Differential diagnosis and management of thrombocytopenia in childhood

Progressive Thrombocytopenia, Splenomegaly, and Abnormal Tone in an Infant With Growth Faltering

A 4-month-old full-term female presented with growth faltering associated with progressive feeding difficulty, rash, abdominal distension, and developmental delays. She was found to have disconjugate gaze, abnormal visual tracking, mixed tone, bruising, and splenomegaly on examination. Initial workup was notable for thrombocytopenia and positive cytomegalovirus (CMV) immunoglobulin G and immunoglobulin M antibodies. She initially presented to the infectious diseases CMV clinic, where she was noted to have severe malnutrition, prompting referral to the emergency department for hospital admission to optimize nutrition with nasogastric tube feeding and facilitate additional evaluation. An active CMV infection with viruria and viremia was confirmed, but elements of her presentation and workup including brain magnetic resonance imaging were not consistent with isolated CMV infection. To avoid premature diagnostic closure, a multidisciplinary workup was initiated and ultimately established her diagnosis.

Meropenem-induced thrombocytopenia: a paediatric case

Meropenem is a broad-spectrum carbapenem widely used to treat both Gram-positive and negative bacterial infections, including extended-spectrum beta-lactamase-producing microbes. We describe the occurrence of thrombocytopenia and hypersensitivity in a boy receiving intravenous meropenem for intra-abdominal sepsis secondary to perforated appendicitis. The patient developed a pruritic maculopapular rash with occasional petechiae, associated with severe thrombocytopenia, after 7 days of meropenem administration. Investigations for other causes of thrombocytopenia, including possible line sepsis, were unfruitful, and the thrombocytopenia did not resolve until cessation of meropenem. Drug-induced reactions should be considered in children receiving meropenem who present with a rash and thrombocytopenia.

Evaluation of coagulation parameters: Coronavirus disease 2019 (COVID-19) between survivors and nonsurvivors

OBJECTIVE

This study aims to investigate and compare the coagulation parameters of coronavirus disease 2019 (COVID-19) patients with mortal and nonmortal conditions.

METHODS

In this study, 511 patients diagnosed with COVID-19 were included. Information about 31 deceased and 480 recovered COVID-19 patients was obtained from the hospital information management system and analyzed retrospectively. Whether there was a correlation between coagulation parameters between the mortal and nonmortal patients was analyzed. Descriptive analyses on general characteristics of the study population were performed. Visual (probability plots and histograms) and analytical methods (Kolmogorov-Smirnov and Shapiro-Wilk test) were used to test the normal distribution. Analyses were performed using the SPSS statistical software package.

RESULTS

Out of 511 patients, 219 (42.9%) were females and 292 (57.1%) were males. There was no statistically significant difference between males and females in terms of mortality (p=0.521). In total, the median age was 67 (22). The median age was 74 (13) in the nonsurvivor group and 67 (22) in the survivor group, and the difference was statistically significant (p=0.007). The D-dimer, prothrombin time, international normalized ratio, neutrophil, and lymphocyte median age values with p-values, in the recovered and deceased patient groups were: 1070 (2129), 1990 (7513) μg FEU/L, p=0.005; 12.6 (2.10), 13.3 (2.1), p=0.014; 1.17 (0.21), 1.22 (0.19), p=0.028; 5.51 (6.15), 8.54 (7.05), p=0.001; and 0.99 (0.96), 0.64 (0.84), p=0.037, respectively, with statistically significant differences.

CONCLUSIONS

As a result of this study, D-dimer, prothrombin time, and international normalized ratio increase were found to be associated with mortality. These parameters need to be closely monitored during the patient follow-up.

Use of Recombinant Factor VIIa in a Pediatric Patient With Initial Presentation of Refractory Acute Immune Thrombocytopenic Purpura and Severe Bleeding

Severe bleeding in acute immune thrombocytopenic purpura (ITP) is rare but can cause significant complications to the patient. Here we report the case of a pediatric patient with acute ITP and hematuria refractory to anti-D immune globulin, high dose intravenous immunoglobulin G, and high dose steroids. Her hematuria was successfully treated with recombinant factor VIIa (rFVIIa). While further investigation on the use of rFVIIa in ITP is warranted, this case report contributes to the pediatric literature for its use during the course of an initial presentation of ITP with hemorrhagic complications.

Idiopathic thrombocytopenic purpura in childhood: twenty years of experience in a single center

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder with a variable clinical course.

METHODS

A retrospective analysis was carried out of ITP patients presenting to a pediatric hematology-oncology department during a period of 20 years, with a focus on treatment and outcome.

