QuestionSBA
QuestionChoice
This would only be considered in patients with life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable; hence this would not be required
32145
c
Intravenous immunoglobulin
QuestionChoice
Platelet transfusions are generally reserved for patients with active life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable, and hence this would not be required
32146
d
Oral vitamin K
QuestionChoice
Glucocorticoids may be given to raise the platelet count if it needs to be raised acutely. However, in the absence of any clinically significant bleeding, there is no need for this
32147
e
Oral prednisolone
QuestionChoice
The patient has immune thrombocytopenic purpura (ITP). Patients usually present with an isolated low platelet count with normal coagulation profile, peripheral blood film and reticulocyte count. The negative DAT rules out autoimmune haemolytic anaemia, which may occur in conjunction with ITP (Evans syndrome). The general approach in stable patients without clinically significant bleeding would be to wait and observe, with safety net advice given to avoid contact sports, blood-thinning medications and to monitor for signs of worsening bleeding
32143
a
Wait and observe
QuestionChoice
Platelet transfusions are generally reserved for patients with active life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable, and hence this would not be required
32144
b
Platelet transfusion
QuestionComment
How do you distinguish this from HSP?
9933
QuestionComment
Dat scan is negative so no haemolytic anemia and in HSP, features include haemolytic anemia, aki and thrombocytopenia i thinkinggg ?
11224
User
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Suture Bradykinin
QuestionComment
HSP is an IgA mediated small vessel vasculitis whereas ITP is destruction of platelets. Therefore HSP would present with a palpable rash (ITP would not), as well as more systemic sx e.g. abdominal pain, arthralgia and haematuria. Platelets should not be low in ITP. 
16141
User
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Neoplasia Dominant
QuestionComment
platelets shouldn't be low in ITP? do you mean HSP?
16750
User
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Monoclonal Wilsons
User
subscriber
Abrasion DNA
QuestionComment
thought palpable rash was is HSP not ITP?
27713
User
subscriber
RNA Gas
QuestionComment
can't agree
60995
User
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Maya
QuestionComment
how is 3 days of nosebleeds not clinically significant :((
62318
User
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Acute Testiculitis
Concept
Chapter
# Summary 
 

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterised by a reduction in circulating platelets. In children, it usually follows a viral infection and is self-limiting. Primary investigation includes Full Blood Count (FBC), blood film and exclusion of differential diagnoses. Management generally involves a 'watch and wait' approach due to the high rate of spontaneous remission. In persistent cases, steroids are employed, and splenectomy may be considered in refractory cases.  
 

# Definition
 

Immune thrombocytopenia purpura (ITP) is an autoimmune condition, characterised by a reduction in the number of circulating platelets. It is a type II hypersensitivity reaction whereby the spleen produces antibodies directed against the glycoprotein IIb/IIIa or Ib-V-IX complex.
 

# Epidemiology
 

In children, ITP often presents as a self-limiting disease following a viral infection in approximately 60% of cases. It affects 4 in 100,000 children per year, with more girls affected than boys and with an average age at onset of 5.7 years. 
 

# Aetiology
 

ITP in children is often triggered by a viral infection or following immunisation. 

Secondary ITP is rare in children but it can be due to:

- Autoimmune conditions (i.e. systemic lupus erythematosus)
- Infections (i.e. H pylori and CMV)
- Medications
- Lymphoproliferative disorders 
 

# Signs and Symptoms
 

ITP typically presents with:
 

 - Easy or excessive bruising (purpura)
 - Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs
 - Prolonged bleeding from cuts
 - Spontaneous bleeding from the gums or nose - ITP presents with mucocutaneous bleeding (rather than e.g. haemarthrosis which is often associated with defects in the coagulation cascade like in haemophilia)
 - Blood in urine or stools
 - Unusually heavy menstrual flow in females 
 

# Differential Diagnosis
 

Differential diagnoses for ITP include aplastic anaemia, leukaemia, and thrombotic thrombocytopenic purpura. These diagnoses can be differentiated by their unique signs and symptoms:
 

 - **Aplastic anaemia**: Children would show symptoms of anaemia - including shortness of breath, rapid or irregular heart rate and pallor. They will also have increased bleeding and frequent or prolonged infections.
 - **Leukaemia**: Children will generally be more unwell with fatigue,  frequent infections, lymphadenopathy, easy bleeding or bruising and weight loss. 
 - **Thrombotic thrombocytopenic purpura**: This is a more severe condition, with purpura, fatigue, fever, thrombocytopenia, haemolytic anaemia, and neurological abnormalities.

