Intracranial hemorrhage in children with immune thrombocytopenic purpura

Incidence and risk factors of systemic lupus erythematosus in patients with primary immune thrombocytopenia: a systematic review and meta-analysis

Background

Immune disorders and autoantibodies has been noted in both primary immune thrombocytopenia (ITP) and systemic lupus erythematosus (SLE). Whether the two disorders are correlated is unclear. The lack of evidence on the incidence of and risk factors for SLE in primary ITP patients poses a challenge for prediction in clinical practice. Therefore, we conducted this study.

Methods

The protocol was registered with PROSPERO (CRD42023403665). Web of Science, Cochrane, PubMed, and EMBASE were searched for articles published from inception to 30 September 2023 on patients who were first diagnosed with primary ITP and subsequently developed into SLE. Furthermore, the risk factors were analyzed. Study quality was estimated using the Newcastle-Ottawa Scale. The statistical process was implemented using the R language.

Results

This systematic review included eight articles. The incidence of SLE during the follow-up after ITP diagnosis was 2.7% (95% CI [1.3-4.4%]), with an incidence of 4.6% (95% CI [1.6-8.6%]) in females and 0 (95% CI [0.00-0.4%]) in males. Older age (OR = 6.31; 95% CI [1.11-34.91]), positive antinuclear antibody (ANA) (OR = 6.64; 95% CI [1.40-31.50]), hypocomplementemia (OR = 8.33; 95% CI [1.62-42.91]), chronic ITP (OR = 24.67; 95% CI [3.14-100.00]), organ bleeding (OR = 13.67; 95% CI [2.44-76.69]), and female (OR = 20.50; 95% CI [4.94-84.90]) were risk factors for subsequent SLE in ITP patients.

Conclusion

Patients with primary ITP are at higher risk of SLE. Specific follow-up and prevention strategies should be tailored especially for older females with positive ANA, hypocomplementemia, or chronic ITP. In subsequent studies, we need to further investigate the risk factors and try to construct corresponding risk prediction models to develop specific prediction strategies for SLE.

Expression of B-cell activating factor in pediatric patients with immune thrombocytopenia: a single institutional series and review of literature

B-cell-activating factor (BAFF) is a crucial cytokine supporting survival and differentiation of B cells. Dysregulation of BAFF is involved in the pathogenesis of B-cell related autoimmune diseases including immune thrombocytopenia (ITP). The aim of this study was to evaluate the significance of BAFF expression in pediatric ITP patients. Eighty pediatric patients with ITP are subdivided in three groups. Group I included (32 patients) diagnosed with acute ITP less than 3 months, group II (48 patients) diagnosed with persistent ITP (from 3 to 12 months) and chronic ITP (more than 12 months) and group III 20 healthy controls. Complete blood picture, autoimmune profile, antiplatelet antibodies, coagulation profile, bone marrow examination, and RT-PCR were performed to detect the expression for BAF for all participants in this study. BAFF expression levels significantly increased in cases rather than in controls. BAFF Expression Value significantly increased in groups I & II (3.10 ± 1.99&3.29 ± 2.58) compared to controls (0.83 ± 0.45) as p < .001 for both. On the other hand, groups I & II were comparable in BAFF Expression Value (p = .470). BAFF expression increased in ITP patients, implying a function in the disease's pathogenesis.

Intracranial hemorrhage in primary immune thrombocytopenia (ITP): 20 years' experience in pediatrics

Incidence of intracranial hemorrhage (ICH) among children with primary immune thrombocytopenia (ITP) varies among different studies. We published data during the period of 1997-2007 of ICH in children with primary ITP, addressing risk factors and outcome. The aim of this study is to assess changes in incidence, risk factors, and outcome of ICH in children with ITP from last decade and to report the overall 20 years' experience. We compared 2008-2018 with the decade before it. Data of children with ITP and ICH during study period and ITP control cases were analyzed. Neurosurgical intervention and outcome were also reported. A total of 4340 children with primary ITP were evaluated. Twenty-five (0.63%) ICH events were reported over 2 decades. Head trauma, hematuria, and platelet counts < 10 × 109/L were the risk factors mostly associated with ICH. Overall mortality was 24%, and a further 28% had neurologic sequelae. Neurosurgical intervention was done in 12% of cases with good outcome.Conclusion: Persistent platelet counts < 10 × 109/L were a significant risk factor for ICH in both time periods, while head trauma and hematuria were more reported in the period of 2008-2018 as significant risk factors for ICH. Outcome was comparable in both periods. What is Known: • ICH is a rare complication of ITP; however, early recognition of risk factors and aggressive treatment might lead to complete recovery without sequalae. Platelet counts less than < 10 × 109/L are the main risk factor for ICH. Few studies reported other significant risk factors. What is New: • Hematuria and head trauma are significant risk factors for ICH in ITP, in addition to having a persistently low platelet count < 10 × 109/L. (more than 90 days in chronic ITP, 45 days in persistent and 21 days in acute ITP) • Combined treatment with IVIG and HDMP followed by platelet transfusion was associated with complete recovery without sequelae in almost 50% of patients.

