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