Friday, February 08, 2013

Recurrent idiopathic thrombocytopenic purpura in childhood

I have a 1.5 year old child who came with petechiae (small skin bleeds) around 15 days back. On presentation the platelet counts were ~ 20,000 and we diagnosed the child as ITP (Immune Thrombocytopenic Purpura). The platelet counts improved dramatically after IVIG infusion, and we discharged the child after 2 days. Unusually, the child came back to us after 15 days with recurrent symptoms and again the Platelet counts were ~ 20,000. At this point of time I discussed the case with a Pediatric hemato-oncologist in PGIMER, and was told that nowadays they have become very liberal in NOT treating cases of ITP. According to him, even platelet counts as low as 5-10,000 may not need treatment unless they have active mucosal bleeding, since the risk of serious bleeds remains very low in children with acute ITP. This is certainly something that I was not aware of. In fact he went on to say, that ITP has now probably become a disease of the mind... in the mind of the patient, and in the mind of the doctor. He did agree that this approach was probably difficult for an individual doctor in Private Practice to adopt, but believes that this is the scientifically accurate approach.

Here is an interesting article that I found related to recurrent ITP.
Recurrent idiopathic thrombocytopenic purpura in childhood.
Haemophilia Center-Haemostasis Unit, Aghia Sophia, Children's Hospital, Athens, Greece.

Idiopathic thrombocytopenic purpura (ITP) is a common haematological disease during childhood, that usually has a benign course; however, literature on the recurrent form of the disease (rITP) is limited.

rITP was characterized by intermittent episodes of thrombocytopenia (TP) followed by periods of recovery, unrelated to therapeutic intervention. We retrospectively reviewed features of patients with rITP, diagnosed and systematically followed up at our center, during the period 1975-2004.

Forty-eight of 795 children with ITP (6.0 %) presented with rITP. The majority of patients (68.8%) had only one recurrence, whereas only one patient had four. A time interval between two episodes longer than 3 months (up to 96) was identified in 2/3 of episodes and less than 3 months in 1/3. The initial episode and the first recurrence mostly shared features of acute ITP; however, 22.9% of the episodes appeared with a chronic self-limited course. Bleeding manifestations were rare (18.6% of episodes) and mild, and they tended to occur in severely thrombocytopenic patients, mainly at the onset of the initial episode; intracranial hemorrhage (ICH) occurred in a toddler with short duration thrombocytopenia. Intravenous gamma globulin (IVIG) or corticosteroids were administered in 24.5% of episodes. None of the patients needed splenectomy. Conclusion: rITP is a rare, mild, self-limited type of ITP, although ICH may occur in a profoundly TP child. Recurrence may occur close or far apart to a previous isolated TP episode. The duration of episodes varies considerably from patient to patient and from episode to episode in the same patient. The pathogenesis of rITP still remains unclear. 

Pediatr Blood Cancer. 2008 Aug;51(2):261-4. doi: 10.1002/pbc.21569.

Comments: What I found interesting was the fact that 6 % kids with ITP would have recurrence, and 1/3rd would have recurrence within 3 months. Also rITP has a good prognosis in general, and serious bleeds are very rare. I believe that it is important to counsel parents regarding the uncommon risk of recurrent thrombocytopenia in this situation, especially when expensive treatment like IVIG is given to the patient.

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