Risk of systemic lupus erythematosus in patients with idiopathic thrombocytopenic purpura: a population-based cohort study

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) may play a role in early-stage systemic lupus erythematosus (SLE). The incidence of SLE in patients with ITP and the potential relationship between them is still unclear. This study was performed to provide epidemiological evidence regarding the relationship between ITP and SLE occurrence.

METHODS

In this population-based retrospective cohort study, the risk of SLE was analysed in a cohort of patients newly diagnosed with ITP between 2000 and 2013. Controls were selected at a 1:2 ratio through propensity score matching (PSM) using the greedy algorithm. The Cox proportional hazard model was used to analyse the association between ITP and SLE incidence. There were four different Cox regression models, and the sensitivity analyses were implemented to evaluate the HR of SLE after exposure with ITP.

RESULTS

In the age-matched and sex-matched ITP and non-ITP cohort, the average follow-up time was about 80 months in this study. There were 34 (4.70%) and 27 (0.19%) incident cases of SLE in ITP and non-ITP group. The incidence rates were 62.0 (95% CI 44.3 to 86.8) and 2.10 (95% CI 1.44 to 3.06), respectively. The adjusted HR of incidental SLE in the ITP group was 25.1 (95% CI 13.7 to 46.0). The other risk factors for SLE were female sex and Sjogren's syndrome. After PSM, the incidence rate and Kaplan-Meir curves of SLE were consistent with the results for the age-matched and sex-matched population, the HR 17.4 (95% CI 5.28 to 57.4) was estimated by conditional Cox model.

CONCLUSION

This cohort study demonstrated that patients with ITP have a higher risk of SLE. Clinically, patients with ITP should be monitored for incidental lupus.

Pediatric ITP: is it different from adult ITP?

Immune thrombocytopenia (ITP) has historically been thought to occur in 2 distinct forms: childhood ITP and adult ITP. This division is based largely on the presumption that childhood ITP is often benign and self-limited, whereas ITP in adults tends to be more chronic and difficult to treat. Although data exist to justify a different approach to the diagnosis and treatment in young children and the elderly, ITP in older children, adolescents, and younger adults is likely to share more similar pathology. This article will highlight the most recent data describing the natural history, diagnostic approach, management strategies, and disease-related outcomes in children and adults with ITP. These data reveal many unexpected similarities between the 2 groups, while confirming some of the more well-described differences. Discussion of these findings aims to highlight similarities and differences between ITP in children and adults, which will underscore important areas of future research and/or changes in management guidelines.

Intravenous immunoglobulin vs observation in childhood immune thrombocytopenia: a randomized controlled trial

Management of children with newly diagnosed immune thrombocytopenia (ITP) consists of careful observation or immunomodulatory treatment. Observational studies suggest a lower risk for chronic ITP in children after intravenous immunoglobulin (IVIg) treatment. In this multicenter randomized trial, children aged 3 months to 16 years with newly diagnosed ITP, platelet counts 20 × 10⁹/L or less, and mild to moderate bleeding were randomly assigned to receive either a single infusion of 0.8 g/kg IVIg or careful observation. Primary outcome was development of chronic ITP, which at the time of study initiation was defined as a platelet count lower than 150 × 10⁹/L after 6 months. Two hundred six children were allocated to receive IVIg (n = 102) or careful observation (n = 104). Chronic ITP occurred in 18.6% of the patients in the IVIg group and 28.9% in the observation group (relative risk [RR], 0.64; 95% confidence interval [CI], 0.38-1.08). Platelet counts lower than 100 × 10⁹/L at 12 months (current definition of chronic ITP) were observed in 10% of children in the IVIg group and 12% in the observation group (RR, 0.83; 95% CI, 0.38-1.84). Complete response rates in the first 3 months were significantly higher in the IVIg group. Immunoglobulin G Fc receptor IIb genetic variations were associated with early complete response in both groups. Grade 4 to 5 bleeding occurred in 9% of the patients in the observation group vs 1% in the IVIg group. This trial was registered at www.trialregister.nl as NTR 1563.

Multicenter Cohort Study Comparing U.S. Management of Inpatient Pediatric Immune Thrombocytopenia to Current Treatment Guidelines

BACKGROUND

Recent pediatric immune thrombocytopenia (ITP) guidelines have significantly altered and are encouraging an observational approach for patients without significant bleeding regardless of their platelet count.

