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    Immune Thrombocytopenic Purpura

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    Faheema Hasan Younus
    This document describes a case of a 2 year 9 month old boy presenting with immune thrombocytopenic purpura (ITP). He presented with blood stained stools on two occasions in the past 3 weeks. On examination, he had ecchymotic patches on his back, shoulders, and shins. Laboratory tests found his platelet count was 16,000/mm3. He was diagnosed with ITP based on his history, examination, and lab results. He received treatment including IV immunoglobulin and follow up with hematology. ITP is an autoimmune disorder where antibodies destroy platelets, causing purpura and bleeding. Diagnosis involves low platelet count with normal other blood counts and bone marrow findings. Treatment

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    Immune Thrombocytopenic Purpura

    Uploaded by

    Faheema Hasan Younus
    72 views28 pages
    This document describes a case of a 2 year 9 month old boy presenting with immune thrombocytopenic purpura (ITP). He presented with blood stained stools on two occasions in the past 3 weeks. On examination, he had ecchymotic patches on his back, shoulders, and shins. Laboratory tests found his platelet count was 16,000/mm3. He was diagnosed with ITP based on his history, examination, and lab results. He received treatment including IV immunoglobulin and follow up with hematology. ITP is an autoimmune disorder where antibodies destroy platelets, causing purpura and bleeding. Diagnosis involves low platelet count with normal other blood counts and bone marrow findings. Treatment

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    Thrombocytopenia

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    This document describes a case of a 2 year 9 month old boy presenting with immune thrombocytopenic purpura (ITP). He presented with blood stained stools on two occasions in the past 3 weeks. On examination, he had ecchymotic patches on his back, shoulders, and shins. Laboratory tests found his platelet count was 16,000/mm3. He was diagnosed with ITP based on his history, examination, and lab results. He received treatment including IV immunoglobulin and follow up with hematology. ITP is an autoimmune disorder where antibodies destroy platelets, causing purpura and bleeding. Diagnosis involves low platelet count with normal other blood counts and bone marrow findings. Treatment

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    72 views28 pages

    Immune Thrombocytopenic Purpura

    Uploaded by

    Faheema Hasan Younus
    This document describes a case of a 2 year 9 month old boy presenting with immune thrombocytopenic purpura (ITP). He presented with blood stained stools on two occasions in the past 3 weeks. On examination, he had ecchymotic patches on his back, shoulders, and shins. Laboratory tests found his platelet count was 16,000/mm3. He was diagnosed with ITP based on his history, examination, and lab results. He received treatment including IV immunoglobulin and follow up with hematology. ITP is an autoimmune disorder where antibodies destroy platelets, causing purpura and bleeding. Diagnosis involves low platelet count with normal other blood counts and bone marrow findings. Treatment

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 28

    Immune

    Thrombocytopenic Purpura
    IMMUNE THOMBROCYTOPENIC PURPURA

    Name – Tharusha Dewuruwan


    Age - 2 years 9 months
    Sex - Boy
    Address- Panadura

    P/C – As requested by the GP due to low


    Plt count, when investigating for blood
    stained stools.
    HPC-
     The child was quite well 3weeks back.
     He developed blood coated loose stools with mucus, 3times/day , lasted for
    3days.
     Mild fever for 1day.

    no chills or rigors.
    responded to PCM.
     Mild abdominal pain at the onset of loose stools, lasted few minutes.

    no vomiting.
     They have taken treatment from a GP. (Milcef 125mg bd) antibiotic syrup given.
     Condition settled on day3.
     Had normal bowel habits for 2weeks.
     After 2weeks, he developed 2nd episode of blood stained stools for 1day
    duration, with mild fever. (101F)
     Mother noticed a bluish patch on the back of the child, which appeared
    after falling from a swing.
     FBC was done by GP- Platelet count was 72,000/mm3 .
    Differential diagnosis-

