CASE REPORT

Presented by: Rahila (070100129) Muhammad Danial Bin Mohd Nor (070100293) Supervisor: dr. Rita Evalina, Sp.A
Pediatric Department H Adam Malik General Hospital Medical Faculty of North Sumatera University Medan 2011

Idiopathic Thrombositopenic Purpura (ITP) Immune Thrombocytopenic Purpura Autoimmune Thrombocytopenic Purpura isolated thrombocytopenia with normal bone marrow and the absence of other causes of thrombocytopenia 2 types: acute and chronic

1 in 4 children with ITP will develop chronic ITP

Acute ITP usually follows an acute viral infections (1-4 weeks). caused by an antibody (IgG or IgM) that binds to the platelet membrane splenic destruction of antibody-coated platelets GP at the surface of thrombocyte in ITP : GP IIb-Iia, GP Ib, and GP V.

Clinical manifestation: petechiae and purpura epistaxis severe thrombocytopenia Diagnosis: clinical presentation the platelet count Bone marrow examination (-)

Bone marrow examination in ITP : increased megakaryocytes normal erythroid and myeloid elements Therapy: Steroids IVIG Anti-D globulin (WinRho SD) Splenectomy

To report a 5 months old baby with Idiopathic Trombositopenic Purpura

YP, 5 months baby, , admitted to Adam Malik Hospital on February 28th 2011 with main complain of bloody urine 3 x in this day. History of fall (-). History of fever (+) 3 days ago, intermittent, with antipyretic. Fever (-) today. Histories of bleeding (+) : gum bleeding, petechiae on his body. History of seizure (-),vomit (-),& diarrhea (-).

Coryza (+) since 2 days ago. History of birth : aterm, spontan, helped by midwife at home, cry immediately, cyanosis (-) BBW: 4300 gr, BBL was unknown. History of vitamin K administration (-).

10

History of massage (+) 3 days ago. Referred from Kumpulan Pare Hospital Tebing Tinggi with the diagnosis DHF grade II. He already had IVFD RL, adona AC, and sanmol syrup.

11

Physical examniation BW: 7.7kg, BL: 68.5cm BB/BL: 92,7% Consciousness: CM, temp: 36.5 C, anaemis (-), icteric (-), dyspnoe (-), cyanosis (-), oedema (-) Head Light reflexes (+/+), isochoric pupils, pale inferior conjungtiva palpebra (-/-). Normal nose and ears. Petechiae was found at his face, and stor cell (+) in his gums. No lymph node enlargement. SF, retraction (-). HR: 144 bpm, regular, murmur (-). RR: 30 tpm, regular, rhonchi or crackles (-) Soft and tenderness, peristaltic (+) N. Liver and spleen enlargement (-), petechiae (+).

Neck Chest

Abdomen

Extremities Pulse: 144 tpm regular, adequate P/V. CRT < 3, oedema (-), BP = 100/60mmHg, petechiae (+) Anogenital male, within normal limit
12

Diffential Diagnosis

ITP + suspect UTI ATP + suspect UTI Hematuria ec. Coagulation disorder ITP+ suspect UTI IVFD D5% 20 gtt/minute Coombs test, indirect & direct bilirubin, reticulocyte. Urine dipstick. Urine culture & sensitivity test. Blood culture & sensitivity test. Urinalysis. Consult to the nephrology.
13

Working Diagnosis Therapy Planning

Laboratory Finding (February 28th 2011) Examination Units Result Normal value

Hematology: Complete blood count (CBC): Haemoglobin Erythrocyte Leucocyte Haematocrit Platelet MCV MCH MCHC RDW Neutrophil Lymphocyte Monocyte Eosinophil g% 10/mm 10/mm % 10/mm fL pg g% % % % % % 10.10 4.03 13.20 30.00 49 74.30 24.90 33.50 12.90 26.10 60.40 9.48 3.01 10,7-17,1 3,75-4,95 6,0-17,5 38-52 217-497 93-115 29-35 28-34 14,9-18,7 37-80 20-40 2-8 1-6
14