PROCEDURE

This retrospective multicenter cohort study utilized the Pediatric Health Information Systems (PHIS) administrative database. Subjects were 6 months to 18 years of age, admitted to a PHIS hospital between January 1, 2008 and September 30, 2014, with a primary diagnosis code for ITP. International Classification of Disease, Ninth Revision, Clinical Modification Code (ICD-9-CM) discharge codes identified significant bleeding. Pharmaceutical billing codes identified the use of pharmacologic therapy for ITP. Clinical management during preguideline admissions (January 1, 2008 to August 31, 2011) was compared to postguideline admissions (September 1, 2011 to September 30, 2014).

RESULTS

A total of 4,937 subjects met inclusion criteria with a mean age of 6.2 (SD 5) years; 93.4% (4,613/4,937) received pharmacologic treatment for ITP but only 14.2% (699/4,937) had ICD-9-CM codes for significant bleeding; 11.5% (570/4,937) of subjects were readmitted. In comparing pre- versus postguideline time periods, the proportion of subjects receiving ITP pharmacologic treatment did not change (92.9% vs. 94.1%; P = 0.26). A decrease was found in the proportion of bone marrows performed (9.7% vs. 6.4%; P < 0.001) and length of stay (2.3 vs. 2 days; P < 0.001). The proportion of ITP admissions from 2012 to 2014 was modestly decreased when compared to 2008-2010 (12.9 vs. 14.5/10,000 PHIS admissions, P < 0.001).

CONCLUSIONS

Despite guidelines and evidence that supports a watchful waiting approach for pediatric patients with ITP, a large proportion of inpatients without significant bleeding are still receiving pharmacologic therapy. Continued efforts are needed to address why inpatient U.S. practice patterns are so discrepant from current treatment guidelines.

Rituximab leads to long remissions in patients with chronic immune thrombocytopenia

OBJECTIVES

To assess the response rate and duration of response in patients with chronic immune thrombocytopenia (ITP) receiving rituximab.

METHODS

We retrospectively analyzed 32 consecutive patients with chronic ITP who were treated in two tertiary centers in Oman. Response assessment was based on the American Society of Hematology criteria.

RESULTS

Nineteen patients (59%) had an initial response. However, six of the 19 patients lost their response leaving 13 patients with long-lasting remissions. The median age at diagnosis was 25 years (range 14-58). The median time from diagnosis to rituximab therapy was 21 months. The median follow-up after starting rituximab was 26 months. The overall cumulative response rate was 59% (complete response 44%, partial response 15%) and the median time to respond was 30 days with a response rate of 44% at four weeks. In all responders, the cumulative rate of loss of response was 32% with a median time to lose response of 54 months.

CONCLUSIONS

The use of rituximab in ITP achieves high response rate and long remission duration. Our study was limited by the small sample size and further larger prospective studies are recommended.

Severe Hemorrhage in Chinese Children With Immune Thrombocytopenia

To better understand the clinical features, therapy, and clinical outcome of Chinese patients with immune thrombocytopenia (ITP) who suffered severe hemorrhage, we retrospectively analyzed 663 children with ITP diagnosed in our hospital during the last 10 years. Of the total 663 patients enrolled in our study, 520 were eligible for bleeding severity assessment, of which 20 children (3.8%) had severe bleeding, including intracranial hemorrhage (ICH) (n = 9), gastrointestinal hemorrhage (n = 6), massive epistaxis (n = 3), urinary tract hemorrhage (n = 1), and pulmonary hemorrhage (n = 1). The age at diagnosis of severe hemorrhage ranged from 47 days to 14 years. Thirteen patients were newly diagnosed with ITP, 3 had persistent ITP, and 4 had chronic ITP. The latency between the onset of ITP and severe bleeding ranged from 6 hours to 10 years. The median platelet count at the time of severe hemorrhage was 6.5 × 10/L (range, 0 to 32 × 10/L). Most patients with severe hemorrhage were treated with intravenous immunoglobulin (90%), corticosteroids (65%), or both (60%). Two patients (10%) died because of ICH and pulmonary hemorrhage, respectively. Four patients (20%) recovered from thrombocytopenia. Our observation showed that severe hemorrhage is rare but can occur anywhere and at any time during the course of ITP. The majority of children with ITP in China should be observed rather than treated.