RESULTS

One hundred and twenty-four cases were recorded (mean patient age, 8.4 years). Forty-nine children (39.5%) had platelet counts <10,000/µL at diagnosis. No episode of severe bleeding was observed. Peak incidence was observed during spring and summer. Respiratory infections proceeded in 58% of cases. Treatment consisted of i.v. immunoglobulin (IVIG) in 93 children at four dosing schedules. Sixteen children received corticosteroids, 10 children received anti-D immunoglobulin and 14 received no treatment. Recovery was observed in 67% of children on IVIG and in 50% on anti-D globulin. Eight patients did not respond initially and received corticosteroids. Three children with refractory thrombocytopenia received anti-CD20 (rituximab). Fourteen children (11%) had persistent/chronic disease. In 10 of them recovery was observed in 13 months-8 years. Splenectomy was performed in six children with resistant/chronic disease.

CONCLUSION

ITP has a benign course in the majority of cases. Anti-D globulin can effectively be used as an alternative first-line treatment. Rituximab can successfully be used in refractory cases, while splenectomy has currently limited indications.

Hematology and Oncology in Critical Illness

This chapter will focus on a variety of hematologic issues pertinent to the care of critically ill children. This is an area of intense research with the pathophysiology underlying these clinical conditions becoming progressively better understood. This improved understanding has resulted in new therapeutic strategies that are being assessed in multicenter clinical trials. The chapter will begin by describing the incidence and pathophysiologic significance of anemia in the pediatric intensive care unit (PICU) providing a differential diagnosis of the many conditions that may present with anemia in this setting. The chapter will next consider disseminated intravascular coagulation (DIC) focusing on the pathophysiology of a condition that has been associated with much morbidity and mortality. The underlying conditions predisposing to DIC will be detailed as well as a number of treatment options that have been implemented in clinical trials. In addition to DIC, thrombocytopenia may be caused by a number of other clinical conditions important to the pediatric critical care provider. The clinical and prognostic significance of thrombocytopenia will be addressed and a focused differential diagnosis will be provided. Thrombotic disorders are becoming increasingly recognized in children and are a particular concern for the pediatric intensivist. The epidemiology of thromboembolism in children will be reviewed focusing on the conditions most commonly associated with these thromboses. Finally, a chapter on hematologic issues in the critically ill child would not be complete without a discussion of sickle cell disease. Acute chest syndrome, one of the most frequent complications of sickle cell disease resulting in the need for intensive care services, will be discussed in detail.

Thrombocytopenic syndromes masquerading as childhood immune thrombocytopenic purpura

Immune thrombocytopenic purpura (ITP) is the most common cause of thrombocytopenia in children and adolescents. However, there are a number of other diagnoses that are often mistaken for ITP. A 10-year retrospective chart review was performed at the Children's Hospital of Alabama to characterize ITP. Initially, 492 patients who had the coded diagnosis of ITP (ICD 287.3) were identified. However, 83 (17%) of patients were found to have alternative diagnoses on chart review. Of the 83 patients, 13 patients (3%) represented coding errors or study classification errors. The 70 remaining patients (14%) had an alternative explanation for their thrombocytopenia, consisting of 31 different diagnoses. The most common diagnoses were familial thrombocytopenia (10%), systemic lupus erythematosus (9%), hypersplenism (9%), neonatal alloimmune thrombocytopenia (7%), Wiskott-Aldrich syndrome (7%), or systemic infection (6%). In total, 16 of the patients (23%) were ultimately diagnosed with one of a number of congenital syndromes with concurrent thrombocytopenia. Although this review confirms that most children with thrombocytopenia are diagnosed with ITP, 14% of the study population manifested other diagnoses. The clinician evaluating a child with thrombocytopenia must keep an open mind about the possible diagnosis and perform a comprehensive and thoughtful evaluation based on the clinical picture. ITP must be a diagnosis of exclusion as misdiagnosis in a child with thrombocytopenia may have a significant impact on morbidity and mortality.

Multimodal management, including precisely targeted irradiation, in a severe refractory case of Evans syndrome

A challenging case of acute autoimmune thrombocytopenia (ITP) which evolved into a chronic refractory case of Evans syndrome over a period of more than 23 years is presented and may illustrate current therapeutic dilemmas now perplexing patients and clinicians. Newer modalities are being developed and their eventual role in the scheme of clinical management remains to be established. While this development unfolds, highly targeted radiotherapy was applied in this case to reduce platelet uptake by a refractory recurrent splenule with the goal of stabilizing the platelet count until promising investigational thrombopoietic agents or other newer, less toxic therapies might become available for wider application.