Acute Idiopathic Thrombocytopenic Purpura of Childhood ... - sepeap

CME Review Article
Acute Idiopathic Thrombocytopenic Purpura of
Childhood—Diagnosis and Therapy
Julie A. Panepinto, MD, MSPH,* and David C. Brousseau, MD, MSy
Key Words: ITP, bleeding, thrombocytopenia, child
TARGET AUDIENCE
This CME activity is intended for physicians, nurse
practitioners, and physician assistants who care for children
who are ill or injured. Specialists including pediatricians,
emergency physicians, pediatric emergency physicians, and
family practitioners will find this information particularly
useful.
LEARNING OBJECTIVES
After completion of this article, the reader will be
able to:
1. Describe the pathophysiology of idiopathic thrombocytopenic
purpura.
2. Recognize common bleeding manifestations of acute
idiopathic thrombocytopenic purpura and learn the clinical
grading scale used to estimate the severity of bleeding
manifestations.
3. Discuss the management of acute idiopathic thrombocytopenic
purpura and understand treatment strategies for
life-threatening bleeding.
Idiopathic thrombocytopenic purpura (ITP) is an immunemediated
illness that results in thrombocytopenia (platelet
count

Panepinto and Brousseau Pediatric Emergency Care Volume 21, Number 10, October 2005
severity of bleeding can be used to determine the optimal
approach for a given child.
Some practitioners have begun using clinical grading
scales to assess the severity of bleeding. 3,13,14 The grading
consists of 4 main categories: asymptomatic, mild, moderate,
and severe. The asymptomatic child has no symptoms in the
setting of a low platelet count discovered at the time of a
blood count obtained for another reason. Mild ITP is defined
as petechiae and bruising of the skin, with or without some
minor epistaxis. Minor epistaxis is defined as bleeding of
short enough duration that there is no significant change in
the child’s daily activity. Increased bleeding symptoms and
more significant skin and mucosal findings are classified as
moderate ITP. Severe ITP is bleeding that requires immediate
treatment because of a significant drop in hemoglobin
or the life-threatening nature of the bleeding. Approximately
75% of patients have mild symptoms at their initial presentation
of ITP, including the majority of children with
platelet counts less than 10 10 9 /L. 15 Guidelines using this
clinical grading of symptoms were developed in the United
Kingdom to provide a reasonable approach to the management
of children with acute ITP. 16
Recently, Buchanan and Adix 13 published a clinical
grading scale that is similar to that developed in the United
Kingdom. Like the United Kingdom scale, there are the
categories of asymptomatic, mild, moderate, and severe
hemorrhage. This grading scale also has a minor hemorrhage
category that recognizes very minimal clinical symptoms of
acute ITP defined as 100 petechiae or less with or without 5 or
fewer bruises and absence of mucosal bleeding. In addition,
the grading can be applied to specific sites of bleeding, which
include the skin, epistaxis, oral bleeding, and life-threatening
bleeding. This scale, or a variation of this and the United
Kingdom grading scale, should prove valuable to determine
the best course of therapy related to the severity of bleeding in
a child with acute ITP. Consistent grading of severity of
bleeding will also be useful in future ITP research.
There is a large variability in severity of bleeding
symptoms in children presenting with acute ITP from no
symptoms to life-threatening hemorrhage. Most commonly,
children with ITP present with skin and mild mucosal
bleeding symptoms.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
ITP is a diagnosis of exclusion. Patients have thrombocytopenia
(platelet count

