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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. REFERENCES 1. Kuhne T, Buchanan GR, Zimmerman S, et al. A prospective comparative study of 2540 infants and children with newly diagnosed idiopathic thrombocytopenic purpura (ITP) from the Intercontinental Childhood ITP Study Group. J Pediatr. 2003;143(5):605–608. 2. Lowe EJ, Buchanan GR. Idiopathic thrombocytopenic purpura diagnosed during the second decade of life. J Pediatr. 2002;141(2):253–258. 3. Sutor AH, Harms A, Kaufmehl K. 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Antibodies against platelet GpIb/IX, GpIIb/IIIa, and other platelet antigens in chronic idiopathic thrombocytopenic purpura. Eur J Haematol. 1995;55(5):307–314. 9. Hou M, Stockelberg D, Kutti J, et al. Immunoglobulins targeting both GpIIb/IIIa and GpIb/IX in chronic idiopathic thrombocytopenic purpura (ITP): evidence for at least two different IgG antibodies. Br J Haematol. 1997;98(1):64–67. 10. Kiefel V, Santoso S, Kaufmann E, et al. Autoantibodies against platelet glycoprotein Ib/IX: a frequent finding in autoimmune thrombocytopenic purpura. Br J Haematol. 1991;79(2):256–262. 11. Imbach PA, Kuhne T, Hollander G. Immunologic aspects in the pathogenesis and treatment of immune thrombocytopenic purpura in children. Curr Opin Pediatr. 1997;9(1):35–40. 12. Ware RE, Howard TA. Phenotypic and clonal analysis of T lymphocytes in childhood immune thrombocytopenic purpura. Blood. 1993;82(7): 2137–2142. 13. Buchanan GR, Adix L. 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Pediatric Emergency Care Volume 21, Number 10, October 2005 Acute Idiopathic Thrombocytopenic Purpura childhood idiopathic thrombocytopenic purpura. Br J Haematol. 2004; 126(2):282–283. author reply, p283. 23. Imbach P, Kuhne T, Zimmerman S. New developments in idiopathic thrombocytopenic purpura (ITP): cooperative, prospective studies by the Intercontinental Childhood ITP Study Group. J Pediatr Hematol Oncol. 2003;25(suppl 1):S74–76. 24. Butros LJ, Bussel JB. Intracranial hemorrhage in immune thrombocytopenic purpura: a retrospective analysis. J Pediatr Hematol Oncol. 2003;25(8):660–664. 25. Iyori H, Bessho F, Ookawa H, et al. Intracranial hemorrhage in children with immune thrombocytopenic purpura. Japanese Study Group on childhood ITP. Ann Hematol. 2000;79(12):691–695. 26. Lilleyman JS. Intracranial haemorrhage in idiopathic thrombocytopenic purpura. Paediatric Haematology Forum of the British Society for Haematology. Arch Dis Child. 1994;71(3):251–253. 27. 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Idiopathic thrombocytopenia purpura: treatment patterns and an analysis of cost associated with intravenous immunoglobulin and anti-D therapy. Semin Hematol. 1998;35(1 suppl 1):58–64. 52. Hong F, Ruiz R, Price H, et al. Safety profile of WinRho anti-D. Semin Hematol. 1998;35(1 suppl 1):9–13. 53. Gaines AR. Acute onset hemoglobinemia and/or hemoglobinuria and sequelae following Rh(o)(D) immune globulin intravenous administration in immune thrombocytopenic purpura patients. Blood. 2000; 95(8):2523–2529. 54. Medeiros D, Buchanan GR. Major hemorrhage in children with idiopathic thrombocytopenic purpura: immediate response to therapy and long-term outcome. J Pediatr. 1998;133(3):334–339. n 2005 Lippincott Williams & Wilkins 695 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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