In neonates, hereditary thrombocytopenia or ITP in the mother should be considered. 
 

# Investigations
 
The primary investigations for ITP include:
 

 - Full Blood Count (FBC)
 - Blood film
 - Inflammatory markers to check for active infection

Further tests may be done to exclude other differential diagnoses:

 - Bone marrow examination (biopsy), which is only required if the case appears atypical or there is suspicion of malignancy
 

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# Management
 

 * The management of ITP is generally conservative, with a watch-and-wait approach typically adopted due to the high rate of spontaneous remission. 
 * Tranexamic acid (TXA) may be used to help blood clot, particularly used for menorrhagia. 
 * For persistent cases, steroids (immunosuppressant) can be used for 4-7 days. 
 * IVIG can also be used as it is immunomodulatory, reducing antibody production. 
 * In cases that prove refractory for 12-24 months, splenectomy may be considered.
 * Platelet transfusions should be avoided unless there is life-threatening bleeding. This is because giving more platelets will increase the rate of platelet destruction.

Ibuprofen should be avoided in children with ITP. 
 
 
#  Complications

ITP is generally mild in children. Serious complications are rare but can include:

- Significant bleeds (affecting 3% of children with ITP)
- Intracranial haemorrhage in 1 in 300 children with ITP

These complications typically occur when platelet counts are less than 20, and occur in patients with pre-existing vascular abnormalities. 

# Prognosis 

ITP is generally self-resolving within weeks to months without intervention. However, up to 1 in 5 children will follow a chronic course. If recovery is not achieved by 6 months, a differential diagnosis should be considered, and a bone marrow aspirate may be needed. For some children, ITP can become chronic. 

ITP is typically an isolated event in children, with only 5% having a recurrence. 

 
# NICE Guidelines

[NICE Guidelines on Platelets - abnormal counts and cancer](https://cks.nice.org.uk/topics/platelets-abnormal-counts-cancer/) 
 

# References

[ITP Support Association - ITP in children](https://itpsupport.org.uk/itp-in-children/#:~:text=How%20common%20is%20ITP%20and,common%20in%20girls%20than%20boys.)

[Patient Info Immune Thrombocytopenic Purpura](https://patient.info/doctor/immune-thrombocytopenia-pro)
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Picture
A blood film showing the typical appearance of idiopathic thrombocytopenia.
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ITP - macrocytic platelets.jpeg
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2236
Immune thrombocytopenic purpura
Topic
29
Paediatrics
Wait and observe
6429
In stable patients with immune thrombocytopenic purpura (ITP) without significant bleeding, the general approach is to observe and monitor, providing safety net advice to avoid contact sports, blood-thinning medications, and watch for signs of worsening bleeding.
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Purpura.jpeg
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Topic
29
Paediatrics
A 10-year-old boy presents to A&E with a 3-day history of nosebleeds and palpable, non-blanching red spots on his arms and legs. (refer to image provided).



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He has no past medical history of note. He has otherwise been well apart from a recent cold two weeks ago. His mother says that he has not had any recent trauma and does not play any contact sports.



Investigations are as follows:



Full blood count:

||||
|--------------|:-------:|---------------|
|Haemoglobin|140 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|55x10<sup>9</sup>/L|150 - 400|
|Reticulocytes|1 %|0.2 - 2|




Coagulation screen:


||||
|---------------|:-------:|------------------------|
|Activated Partial Thromboplastin Time (APTT)|30  seconds|22 - 41|
|Prothrombin Time (PT)|12  seconds|10 - 12|
|Fibrinogen|0.4 g/dL|1.5 - 4.0|





Peripheral blood film:



  - Normal sized platelets, no clumping seen



Direct antiglobulin test (DAT): Negative



Which is the most appropriate management of his condition?
a