Let’s switch gears now to immune
This is an acquired cause of
an acute bleed in children.
ITP is really an autoimmune
attack against platelets.
The spleen clears the platelets
with the bound antibodies
and the platelet count typically
falls less than 20,000.
If a patient has 80,000 platelets,
it’s unlikely to be ITP.
Now, the majority of ITP
is going to be acute.
It’s going to be an autoimmune
disease that suddenly strikes.
The platelet count typically will
return to normal after about six months
and usually does not come back.
This disease is not usually chronic.
Many may resolve without
any therapy at all.
It’s usually associated with a previous
viral infection or perhaps a vaccination.
Now, this is to be compared
to the minority of cases
which are chronic ITP and
that’s about 20% of cases.
In this case, the ITP
persists more than 12 months
and it’s usually associated with some
underlying autoimmune disorder such as lupus.
These patients will generally appear with
acute bleeding without any known cause.
There is sometimes a
preceding viral illness,
like any acute ITP example
we gave previously.
These patients may have intracranial
hemorrhage, but that’s really rare.
Usually, you need less than 5,000 platelets
in order to have intracranial hemorrhage.
They may notice bruising.
They may have more severe nose bleeds
and you may notice a petechial rash on the
skin which is indicative of bleeding.
Diagnosis is made very simply by a CBC which
shows a platelet count less than 20,000
and nothing else
wrong with the CBC.
Additionally, the patient should have
no other physical exam findings.
For example, if a patient has a matted
area of lymph nodes in their neck,
this is probably lymphoma or leukemia
and this probably isn’t ITP.
So we want to diagnose other conditions
through a complete physical exam that
will then rule out ITP as the diagnosis.
So how do we manage these kids?
Well, we will check weekly CBCs to
track the severity of the disease.
If it’s not clear what’s
going on with this patient,
if we’re not convinced
this is ITP,
then we may get a bone marrow to make sure
that the other cell lines are looking okay.
In event of severe ITP, which is
platelet count of less than 10,000,
we only give platelets if
they’re actively bleeding.
This is because those platelets
are likely to be consumed quickly
by the autoimmune process.
We do want to avoid ibuprofen or any drug
that can prevent the clotting
cascade from recurring.
In patients with severe
ITP, we may give IVIg.
What IVIg does is it provides an
alternative target for the immune system.
Instead of consuming those immunoglobulins
that are bound to platelets,
the body is now busy consuming
which we have transfused
in the patient.
And remember, IVIg tends to stick around
for a while, three or four weeks,
and so we can get by
for a period of time.
One alternative to IVIg that
some people like to use
is if a patient is Rh positive, they can
give anti-D immunoglobulin or RhoGAM.
Now, RhoGAM is usually
given to pregnant women,
but in this case
we might use it.
Because the RhoGAM will stick
to those red blood cells
and again provide an alternative
target for the immune system
instead of attacking
in these patients,
they may get an anemia because now they
are, in fact, targeting the red blood cells
and so we should watch these
patients carefully in terms
of developing anemia by
getting weekly CBCs anyway.
Another alternative is steroids and
sometimes that can be helpful in reducing
the autoimmune component
of the disease.
Remember though, the therapy temporizes
the disease, it doesn’t cure it.
In the majority of cases,
it goes away on its own.
In the minority of cases, it’s
part of a bigger disease process
that we now have to
treat such as lupus.
So that’s a quick review of these
acquired bleeding problems in children.
Thanks for your time.