This post contains links to and excerpts from Primary Immune Thrombocytopenia (ITP) – CPS Podcast from Peds Cases*.
Here is a direct link to the Script.
- CPS Position Statement: Diagnosis and Management of typical, newly diagnosed primary immune thrombocytopenia (ITP) of childhood
- Podcast: Approach to Purpura
- Podcast: Approach to Acute Leukemia in Children
And here are the excerpts:
• Typical ITP can be diagnosed with a thorough history, physical exam, and review of lab investigations
• Diagnosis can be made in a well appearing child with isolated thrombocytopenia on CBC and normal peripheral smear.
• Any ‘red flags’ on history, exam, or investigations warrant consideration of alterative diagnoses, further evaluation, and referral to hematology.
• Management recommendations should be based on severity of symptoms and patient/family factors, and range from observation when bleeding is mild, to corticosteroids or IVIG in cases with moderate or severe bleeding
• Shared decision making with families should take place to create an individualized approach that tailors management to the individual’s specific needs.
Primary immune thrombocytopenia or ITP, is a condition characterized by immunemediated destruction of platelets. The condition most commonly affects children ages 2 to 5; however, this CPS statement [link above]can be applied to children aged 90 days old to 17 years of age. ITP typically presents as mild petechiae and bruising; although, some cases present
with more severe bleeding episodes.
Usually, the cause of ITP is not known; however, in some cases, preceding viral illnesses or other immune mediated phenomena are triggers. The incidence of ITP is 5 in 100,000
children per year. ITP is typically a self-limited illness, lasting less than 6 months in 75-80% of cases and approximately 90% of cases resolved by one year.
[The] differential diagnosis includes but is not limited to isolated thrombocytopenias such as ITP, coagulopathies such as von Willebrands disease, vasculitides such as HSP, trauma including non-accidental injury, malignancies such as leukemia, and infectious causes such as meningococcus.
Ok, so in summary, the key features that suggest a diagnosis of ITP are:
1. New onset petechiae, bruising, and/or bleeding in an otherwise healthy child
2. Isolated thrombocytopenia with an otherwise normal CBC and a normal peripheral smear
3. Absence of systemic symptoms or red flags to raise concerns for other diagnoses
Red flags on history include:
1. Constitutional symptoms, such as fevers, weight loss, and night sweats
2. Bone pain
3. Poor response to treatment
4. Recurrent thrombocytopenia
Red flags on physical exam include:
4. Signs of chronic illness
5. Unwell appearing child
Red flags in investigations include:
1. Unexplained abnormalities in hemoglobin, WBC or neutrophil count
2. Abnormalities in the peripheral smear
Presence of any of these red flags should prompt you to consider alternative diagnoses, such as coagulopathies, vasculitides, trauma, malignancies, and infectious causes, and to involve a pediatric hematologist.
Treatment options include observation, corticosteroids, and IVIG.