The changes in our understanding of ITP biology and our better appreciation of the natural history have resulted in a change in the nomenclature to immune thrombocytopenia (not immune thrombocytopenic purpura or idiopathic thrombocytopenic purpura), although the acronym remains ITP. Seventy-five percent of children will have platelet counts > 100,000 by 3 months from diagnosis, and 85 percent will resolve by 12 months. However, in most children with ITP the risk of bleeding is low, and treatment is rarely needed initially. Eltrombopag was approved for use in children in 2015. Novel therapies, which have recently been FDA-approved in adult chronic ITP management (romiplostim and eltrombopag), target platelet production. Treating the underlying immune dysregulation was the mainstay of prior therapy. ITP is an autoimmune process triggered most often by antecedent viral infection or vaccination (MMR vaccine has been most commonly implicated). In fact, although data is primarily retrospective, examination of large cohorts of patients presenting with leukemia shows that none of them presented with ITP. Parents and practitioners are always concerned about malignancy, in particular leukemia, but this is rare in isolated severe thrombocytopenia. When screening labs and history reveal an isolated thrombocytopenia, there is only one diagnosis that is most likely: immune thrombocytopenia (ITP). The differential of petechial rash in a well toddler is broad, but when combined with sudden appearance of bruising, it becomes more limited to include non-accidental trauma, Henoch-Schönlein purpura (HSP), and immune thrombocytopenia. The hemoglobin was 11.1 gm/dL, the WBC was 10.1/mcL with a normal differential, and there were no white cell abnormalities on review of the smear. An immature platelet fraction was elevated at 22 percent and there were giant platelets present on review of the peripheral smear ( see Figure 1). Discussionįigure 1: Giant platelets visible on a peripheral smear A CBC was normal except for a platelet count of 5K. There is no family history of any bleeding disorders, and he has not had a previous history of bleeding problems. He has no lymphadenopathy or hepatosplenomegaly. Physical exam is remarkable for the lack of other findings beyond the bruising, particularly of the extremities with some raised bruises of the anterior lower extremities and diffuse petechiae. He has had no fevers, no weight loss, no change in appetite or activity. The rash is petechial and most pronounced in the inguinal region, but also along the diaper line at the waist and more diffusely throughout the body. He presents today because of a red, pinpoint rash on his diaper creases and belly that has been spreading. He has not had any gingival bleeding or epistaxis, and no blood has been noted in his diapers. A 20-month-old previously healthy male presents to primary care with a history of a few weeks of bruising noted by the parents on the extremities, which are appearing without significant trauma.
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