Chronic idiopathic thrombocytopenic purpura: the pediatrician's dilemma

Is Bone Marrow Examination Justified in Isolated Childhood Thrombocytopenia?

Immune thrombocytopenic purpura (UP) is a common pediatric hematologic disorder. Bone marrow aspiration (BMA) is often performed in children with acute ITP to rule out leukemia, aplastic anemia or other hematologic diseases. However, whether BMA is needed in children with typical and hematological features of acute ITP has been questioned. To determine whether BMA is indicated in acute childhood ITP, samples were examined from 122 patients with the provisional diagnosis of acute ITP attending Hevi Pediatric Teaching Hospital, Duhok/North of Iraq between August 2006 and July 2010. Typical acute ITP was defined as an appearance of well being, no hepatosplenomegaly, no lymphadenopathy, normal Hb, WBC, neutrophil count and peripheral blood smear except for thrombocytopenia. A platelet count of 50 x109/L or lower was the cut-off level. No diagnoses of leukemia or aplastic anemia were revealed in the 122 (100%) children with typical hematologic features of ITP and it was concluded that routine BMA is not needed for children with typical features of acute ITP.

Idiopathic thrombocytopenic purpura diagnosed during the second decade of life

OBJECTIVE

To retrospectively review our institutional experience of adolescents with idiopathic thrombocytopenic purpura (ITP).

STUDY DESIGN

Medical record review of all patients diagnosed with ITP between the ages of 10 and 18 years seen at our center from January 1976 to March 2000.

RESULTS

Data were collected from 126 patients. Of the evaluable 110 cases, 63 (57%) satisfied the criteria for chronic ITP, 30 (27%) for acute ITP, and 17 (15%) were uncertain. Sex distribution and mean ages were similar in all 3 groups. Platelet count at presentation was higher in patients with chronic ITP. Splenectomy was performed in 24 patients, with 17 (77%) of 22 having normal platelet counts at last follow-up. Outcome for the nonsplenectomized patients with chronic ITP included normalization of platelet count (n = 4), minimal or no bleeding without treatment (n = 29), treatment for ongoing symptoms (n = 5), and unknown (n = 1). Two patients died, 1 from intracranial hemorrhage and 1 from Escherichia coli sepsis and pulmonary hemorrhage.

CONCLUSIONS

Patients 10 to 18 years of age with ITP are more likely than younger children to have chronic disease. Many patients with ITP recover without drug therapy or need for splenectomy. ITP in adolescents shares features of both childhood and adult ITP.

Elective splenectomy in children with idiopathic thrombocytopenic purpura

PURPOSE

The aim of this study was to review the safety and efficacy of elective splenectomy in children with idiopathic (immune) thrombocytopenic purpura (ITP).

METHODS

The authors reviewed the medical records of children with ITP treated with elective splenectomy at Children's Medical Center of Dallas since 1961. Indication for splenectomy was symptomatic thrombocytopenia unresponsive to medical management.

RESULTS

Thirty-eight evaluable patients who had elective splenectomy for ITP were identified. Twenty-one (55%) were girls and 17 (45%) were boys. Twenty-two had splenectomy since January 1990. Age at diagnosis ranged from 6 months to 15.9 years (median 9 years), and age at splenectomy ranged from 3.6 to 16.4 years (median 11.8). Laparoscopic splenectomy was performed in 11 patients. No patient died and only one (2.6%) had postoperative hemorrhage. There were no other complications related to surgery. No cases of postsplenectomy sepsis were observed. At follow-up ranging from 1 month to 19.9 years (median 2.1 years), 29 patients (76.3%) had a normal platelet count (>150 x 109/L) and 4 (10.5%) had a platelet count between 50 and 150 x 109/L. Only two of the five (13.2%) remaining patients who continued to have a platelet count less than 50 x 109/L had hemorrhagic manifestations necessitating intermittent therapy with corticosteroids.

CONCLUSION

Laparoscopic or open splenectomy is a safe and effective procedure for children with chronic or refractory ITP and should be considered when medical management fails or causes excessive toxicity.