    1. DHF
    2. ITP
    3. ALL
    4. Drugs
    5. HUS
    6. WVD
    7. DIC
    8. Non accidental injuries
    9. Rectal Polyp
    Systemic inquiry-
    Abdomen-mild abdominal pain, LOA
    No vomiting, malena or gum
    bleeding.
    Skin- No Rashes
    Rs –No cough, cold, wheezing, sob
    ENT- No sore throat, epistaxis
    CVS- No dyspnoea on exertion, palpitation,
    Musculoskeletal- No joint pain
    Renal- No haematuria
    CNS- No fits, headache

    No contact history of fever or diarrhoea


    No outside food was taken.
    PMH-
    Acute
     gastroenteritis at 1 year 6 months.
    No Bleeding disorders, fits, BA,
    No history of measels, mumps, Rubella
    Immunization H-
    Up to date
    JE and Hib vaccine not given.

    Drug History-
    Cefalexin 3weeks back.

    FH-
    No bleeding disorders
    No consanguinity
    No connective tissue or autoimmune disorders

    SH-
    Mother-28years, house wife
    Father- 32years , mason
    Both educated up to O/L
    Nearest hospital- Panadura base hospital, can reach within 20 minutes by Three wheeler.
    O/E-
     Looks well & active
     Weight 13.75kg (25th-50th centile)
     Height 97cm (75th-91st centile)
     Not pale
     Ecchymotic patches- back
    right shoulder
    B/L shins
    bluish in colour
    1-2 cm in diameter
     Bruises around venepuncture sites.
     No lymph node enlargement.
     ENT- no tonsillitis
    no oral ulcer
    no ear discharge
     Abdomen- tenderness over right iliacfossa
    no hepatospleenomegaly
     Other systems- normal
    Investigations-
     FBC- WBC- 10600

    N-67%
    L -20%
    M-6.9%
    E -1.7%
    B -3.5%
    Hb- 13.3g/dl
    Plt -16000/mm3
    PCV-38.6%
     Repeated FBC done- Plt -16000/mm3

    35000/mm3
    20000/mm3
    57000/mm3
     SGOT- 40 u/l
     SGPT- 15 u/l
     PT - 11.9sec
     INR- 1.06
     APTT- test -32.7sec
    control -35sec
     BT - 3 ½ min
     CT - 3min
     ESR -40min- 1st hour
     Hess’s test (+)ve
     Mono spot (-)ve
     Ds DNA (-)ve
     Blood picture-
    RBC- normocromic normocytic
    WBC-mild eosinophilia
    few reactive lymphocytes
    PLT -low
    few large forms
     Flexible sigmoidoscopy- when Plt >50000/mm3
     ANA
    Management
     Initially managed as blood & mucus diarrhoea.(furazolidone 50mg/6h given)
     QHT
     PCM 200mg/6h
     ORS- 50-100cc/loose stool
     FFP 140cc given when Plt count 16000/dl
     After hematological referral, management plan-
     To exclude 2ry causes -SLE screen
    -USS abdomen
    -ESR
    -CRP
    -drug history
    -renal &liver functions test
     If bleeding + Plt <20000/mm3 - give IV Immunoglobulin(Ig 0.4g/kg/day)for 2-
    3days
     Delay steroids, unless thrombocytopenia become chronic
     Bone marrow aspiration to exclude hematological malignancies
     Follow up with regular counts
     Review at the hematological clinic
    Thrombocytopenia?
    Reduction in platelet count
    Purpura
    ◦ Occurs when platelet count
    <20000/mm3
    What causes thrombocytopenia?