Clinical practice: immune thrombocytopenia in paediatrics

Immune thrombocytopenia (ITP) is a disease affecting both children and adults. It is defined as acquired isolated thrombocytopenia caused by the autoimmune production of anti-platelet antibodies. Childhood ITP most frequently occurs in young children who have been previously well, although a viral respiratory tract infection often precedes thrombocytopenia. A benign and self-limiting course is common, but major bleeding complications such as intracranial haemorrhage may occur. Yet one cannot predict which child will have a prolonged course of thrombocytopenia and who will develop an intracranial haemorrhage. In children without atypical characteristics, only minimal diagnostic investigations are needed, and most paediatric ITP patients do not need platelet-enhancing therapy even though various treatment options are available. A "watch and wait" strategy should be considered in paediatric patients with mild disease. Steroids, intravenous immunoglobulin G or anti-D immunoglobulin are the current first-line therapeutic measures for children at risk for severe bleeding. When life-threatening bleeding occurs, a combination of therapies is needed. In this review, we summarise the current knowledge on primary ITP in children and adolescents.

Only severe thrombocytopenia results in bleeding and defective thrombus formation in mice

Hemostasis, thrombosis, and ischemic brain infarction efficiently occur at unexpectedly low platelet counts in mice. The threshold platelet count required for occlusive thrombus formation differs between thrombosis models.

Quality of life in childhood immune thrombocytopenia: international validation of the kids' ITP tools

BACKGROUND

The Kids ITP Tools (KIT) is a disease-specific measure of health-related quality of life for children with immune thrombocytopenia (ITP). To facilitate use in international trials it has been cross-culturally adapted for France, Germany, the United Kingdom and Uruguay. This study assessed the validity and reliability of the translated KIT in comparison to generic quality of life measures.

METHODS

Children 2-18 years of age with ITP and their parents were recruited in France, Germany, the United Kingdom and Uruguay. Participants completed the KIT, PedsQL and KINDL. We examined the Pearson's correlation between these measures for our pooled sample and estimated the reliability over a 2-week time period. Findings were further explored by country.

RESULTS

A total of 127 families (81 children self-reported) participated. Mean child-reported scores were: KIT 74.3 (SD = 15.3), PedsQL 81.3 (SD = 13.0), and KINDL 70.5 (SD = 14.3). Corresponding mean parent proxy-reported scores were: 70.6 (SD = 18.1), 75.7 (SD = 16.8) and 72.3 (SD = 12.7), respectively. Correlation between KIT and the generic measures was consistent with our a priori hypothesis (PedsQL r = 0.54, KINDL r = 0.48, both P < 0.0001). Child KIT scores for newly diagnosed ITP patients were significantly lower than for chronic ITP patients (67.3 vs. 77.3; P = 0.005). There was a significant correlation (P < 0.001) between the child and parent proxy KIT scores (ICC = 0.52). Child KIT test-retest reliability was acceptable at 0.71.

CONCLUSIONS

The cross-culturally translated KIT is valid and reliable with acceptable correlation to the PedsQL and KINDL. There is a significant difference in child self-reported KIT scores between newly diagnosed and chronic ITP.

Intracranial hemorrhage after blunt head trauma in children with bleeding disorders

OBJECTIVE

To determine computerized tomography (CT) use and prevalence of traumatic intracranial hemorrhage (ICH) in children with and without congenital and acquired bleeding disorders.

STUDY DESIGN

We compared CT use and ICH prevalence in children with and without bleeding disorders in a multicenter cohort study of 43 904 children <18 years old with blunt head trauma evaluated in 25 emergency departments.

RESULTS

A total of 230 children had bleeding disorders; all had Glasgow Coma Scale (GCS) scores of 14 to 15. These children had higher CT rates than children without bleeding disorders and GCS scores of 14 to 15 (risk ratio, 2.29; 95% CI, 2.15 to 2.44). Of the children who underwent imaging with CT, 2 of 186 children with bleeding disorders had ICH (1.1%; 95% CI, 0.1 to 3.8) , compared with 655 of 14 969 children without bleeding disorders (4.4%; 95% CI, 4.1-4.7; rate ratio, 0.25; 95% CI, 0.06 to 0.98). Both children with bleeding disorders and ICHs had symptoms; none of the children required neurosurgery.

CONCLUSION

In children with head trauma, CTs are obtained twice as often in children with bleeding disorders, although ICHs occurred in only 1.1%, and these patients had symptoms. Routine CT imaging after head trauma may not be required in children without symptoms who have congenital and acquired bleeding disorders.

