VISUAL DIAGNOSIS VISUAL DIAGNOSIS

VISUAL DIAGNOSIS

A “ spidery ” rash
Lindsay Jackson, MD
October 14, 2009

Case of a “spidery “ spidery” ” rash
3 year old male develops a spidery rash over
the past week on his arms and legs
3 year old male develops a spidery rash over
Bruising noted over lower extremities
Dried blood noted at ears, nose
“Blood “ Blood blister” blister ” on lower lip

Purpura

The “spidery “ spidery” ” rash

Exam
Growth parameters and vital signs normal
Well appearing
HEENT: ecchymosis over left eye, crusted
blood in nares, palatal petechiae
HEENT: ecchymosis over left eye, crusted
Abdomen: no hepatosplenomegaly
Skin: petechiae on arms, back, legs. Pretibial
bruising
Skin: petechiae on arms, back, legs. Pretibial

Differential Diagnosis
What causes thrombocytopenia (platelet count
below 150,000) in children?
What causes thrombocytopenia (platelet count
Idiopathic thrombocytopenic purpura
Drug induced thrombocytopenia (heparin)
TTP
Sepsis/DIC
Congenital
TAR (Thrombocytopenia, absent radii)
Kasabach­ Kasabach ­Merritt Merritt
Wiskott­ Wiskott ­Aldrich Aldrich

Labs
WBC 7.3 (29% neutrophils, 63% lymphocytes,
6% monocytes, 2% eosinophils)
WBC 7.3 (29% neutrophils, 63% lymphocytes,
Hemoglobin 11.9 with Hematocrit 34.4
Platelet count 2000
Chemistry panel
Chemistry panel
Na 132, K 5.6 (Hemolyzed) and LDH 473
Liver function studies normal

Figure 2. Peripheral smear in a patient with ITP showing an almost total absence of platelets
Lazarchick, J. ASH Image Bank 2001;2001:100177
Copyright ©2001 American Society of Hematology. Copyright restrictions may apply.

Idiopathic Thrombocytopenic
Objectives
Purpura (ITP)
Objectives
Know function and life span of platelets
Describe the usual presentation and laboratory
tests in the child with ITP
Describe the usual presentation and laboratory
Review the treatment options
Know the usual prognosis

Normal peripheral smear
Normal platelets are one fifth the
diameter of erythrocytes.
They survive in the body for 9 to 10
days

Idiopathic Thrombocytopenic
Purpura (ITP)
Estimated to be one of the most common
acquired bleeding disorders encountered by
pediatricians
Estimated to be one of the most common
3 to 8 cases per 100,000 children per year
3 to 8 cases per 100,000 children per year
A general pediatrician can care for most
children with ITP
A general pediatrician can care for most

ITP
Autoantibodies (usually IgG) are directed against
platelet membrane antigens
Autoantibodies (usually IgG) are directed against
Antibody­ Antibody ­coated coated platelets have a shortened half­ half ­life life
because of accelerated clearance by tissue
macrophages in the spleen and other portions of the
reticuloendothelial system.
The net effect is a decrease in the platelet count.

IgG coated Platelets

Presentation
Most common in ages 2 to 5
Characterized by the sudden appearance of
bruising/bleeding/petechiae in an otherwise
healthy child
Characterized by the sudden appearance of
Association with prior infection
Association with MMR vaccination

Petechiae in ITP

Pertinent Negatives
No systemic symptoms
Absence of lymphadenopathy and
hepatosplenomegaly on exam
No evidence of hemolysis
Absence of lymphadenopathy and
No evidence of hemolysis

Laboratory findings
Platelet count typically below 30,000
15% of patients will have mild anemia due to
bleeding
Essential to review peripheral smear
15% of patients will have mild anemia due to
Essential to review peripheral smear
Large platelets

Leukemia
Leukemia
What do parents fear?
In one study of 2239 patients with newly
diagnosed ALL, NONE exhibited isolated
thrombocytopenia
Bone marrow examination not necessary in routine
cases
In one study of 2239 patients with newly
Bone marrow examination not necessary in routine
Dubansky AS, Boyett JM, Falletta J, et al: Isolated thrombocytopenia thrombocytop enia in children with
acute lymphoblastic leukemia: A rare event in a Pediatric Oncology Oncolo gy Group study.
Pediatrics 1986;77:49

Chronic ITP
Thrombocytopenia lasting longer than 6
months
Thrombocytopenia lasting longer than 6
Thyroid studies
Thyroid studies
ANA
Coombs test
HIV/CMV/EBV
Immunodeficiency

Pharmacologic Therapy
70 to 80 percent of children with ITP will recover
within a few months of presentation with or without
treatment
70 to 80 percent of children with ITP will recover
Most patients do not have serious bleeding including
those with platelet counts

Pharmacologic therapy
IVIG
Steroids
Anti­ Anti ­Rh(D) Rh(D) (Win Rho)
Splenectomy

Patient follow up
Patient admitted overnight and given IVIG
Platelet count after IVIG increased to 97,000
Discharged with a note for preschool (activity
restriction)
Discharged with a note for preschool (activity
Instructed to avoid aspirin, NSAIDS

Platelet counts
Patient Follow Up
Platelet counts
2,000 (admit June 6, 2008)
97,000 (June 10)
67,000 (June 24)
25,000 (July 11)
70,000 (August 8)
140, 000 (October 14)
472,000 (January 29, 2009)

Questions?
Free YOGA class tonight!
6:15pm, Third floor LPCH in the
physical therapy rooms (near the
MD workroom just off 3 South)
Thank you Mark Halpert for
teaching!

References
Steuber, C. Treatment and prognosis of immune
(idiopathic) thrombocytopenic purpura in children.
UpToDate online.
Buchanan, G. Thrombocytopenia During Childhood.
Pediatrics in Review 2005;26:401­
2005;26:401 ­409 409
Chu, Y et all. Itopathic Thrombocytopenic Purpura.
Pediatrics in Review 2000;21:95­ 2000;21:95 ­101 101
Buchanan, G. ITP: How much treatment is enough?
Contemporary Pediatrics 2000;14: 112­ 112 ­121 121
Steuber, C. Treatment and prognosis of immune
Buchanan, G. Thrombocytopenia During Childhood.
Chu, Y et all. Itopathic Thrombocytopenic Purpura.
Buchanan, G. ITP: How much treatment is enough?