Pediatric Emergency Care Volume 21, Number 10, October 2005
Acute Idiopathic Thrombocytopenic Purpura
TABLE 1. Treatment for Acute Idiopathic Thrombocytopenic Purpura
Treatment
Dosing
Time to Increase
in Platelet Count
Observation N/A 3–4 wk N/A
Corticosteroid
Traditional dose
1–2 mg/kg per
d for 7–21 d
Complications
of Treatment
3–10 d Behavioral changes,
glucosuria, hypertension,
osteopenia, increase in
appetite and weight gain
High dose 4 mg/kg per d for 4 d 2–4 d
IVIg 0.8–1 g/kg IV for 1–2 d 24 h Fever, nausea, vomiting,
chills, headache, aseptic
meningitis
Anti-D immunoglobulin 50–75 mg/kg IV for 1–2 d 24–48 h Fever, nausea, vomiting,
chills, myalgias, hemolysis
N/A indicates not applicable.
corticosteroids includes decreased clearance of the antibodyplatelet
complex and impaired phagocytosis of platelets. 27–31
Early studies of corticosteroids used to treat acute ITP
showed that there was some benefit when given in low doses
over longer periods compared with placebo. This traditional
dosing was 1 to 2 mg/kg of oral prednisone per day for 1 to 3
weeks. 32,33 Time to an increase in platelet count varied from
3 to 10 days. This dose is well tolerated and not usually
associated with significant side effects if it is tapered or
discontinued within a month. However, this is not commonly
used at presentation of acute ITP because of the longer time
it takes to see platelet recovery. Higher dose steroids given
for a short period have recently been shown to be effective at
raising the platelet count within 2 to 4 days. 34–36 The dose of
corticosteroids given varied across the studies and ranged
between 4 mg/kg per day to 30 mg/kg per day of prednisone
or methylprednisolone for up to 4 days. There were no undue
side effects noted when a dose of 4 mg/kg per day for 4 days
orally was used. 34
The benefits of using corticosteroids are the relative
ease of administration in an outpatient or inpatient setting,
the low cost compared with other treatments, and the absence
of exposure to human plasma. The longer time to platelet
increase, however, precludes the use of steroids alone to treat
patients who may have moderate or more severe bleeding
symptoms at presentation. High-dose corticosteroids are
effective initial therapy for acute ITP and are used with some
frequency. The Intercontinental Childhood ITP Study Group
reported recently that approximately 25% to 40% of children
in their registry received corticosteroids as initial therapy
when they presented with acute ITP. 1 The relationship of
bleeding symptoms or dose of corticosteroids used was not
presented in this observational study.
Intravenous Ig
The third treatment option is intravenous (IV)Ig. IVIg
is thought to work, in part, by causing a temporary but
prolonged blockade of the Fc receptor of the phagocyte that
mediates immune clearance. 31,37,38 This blockade leads to a
compensatory increase in the platelet count. Recently, IVIg
has been shown in a mouse model to more specifically act by
causing up-regulation of the inhibitory receptor FcgRIIb to
cause blockade of Fc receptors on splenic macrophages. 39,40
There are a variety of doses of IVIg that may be used, but,
most commonly, the dose given is 0 .8 to 1.0 g/kg daily for 1 to
2 days. 41–45 Given at this dose, IVIg leads to a rapid increase in
platelet count as early as 24 hours after infusion and has been
effective when used for moderate or severe bleeding in acute
ITP. The side effects associated with IVIg are fever, chills,
headache, nausea, vomiting, and aseptic meningitis. There is
also the small risk of an infectious complication as IVIg is an
albumin-containing product. Most often, IVIg, which is
usually administered over 4 to 6 hours or more, is given in a
hospital setting and requires more resources and cost to
administer than corticosteroids. However, it is commonly
used at first presentation of acute ITP.
Anti-D Ig
Anti-D Ig, which is purified human IgG directed at the
erythrocyte D antigen, has more recently been used to treat
acute ITP in children who are nonsplenectomized and who
have rhesus-positive (Rh + ) red blood cells. 43,46,47 The
mechanism of action of anti-D is similar to IVIg in that it
decreases the clearance of platelets. More specifically, anti-D
binds to the Rh + red blood cell and sensitizes it to bind to the
macrophage Fc receptor and thereby promotes its clearance by
the spleen. 31,48 This frees platelet-antibody complexes from
being trapped. 48 Higher doses of anti-D (50–75 mg/kg) have
been shown to be the most effective at increasing the platelet
count within 24 to 48 hours similar to IVIg. 46,47,49,50 Anti-D is
given IV over 15 to 30 minutes and thus can be easily administered
in an outpatient or emergency department setting. It
has also been shown to be less costly than an equivalent dose
of IVIg. 51 The side effects of anti-D include headache, fever,
chills, nausea, and vomiting and myalgias. 52 In addition, anti-
D causes hemolysis and a transient decrease in the hemoglobin
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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.
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Panepinto and Brousseau Pediatric Emergency Care Volume 21, Number 10, October 2005
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CME EXAMINATION
October 2005
Please mark your answers on the ANSWER SHEET.
Acute Idiopathic Thrombocytopenic Purpura of Childhood—Diagnosis and Therapy, Panepinto and Brousseau
1. The clinical manifestations of ITP are due to:
a) altered platelet function
b) decreased production of platelets in the bone marrow
c) autoimmune destruction of platelets
d) increased consumption of platelets from mucosal
bleeding
2. All of the following are common signs/symptoms in ITP
except:
a) splenomegaly
b) petechiae
c) ecchymoses
d) hemorrhagic blisters in the mouth
e) epistaxis
3. Which of the following treatments would be least appropriate
for a child with ITP and mild to moderate
symptoms?
a) oral corticosteroids
b) IVIg
c) platelet transfusion
d) IV anti-D Ig
4. A child with known ITP presents with the acute onset of a
severe headache and focal neurological findings. Which
treatment(s) should be given or strongly considered at this
time?
a) high-dose IV steroids
b) platelet transfusion
c) IVIg
d) splenectomy
e) all of the above
5. Which of the following is correct about the treatment of
childhood ITP?
a) Observation is never indicated due to the risk of
intracranial hemorrhage.
b) Treatment should be based on the platelet count alone.
c) The natural course of ITP is a return to normal platelet
count without sequelae.
d) A bone marrow aspiration is required for all children
treated for ITP.
e) Children between 3 and 5 years of age have the
highest risk of progression to chronic ITP.
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Pediatric Emergency Care Volume 21, Number 10, October 2005
Acute Idiopathic Thrombocytopenic Purpura
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October 2005
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Panepinto and Brousseau Pediatric Emergency Care Volume 21, Number 10, October 2005
CME EXAM ANSWERS
Answers for the Pediatric Emergency Care CME Program Exam
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examinations were postmarked by September 15, 2005 and who achieved a score of 80% or greater will receive a certificate
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EXAM ANSWERS
July 2005
1. B
2. C
3. D
4. C
5. D
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