Intracranial hemorrhage (ICH) in children with immune thrombocytopenia (ITP): study of 40 cases

Intracranial hemorrhage (ICH) is a rare but devastating complication of childhood immune thrombocytopenia purpura (ITP). A survey of ICH from 1987 to 2000 identified cases of ICH in childhood ITP in the United States. Forty patients with ICH and 80 matched ITP control subjects were accrued. The estimated incidence of ICH was 0.19% to 0.78%. Platelet counts were less than 20 x 10(9)/L in 90% and less than 10 x 10(9)/L in 75% of children with ICH. Eighteen (45%) children developed ICH within 7 days of diagnosis of ITP; for 10 of these, ICH was the presenting feature of ITP. Twelve (30%) children had chronic ITP. Head trauma and hematuria were the most prominent features associated with ICH, identified in 33% and 22.5% of the patients with ICH and 1 and none of the controls (both P < .001). Bleeding beyond petechiae and ecchymoses was also linked to ICH. Mortality was 25%; a further 25% had neurologic sequelae. Strategies by which high-risk children could be identified were considered, and the costs of preventive combination treatment were estimated. Children with severe thrombocytopenia plus head trauma and/or hematuria appeared to be at particularly high risk of ICH. Aggressive treatment of these children may be appropriate.

Controversies in the diagnosis and management of childhood acute immune thrombocytopenic purpura

Acute immune thrombocytopenic purpura (ITP) occurs most commonly in young children who present with severe isolated thrombocytopenia and purpura. A marrow examination is not required unless glucocorticoids are used, lest treatment mask incipient acute lymphoblastic leukemia, but controversy exists here. The recommendations for evaluation and management remain controversial, since prospective controlled trials have not been done. There is some consensus based on experience and empiric data. Almost all children with acute ITP will recover completely without therapy. Although the various treatments may increase the platelet count, they do not influence the outcome of the illness, may increase cost, and cause significant side effects. Therefore, careful observation may be the best management option for the patient with ITP, in the absence of severe bleeding. The data available relevant to these issues are discussed.

Intracranial hemorrhage in childhood immune thrombocytopenic purpura

We retrospectively analyzed 750 patients with ITP for development of intracranial hemorrhage (ICH). Seventeen cases with age range of 10 months to 18 years were studied. Ten patients were of acute ITP and seven had chronic ITP. Nine patients developed ICH one month after the onset of ITP and five patients had ICH on presentation. ICH was precipitated by trauma in four patients and possibly the use of NSAIDs in one patient. Median platelets counts at the time of ICH were 12 x 10(9)/L (range 2-50 x 10(9)/L). Most patients were treated with corticosteroids. Four patients (24%) died due to ICH.

Idiopathic thrombocytopenic purpura complicated with biliary atresia: a rare occurrence and literature review

The association of biliary atresia (BA) and idiopathic thrombocytopenic purpura (ITP) is extremely rare, with only 2 cases being reported in the literature. This report describes the very rare case of a 1-year-old boy with BA complicated with ITP after cholangitis and the successful steroid treatment of ITP. We review the literature on this type of relationship between BA and ITP and discuss the clinical features of this complication. Furthermore, the possible cause of the onset of ITP complicated with BA was explored in this report.

Management of acute childhood idiopathic thrombocytopenic purpura according to AIEOP consensus guidelines: assessment of Italian experience

BACKGROUND

Consensus guidelines for diagnosis and treatment of acute childhood idiopathic thrombocytopenic purpura (ITP) were published in 2000 by the Italian Association of Pediatric Haematology and Oncology (AIEOP). The assessment of guideline implementation was the primary objective of the present study.

PATIENTS AND METHODS

Information on each newly diagnosed case of ITP referring to centres conforming with the guidelines was obtained by a questionnaire.

RESULTS

Data concerning 609 new cases of acute childhood ITP were collected including 346 (56.8%) asymptomatic-paucisymptomatic forms (type A), 262 (43%) intermediate clinical forms (type B), and 1 (0.2%) severe form (type C). At diagnosis, 82% of cases were hospitalized. Age, platelet count and duration of hospitalization were significantly different in type A and type B cases. Of the total number of cases, 25% were kept under observation, 38.6% received intravenous immunoglobulins, 23.9% oral or parenteral steroids, and 12.7% other treatments. The initial treatment turned out to be appropriate for 428 cases (72.2%), of uncertain appropriateness in 71 (11.9%), and inappropriate in 95 cases (15.9%). The total level of implementation was 84.1%.

CONCLUSIONS

A high rate of guideline implementation was observed during the study period. The guidelines should be reviewed taking into account more recent evidence.

Validity, reliability, and responsiveness of a new measure of health-related quality of life in children with immune thrombocytopenic purpura: the Kids' ITP Tools

OBJECTIVE

To refine the disease-specific health-related quality of life measure in immune (idiopathic) thrombocytopenic purpura (ITP) and to determine its validity, reliability, and responsiveness to change.