    Thrombocytopenia

    Increased consumption

    Bone marrow failure


    Immune
    Splenomegaly
    Non immune

    Primary
    ITP Secondary - DIC
    - TT P
    - HUS
    - L ive r di se ase
    What Is Immune
    Thrombocytopenic
    Purpura?
    Pathogenesis of ITP
    ( auto immune disorder, post viral)
    ↓
    Antibodies binds to platelets
    ↓
    Antibody coated platelets binds to the fc receptors of the macrophages in
    the reticular endothelial system
    ↓
    Diminished t1/2 of the platelets in reticular endothelial system
    IgG- spleen
    IgE-liver
    What are the presentations of ITP?
    Acute Chronic
    Onset acute Onset insidious
    Lasts 4-6 weeks Lasts >6 months
    Peak age of incidence is 2-6 years. Can occur in all ages
    Sex F:M=1:1 Sex F:M=3:1
    Presents as Bruising, petichial Presents with Prolonged history of
    hemorrhages and bleeding from mucosal bruising and bleeding.
    surfaces. Bleeding is less severe.
    Severity of bleeding is less even with
    Association with SLE, Rheumatoid
    lower counts compared to marrow
    disease and other collagen disorders.
    failure due to functionally superior
    In 10%-20% natural remission.
    juvenile platelets.
    Death is mainly due to uncontrolled
    bleeding\ICH.
    In 80% patients spontaneous remission
    within 1-2 weeks.
    Eosenophillia \ thrombocytosis common.
    Eosenophillia \ thrombocytosis rare.
    Bleeding manifestations in ITP..
    Diagnosis of ITP…
    Mainstay of the diagnosis is the Typical history, examination and
    exclusion of secondary causes.

    FBC- Platelet count reduced <20,000/ mm3 is


    the only abnormality.
    Other counts normal.
    Hb normal.

     Blood picture- Low platelets which are increased or normal


    in size.

    Bleeding time- is prolonged but APTT and


    PT are normal.
    Bone marrow aspirate-
    - Done before starting steroid
    treatment.
    - Shows increased or normal
    number of megakaryocytes.
    - Platelet turnover is increased.

    Screening for secondary causes-


    -ANA
    -Coombs
    -Double stranded DNA
    -HIV screening
    -Anti platelet antibodies
    How to manage ITP?

    Management of ITP

    Specific Treatment Supportive treatment


    Specific treatments
    Corticosteroid therapy
    mode of action
    1. Inhibit platelet antibody production
    2. Inhibit interaction between antibodies and platelets
    3. Prolong platelet survival
    4. Increase vascular stability
     Given if bleeding is present
     Only a short course of prednisolone is given 1-2mg/kg
    over 2-3 weeks and should be discontinued irrespective of the
    platelet count
    (because response after ) this is unlikely
     Iv methyl prednisolone pulse therapy is more effective (given
    for 3 days)
    • Splenectomy

    spleen is the main site of antibody production against platelets


    as well as main site of destruction of platelets
    indications
    1. >4years child with severe ITP for >1 year Symptoms not
    controlled by therapy
    2. Life threatening hemorrhages if platelet count cannot be
    controlled with platelets
    • children after splenectomy are more susceptible to develop
    post splenectomy sepsis secondary to infections by
    encapsulated organisms. Risk is much higher if <5years.
    • Meningococcal, pneumococcal, Hib vaccine should be given
    prior to splenectomy
    • Prophylactic penicillin to prevent gram +ve infections
    IV Immunoglobulin

     Increase the platelet count by blocking Fc


    receptors and protect the plt from the plt
    antibodies.
     Some children respond within 48hrs
    [rapid responders].
     Dose- 0.4mg/kg for 5 days
    1mg/kg for 2 days
     Side effects- Vomiting, headache.
    Supportive treatment

    Treatment

    Advice
    - Usually remits spontaneously
    -Side effects of steroids Restriction of physical Platelet transfusion
    -Prevent trauma
    -If headache/ vomiting admit immediately activity/outdoor in life threatening
    -If splenectomy indicated vaccination
    -Avoid NSAIDS games bleeding tendencies
    -Avoid IM injections
    Presentedby
    Lopali
    Shanaka
    Rasangika
    Prasad

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