1056

Archives of Disease in Childhood 1992; 67: 1056-1058

CURRENT TOPIC

Guidelines for management of idiopathic thrombocytopenic purpura 0 B Eden, J S Lilleyman on behalf of the British Paediatric Haematology Group Children with idiopathic (immune) thrombocytopenic pupura (ITP) are almost invariably admitted to hospital for diagnosis. The usual presentation is an acute onset of bruising, purpura and petechiae or, less commonly, with mucosal bleeding from gums, nose, or rectum. Serious mucosal bleeding is unusual in uncomplicated ITP and should provoke a search for other causes. The majority of patients (80%) will provide a history of some infection, usually viral, within the preceding three weeks. The peripheral blood normally shows simple thrombocytopenia without other abnormality, although some idividuals have a modest relative or absolute lymphocytosis. In 75% of cases the platelet count returns to normal within 3 months (90% by 9-12 weeks), but a history of bruising for one to two weeks before diagnosis often suggests a more chronic course is likely. 1-3

Department of Paediatric Oncology, St Bartholomew's Hospital, West Smithfield, London ECIA 7BE 0 B Eden Haematology Department, Sheffield

Children's Hospital J S Lilleyman Correspondence

Professor Eden.

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Should bone marrow aspiration be done? The presence of associated symptoms or signs such as pallor, lassitude, pain (particularly in the abdomen or limbs), a limp, lymphadenopathy, or hepatosplenomegaly should lead to the suspicion of more serious pathology, and in such circumstances bone marrow aspiration is obviously essential. But the majority of patients present just with a short history of bruising, petechiae, or bleeding without other symptoms or signs. They show no pancytopenia and have a blood picture which does not suggest marrow infiltration or aplasia. For such children, provided no treatment is contemplated, urgent marrow examination is probably not necessary, but despite this some clinicans and parents still feel happier if infiltration and aplasia are immediately and absolutely excluded and so perform the procedure on all patients. A legitimate alternative approach is observation without treatment or investigation, especially if the platelet count is above 30x 109/l, and only to perform a bone marrow examination if a child fails to remit within two to three weeks or if treatment, especially with steroids, is contemplated. Other recommended investigations Childhood ITP is only rarely associated with other immunological disorders. Immunoglobulin concentrations (especially IgA and IgG) are worth measuring, and viral serology can occasionally be informative. Cytomegalovirus

infection should be considered in infants under 1 year old (perinatally acquired infection) and infectious mononucleosis in older children. Immune thrombocytopenia has been reported as the first manifestation of HIV infection in vertically transmitted and blood product associated infection. Clinical pointers from the history should alert the clinician to the necessity for exclusion of this cause of ITP and routine investigation of all patients is clearly not required. There is probably no need regularly to perform a Coombs's test or coagulation screen or to look for antinuclear factor (ANF) and DNA antibodies. ITP as a feature of systemic lupus erythematosus (SLE) is reported more commonly in adolescent girls and is usually associated with other stigmata of the disease. It is sometimes informative to check patients with chronic disease for these other autoimmune disorders. Finally, platelet antibody tests are surprisingly unhelpful for either diagnosis or management, certainly in acute ITP. They may be more useful if the disease progresses to chronicity (defined as lasting for more than six months). Platelet associated immunoglobulin assay is more helpful; but the test is impossible with very low platelet counts and not readily available. Should children with ITP stay in hospital? Once the diagnosis is confirmed there is usually no justification for keeping a patient in hospital until the platelet count rises. Exceptions depend on bleeding problems or social circumstances, and (to a lesser extent) whether the parents will be able to prevent fights or vigorous knockabout games. The risk of serious bleeding, in particular intracranial haemorrhage, is probably as small at home as in hospital. Confining children to bed or putting severe restrictions on their activity is difficult to achieve, of no proved benefit, and produces boredom in the patient and anxiety in the parents. The risk of intracranial haemorrhage, based on published series, is under 1%, but that risk persists throughout the time of profound thrombocytopenia (platelet count

Guidelines for management of idiopathic thrombocytopenic purpura. The British Paediatric Haematology Group.

1056 Archives of Disease in Childhood 1992; 67: 1056-1058 CURRENT TOPIC Guidelines for management of idiopathic thrombocytopenic purpura 0 B Eden,...
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