STUDY DESIGN

The initial phase involved cognitive debriefing of 12 families, on the basis of which the measure was modified and then named Kids' ITP Tools (KIT). The measure was administered on 2 occasions with the Pediatric Quality of Life Inventory (PedsQL) to 41 patients with acute ITP and 49 patients with chronic ITP, 2 to 18 years old, and their parents (proxy-respondents) at 6 North American centers.

RESULTS

Patients with acute ITP had lower scores when compared with patients with chronic ITP (child 64 versus 76, proxy 69 versus 77). The KIT moderately correlated with the PedsQL. Child versus proxy KIT scores showed moderate correlation, and the KIT was superior to the PedsQL. Test-retest reliability was substantial in the child report, but only moderate for the proxy report, similar to the PedsQL. The KIT showed a mean score change of 13 in the child and 15 in the proxy, which was greater than the PedsQL child's change of 7 and proxy change of 5.

CONCLUSION

The KIT is valid, with good distinction between acute and chronic ITP and a moderate correlation with the PedsQL. The KIT demonstrated reliability comparable with that of the PedsQL, yet it was more responsive to change. Therefore the KIT can be used as an outcome measure in future clinical trials of childhood ITP.

Spontaneous Subdural Hematoma in the Setting of Immune Thrombocytopenia Complicated by Ischemic Infarcts

The occurrence of spontaneous subdural hematoma (SDH) in immune thrombocytopenia (ITP) is rare. We report a spontaneous subacute subdural hematoma in a patient with chronic ITP. The patient presented with headache and a noncontrast head CT scan showed an 11 mm subacute right frontoparietal SDH causing an 8 mm right to left midline shift. The patient underwent medical management with platelets, FFP and packed RBC transfusions, steroids, IVIG and mannitol, which failed to prevent deterioration of her clinical condition. The patient then underwent burr hole drainage of the SDH. Her postoperative course was complicated by ischemic infarcts in the right posterior cerebral artery territory leaving her with a residual left homonymous hemianopia. Our patient was unique in the concurrent development of ischemic infarcts postoperatively, following burr hole drainage of the SDH in the setting of ITP. This case highlights the diagnostic and therapeutic dilemmas involved in taking care of such patients.

An extremely uncommon complication of ITP: spontaneous rupture of an ovarian follicle cyst and massive intra-abdominal bleeding

Idiopathic thrombocytopenic purpura usually presents with minor bleeding such as petechia and purpura. Rarely, life-threatening events as intracranial and intra-abdominal bleedings can be seen. We would like to present a rare case diagnosed as idiopathic thrombocytopenic purpura, presenting with abdominal pain and paleness. In this 17-year-old female patient, extensive abdominal sensitivity was revealed on physical examination and massive intra-abdominal hemorrhage secondary to distended ovarian follicle rupture was seen on ultrasonography and abdominal computed tomography. The case was treated successfully with intravenous immunoglobin, thrombocyte suspension, and pulse methylprednisolone.

Risk factors for future development of systemic lupus erythematosus in children with idiopathic thrombocytopenic purpura

The risk of later development of systemic lupus erythematosus (SLE) in childhood idiopathic thrombocytopenic purpura (ITP) is currently unknown. We retrospectively evaluated the incidence and risk factors of this complication in 222 children with ITP who were followed for a mean of 4.2+/-4.9 years. During that time 3.6% of the children (8/222) developed SLE; all were females with positive anti-nuclear antibody (ANA), older (12.7+/-3.6 vs. 6.4+/-4.3 years old; P<0.01), and were more likely to have chronic ITP (87.5 vs. 46%; P=0.02), and had high titers of ANA. The majority of children with ITP who had a positive ANA (14/22, 64%) did not develop SLE.