Current controversies in the management of idiopathic thrombocytopenic purpura during childhood

Both acute and chronic ITP in children are generally benign conditions. Few patients develop serious complications or long-term sequelae. Therefore, most patients require little or no specific therapy. IVIG or high-dose steroids may benefit some patients who have evidence of clinical bleeding, and splenectomy may be of value in patients with chronic ITP whose lives are altered by low platelet counts or bleeding. It is difficult to predict which patients are at risk for the development of ICH, and severe hemorrhage is not always curtailed by prior or concomitant therapy. The decision to treat a child with ITP should be based on the entire clinical picture rather than on the platelet count alone.

Intra-abdominal bleeding in a 14-year-old girl with acute immune thrombocytopenic purpura

We describe a 14-year-old girl with acute immune thrombocytopenic purpura. She presented with acute abdominal pain, and her hematocrit decreased from 44% to 29%. The bleeding was due to the rupture of a distended follicle on about the 14th day of her menstrual cycle. The patient's low platelet count made possible the continuous oozing of blood from the follicle into the abdominal cavity, causing peritoneal irritation and the fall in hematocrit. She received treatment with intravenous Ig. This case indicates that unnecessary surgery can be avoided if there is reason to believe that the cause of internal bleeding does not require surgical intervention.

Chronic idiopathic thrombocytopenic purpura: incidence, treatment, and outcome

In order to determine incidence, outcome, trends in management and natural history, data on 92 children with chronic idiopathic thrombocytopenic purpura (ITP), comprising 66 from a single centre's experience between 1950 and 1980 and all 26 presenting from a defined population between 1984 and 1994, have been analysed. Its incidence, calculated from the population based group, is 0.46/10(5) children per year. Twenty nine of 34 (85%) remitted after splenectomy. Short initial histories predicted response to splenectomy. Splenectomy was offered only half as frequently in the last 10 years as in the 30 year, single centre group of children. Most (39 cases) of those not offered or successfully treated by splenectomy recovered spontaneously. The predicted spontaneous remission rate in 85 with adequate follow up data is 61% after 15 years. No other form of active treatment was of lasting benefit. No death solely attributable to chronic ITP occurred. The high spontaneous recovery rate, low mortality, and generally benign outcome may encourage a less interventionist approach to management.

Seventeen years of experience with chronic idiopathic thrombocytopenic purpura in childhood. Is therapy always better?

Between 1975 and 1992 450 children with idiopathic thrombocytopenic purpura (ITP) were diagnosed, and of those 100 (22%) developed the chronic form of the disease. Approximately half the patients with chronic ITP presented with mild to moderate hemorrhagic manifestations at the onset of purpura (30 cases) and/or later during the course of the disease (25 cases). The incidence of intracranial hemorrhage was 1%, and the mortality rate due to overwhelming septicemia after splenectomy was also 1%. Overall one-third of the patients received no therapy; two-thirds of them went into spontaneous remission within 8 months to 8 years from the onset of ITP. Steroids given in conventional or high doses (51 cases) achieved a transient (if any) rise in platelet count, but in no case were steroids curative. Remission related to intravenous immune globulin (IVIG) therapy was noticed in 38.5% of the children (10 of 26) after variable courses. The response rate to splenectomy was 95.0%. Ultimately the long-term outcome in children with chronic ITP was as follows: remission, 58 cases (spontaneous, 30; after IVIG therapy, 10; after splenectomy, 18); hemostatic platelet values, 22 cases (spontaneous, 16; after IVIG, 5; after splenectomy, 1). Thirteen children were lost in follow-up, and 7 remain thrombocytopenic but asymptomatic. These data indicate that chronic ITP in childhood runs a benign course in most cases and may remit with or without therapy even several years from onset. Therefore, therapeutic intervention has to be individualized, and splenectomy, which is not always safe, should be reserved for problematic cases that fail to respond to conventional therapeutic modalities.