EASY BRUISING
History
Ahmed is a 2-year-old boy who presents to the paediatric rapid referral clinic with easy bruising. His mother states that over the last 2 days bruises have been appearing on his body spontaneously or with minimal trauma and that he also had two short nose bleeds the previous day. He is otherwise well but his mother says that he had a cold about 2 weeks ago. He has had no previous illnesses but had a circumcision at 2 months of age for religious reasons with no excessive bleeding. He is on no medication. There is no family history of bleeding disorders.
Examination
He is well, playing and apyrexial. There is no pallor. He has widespread purpura and bruising over the flexor and extensor surfaces of all four limbs, trunk and face. There is some blood crusted around his nose. There is no lymphadenopathy or hepatosplenomegaly. There are no respiratory or cardiological signs and there are no joint abnormalities.
INVESTIGATIONS
Normal
Haemoglobin 10.2 g/dL 10.5–14.0 g/dL
White cell count 9.6 109/L 5.0–15.0 109/L
Neutrophils 4.2 109/L 1.7–7.5 109/L
Platelets 6 109/L 150–400 109/L
Clotting screen Normal
Urea and electrolytes Normal
C-reactive protein 5 mg/L 6 mg/L
Blood film – large (young) platelets; no blasts seen
Urine dipstick
Blood – negative
Protein – negative
Leucocytes – negative
Nitrites – negative
Questions
• What is the diagnosis?
• What are the causes of purpura in a child?
• Are any further investigations necessary?
• What is the treatment?
Medicine
The diagnosis is idiopathic thrombocytopenia purpura (ITP). This condition is caused by antibodies to platelets. The history of a viral infection 2 weeks prior to the onset of the ITP is typical, as is the isolated, very low platelet count in an otherwise well child.
Causes of purpura in a child
• Infections
• Thrombocytopenia secondary to ITP, leukaemia or chemotherapy
• Henoch–Schönlein purpura (HSP) and other vasculitides
• Vomiting or coughing
• Trauma
• Clotting disorders
• Drugs, e.g. steroids
Meningococcal septicaemia is an important cause of purpura. However, the absence of a temperature and the normal inflammatory markers make this diagnosis unlikely. Viral infections, e.g. cytomegalovirus, can cause purpura. The lesions are usually small (2 mm) and the diagnosis is often made by elimination. The absence of signs such as hepatosplenomegaly and blasts in the film makes leukaemia unlikely. HSP is characterized by a purpuric rash on the extensor surfaces of the lower limbs, joint swelling and blood and/or protein in the urine. Children with vomiting and/or coughing can get purpura in the drainage distribution of the superior vena cava. Accidental or non-accidental trauma does not present with generalized purpura. Clotting disorders more frequently present with haemarthrosis. No further investigations are required. A bone marrow examination is only indicated if there are atypical clinical features which suggest possible leukaemia. It should also be performed prior to steroid treatment to definitely exclude leukaemia that may be partially treated by steroids. Treatment is controversial. Most doctors would not treat Ahmed. Approximately 4 per cent of children with ITP have serious symptoms such as severe epistaxis or gastrointestinal bleeding. The most serious complication is an intracranial haemorrhage, the incidence of which is 0.1–0.5 per cent. The indications for treatment are based on symptoms and not on the platelet count alone. If the child has mucous membrane bleeding and extensive cutaneous symptoms, prednisolone should be administered. Intravenous immunoglobulin can raise the platelet count more rapidly than steroids. However, it carries the risks of pooled blood products and has side-effects, e.g. headache. It should be reserved for the emergency treatment of patients with serious bleeding. Platelet transfusions are only indicated in the case of an intracranial haemorrhage or to treat life-threatening bleeding. Splenectomy is rarely needed. Activities with a high risk of trauma should be avoided. Medication, such as ibuprofen, that can affect platelet function should also be avoided.
A repeat full blood count should be performed at 7–10 days to ensure that there is no evolving bone marrow disorder, e.g. aplasia. ITP is usually a self-limiting disorder. Fifty per cent resolve in 2 months, 75 per cent in 4 months and 90 per cent in 6 months.
KEY POINTS
• Treatment in ITP should be guided by symptoms rather than the platelet count.
• The most serious complication is an intracranial haemorrhage.
• Meningococcal septicaemia is an important cause of purpura that requires urgent treatment.
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