Treatment of immune thrombocytopenic purpura in children : current concepts

Treatment of immune thrombocytopenic purpura (ITP), the most common bleeding disorder of childhood, is a controversial subject for most practitioners. Diagnosis and management of ITP has historically been based primarily on expert opinion rather than on evidence. Due to a paucity of carefully conducted clinical trials in children, the management of ITP varies widely, ranging from observation only, to aggressive management with intravenous immunoglobulin (IVIG), intravenous anti-D rhesus (Rh)0 immunoglobulin (IV RhIG), corticosteroids, and splenectomy. To address the controversies, the American Society of Hematology (ASH) and the British Society for Hematology (BSH) have developed ITP practice guidelines. These guidelines, based on expert opinion, differ in their recommendations for treatment. The ASH guidelines favor therapy based on a low platelet count, and the more current BSH guidelines recommend a more conservative 'wait and watch' approach. In addition to treating children with severe bleeding symptoms, there is a tendency (not evidence based) to treat early in order to prevent a life-threatening bleeding episode, including intracerebral hemorrhage. Corticosteroids are a highly effective therapy, inexpensive, and can usually increase the platelet count within hours to days. However, chronic or prolonged use is associated with toxicity. In the US, based on the knowledge of known toxicities of corticosteroids, as well as the efficacy of alternative treatments (IV RhIG, IVIG), many pediatricians prefer to treat with IVIG and IV RhIG, reserving corticosteroid treatment for serious bleeding or refractory disease. However, in the UK, for the most part, corticosteroids are used as first-line therapy in children with ITP. Splenectomy is rarely indicated in children except for those with life-threatening bleeding and chronic, severe ITP with impairment of quality of life. For children who develop chronic or refractory ITP, immunosuppressive drugs and/or chemotherapy agents may offer some promise. However, the long-term effects of these drugs in children are unknown and they should not be considered unless there is unequivocal evidence that the patient is refractory to IV RhIG, IVIG, and corticosteroids. To date, virtually all of the randomized clinical trials conducted in children with ITP have focused on platelet counts as the sole outcome measure. Only carefully designed, multicenter, randomized clinical trials comparing the effects of different treatment modalities in terms of bleeding, quality of life, adverse effects, and treatment-related costs will be able to address the controversies surrounding childhood ITP treatment and allow management of this condition to be based on scientific data rather than treatment philosophy.

Immune thrombocytopenic purpura – current management practices

The treatment of patients with immune thrombocytopenic purpura (ITP) is changing rapidly, as new agents demonstrate the capability of improving outcomes and decreasing toxicity. Prior to 1981, the only effective treatment options available to increase platelet counts in persons with ITP were corticosteroids and splenectomy. In recent years, intravenous immunoglobulin (IVIg) and intravenous Rh immunoglobulin (IV RhIg) have demonstrated efficacy comparable to that of corticosteroids for increasing platelet counts in ITP. In addition, IVIg and IV RhIg have demonstrated efficacy for maintaining corticosteroid-induced increased platelet counts by periodic infusion, causing a transient impairment of reticuloendothelial clearance function (medical splenectomy). Thus, the time-proven efficacy of corticosteroids for initial treatment of ITP (induction) may now be supplemented with IVIg or IV RhIg infusions for patients requiring ongoing treatment to support a timely and complete steroid taper, while sustaining the increased platelet count (maintenance) with less toxicity. Several investigators have reported that rituximab (anti-CD20) induced sustained remissions with minimal toxicity, in patients with chronic ITP. These reports are promising and, if confirmed, will provide another effective (spleen-sparing) option for managing acute ITP and a long-awaited option for patients who have had a splenectomy and are refractory to conventional agents. Other treatments, including danazol, azathioprine, cyclophosphamide, vinca alkaloids and cyclosporin A, have advocates, but evidence of their efficacy is limited to relatively small and mostly uncontrolled clinical trials. In our opinion, these agents should be reserved for symptomatic thrombocytopenia after refractoriness to corticosteroids, IVIg, IV RhIg, splenectomy and rituximab has been clearly established.

Intracranial hemorrhage in immune thrombocytopenic purpura: a retrospective analysis

PURPOSE

To ascertain characteristics of children with immune thrombocytopenic purpura (ITP) and intracranial hemorrhage (ICH).

METHODS

The authors identified 75 published cases of ICH in children with ITP by review of the literature from 1954 to 1998. Data pertaining to the ICH was recorded for age, gender, time from diagnosis of ITP (to ICH), platelet count, head trauma or arteriovenous malformation, concomitant medications, associated infections, other bleeding manifestations, prior treatment, and outcome. RESULTS Sixty-two cases represented 6 months to 20 years of age; 65% of patients were female. The median time from the diagnosis of ITP to ICH was 32 days (range 0 days to 8 years). Fifty of 69 ICH cases (72%) occurred within 6 months of diagnosis, but only 7 (10%) occurred within 3 days of diagnosis. The platelet count was less than 10000/microL in 71.4% of the cases. Treatment prior to the ICH was primarily steroids but also included intravenous immune globulin (IVIG), splenectomy, and others (interferon, azathioprine, or vincristine). There was no difference in mortality of patients before (56%) or after (54%) 1980.

CONCLUSIONS

A very low platelet count appears permissive but not sufficient for ICH to occur in children with ITP. ICH occurs more commonly in acute ITP but can occur years after diagnosis. A significant number of patients develop an ICH despite having already initiated steroid treatment of ITP.

Idiopathic thrombocytopenic purpura of childhood: a problem-oriented review of the management

Idiopathic thrombocytopenic purpura (ITP) is an often, but not always, self-limited bleeding disorder of childhood of unknown etiology. Duration of more than 6 months defines the chronic form and this occurs in approximately 20% of children and is the common form of the disorder in adults. At initial diagnosis, neither the individual bleeding risk nor the form of the disease, acute or chronic, is predictable, which exposes doctors and parents to fear of life-threatening bleeding. Consequently a majority of children will receive platelet-enhancing therapy to prevent major bleeding manifestations. Prophylactic interventions have proven to be effective in raising the platelet count within a short time period in several prospective trials, however two questions may be raised, (1) whether a rapid platelet increase efficiently prevents serious bleeding and (2) whether such a prophylactic intervention is of clinical value. Furthermore, a small subgroup of patients with major bleeding manifestations seems to be treated inadequately, since patients of this subgroup may bleed in spite of platelet-enhancing therapy. Clinical trials with long-term follow-up are needed, using clinical parameters as study endpoints, to answer the question of which subgroup of children with ITP should be treated upfront with platelet-enhancing therapy.

Immune thrombocytopenic purpura

Although many advances have been achieved in the understanding of ITP, critical issues regarding the pathophysiology and biology of the disease remain to be elucidated. The recent characterization of the human genome along with new sophisticated molecular biology techniques will allow basic researchers to study genes that may affect the presentation and clinical course of the disease. Different patterns of gene expression in this population can be studied, leading to the identification of subsets of patients with ITP at higher risk of bleeding. The multigene patterns of expression might also provide clues about regulatory mechanisms and broader cellular functions. In order to answer essential clinical questions, like the incidence of ICH in relation to drug treatment or observation alone, clinical trials should be appropriately designed. More studies are necessary to better define the optimal treatment approach for each child with ITP. Even though the incidence of intracranial hemorrhage cannot be used as the primary outcome measure because of its rarity, numerous other outcomes, such as rate of rise in platelet count, cost and side effects of therapy, health related quality of life of the patient and family, and severity of hemorrhage can be measured and compared between treatment groups. Future investigators should find it attractive to conduct trials in children with this common hematological disease so that decision making can be based more on scientific evidence than on anecdote and opinion.

Systemic lupus erythematosus and antiphospholipid syndrome in children and adolescents

Systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS) can be associated with significant morbidity in children and adolescents. Renal involvement in SLE appears to be more severe and more frequent in the pediatric age group, with the major predictors for poor outcome being the severity of histopathologic lesions, severity of renal impairment at diagnosis, and hypertension. In addition to currently recognized cardiovascular and pulmonary involvement, accelerated atherosclerosis is of increasing concern in young individuals with SLE, because of both disease effects and medication usage. Neuropsychiatric SLE seen in childhood ranges from subtle cognitive dysfunction to severe central nervous system involvement; however, there is controversy over the value of different diagnostic studies. APS in children may be associated with SLE, idiopathic, or associated with viral infections. Systemic anticoagulation is recommended for patients with thrombotic events, but long-term management has not been well studied in children.

Management of immune thrombocytopenic purpura in children

Immune thrombocytopenic purpura (ITP) is the most common acquired bleeding disorder occurring in previously healthy children and can be classified into two major forms. Acute and chronic ITP are benign conditions with a high probability of spontaneous recovery with or without therapy. Rates of 80-90% complete remission can be achieved irrespective of the treatment given. In only 10-20% of children thrombocytopenia persists for more than six months, showing a chronic course, which also has a high probability of remitting over time (up to 80% or more). The variability of the clinical course, and the lack of consistent clinical features, make the decision on whether and how to treat difficult. Most physicians are driven to treat all children with symptoms by concern over life-threatening hemorrhage, although the risk of intracranial hemorrhage (ICH) is only 0.1-0.9%. The commonly used treatment regimens for acute ITP are corticosteroids, intravenous immunoglobulins (IVIgG), or intravenous anti-D immunoglobulin (anti-D). So far, there is no evidence that initial therapy can prevent ICH or a chronic course of the disease. In chronic ITP the same drugs are generally used and it seems that pulses with steroids may be just as effective as IVIgG. Anti-D may also be considered a reliable and cheap alternative for chronic disease. A major problem in the management of chronic ITP is the question of whether repeated infusions of Ig (IVIgG or anti-D) and/or corticosteroids can postpone or ultimately preclude splenectomy, which must be considered only for a small proportion of patients resistant to therapy. In these cases, a laparoscopic approach should be preferred. Children who fail to respond to splenectomy (< 20% of cases) warrant second line treatment with other drugs, like cyclophosphamide or azathioprine and deserve a revisit of diagnosis for exclusion of secondary ITP.