Follow up (February 28th 2011) S: Bloody urine O: Consciousness : CM. T: 36,8C. BW: 7,7 kg. BL: 68,5 cm. BW/BL: 92,7%. Head Face: petechiae (+). Eye: light reflex (+/+), isochoric pupil, pale inferior conjungtiva palpebra (-/-). Ear and nose was normal and stor cells (+) in his gums. No lymph node enlargement. SF, retraction (-). HR: 140 bpm, reg, murmur (-). RR: 24 tpm, reg, rhonchi/crackles (-). Soft and tenderness, peristaltic (+) normal. No liver and spleen enlargement. Petechiae (+). Pulse: 140 tpm, regular, adequate pressure/volume CRT < 3. BP: 110/60 mmHg. Petechiae (+). Male, within normal limit DD: - ITP + suspect UTI. - ATP + UTI. - Haematuria ec. Coagulation disorder. - IVFD D5% (20 gtt/i) - Transamin inj. 100mg/8 hours/IV - Breast milk diet ad. Libitum

Neck Chest Abdomen Extremities Anogenital A:

P:

15

JENIS PEMERIKSAAN FAAL HEMOSTASIS PT + INR Kontrol Pasien INR APTT Kontrol Pasien WAKTU TROMBIN Kontrol Pasien

SATUAN HASIL RUJUKAN

detik detik detik detik detik detik detik

13.80 22.5 1.78 32.8 40.1 12.0 15.3

16

KIMIA KLINIK HATI AST/SGOT ALT/SGPT METABOLISME KARBOHIDRAT Glukosa Sewaktu: Glukosa Darah GINJAL Ureum Kreatinin Electrolyte Serum Electrolyte Natrium (Na) Kalium (K) Klorida (Cl) mEq/L mEq/L mEq/L 120 2.7 90 135-155 3.6-5.5 96-106
17

UL UL

14 14

< 38 < 41

mg/ dL mg/ dL mg/ dL

84.00 15.00 0.29

< 200 < 50 0,17-0,42

Advice from Hemato-Oncology Division on February 28th 2011: Therapy: Transamin inj. 100mg/8 hours/IV to overcome haemorrhage. Transfusion 2 units of FFP and 1 unit of thrombocyte. Advice: check direct and indirect bilirubin level, Coombs test, and reticulocyte. Urine dipstick : Blo: +++ Leu: +1, Nit: -, SG: 1,020 Ket: Uro: 0.2, Bil: Prot: +, pH: 6, Glu:
18

Follow up (March 1st 2011) S: Bloody urine (-) O: Consciousness CM. T: 37.6C. BW: 7,7 kg. BL: 68,5 cm. BW/BL: 92,7%. Head Face: petechiae (+). Eye: light reflex (+/+), isochoric pupil, pale inf. Conj. Palp (-/-). Ear and nose was normal and stor cells (+) in his gums. No lymph node enlargement. SF, retraction (-). HR: 130 bpm, reg, murmur (-). RR: 26 tpm, reg, rhonchi/crackles (-). Soft and tenderness, peristaltic (+) normal. No liver and spleen enlargement. Petechiae (+). Pulse: 130 tpm, regular, adequate pressure/volume CRT < 3. BP: 80/50mmHg. Petechiae (+). Male, within normal limit DD: - ITP + suspect UTI. - ATP + UTI. - Haematuria ec. Coagulation disorder. -IVFD D5% (20 gtt/i)

Neck Chest Abdomen Extremities Anogenital A:

P:

-Cefotaxime inj. 450mg/12 hours/IV.

- Transamin inj. 100mg/8 hours/IV - Breast milk diet ad. Libitum
19

Advice from Nephrology Division on March 1st 2011: Working Diagnosis: Suspect UTI. Therapy: Cefotaxime inj 450mg/12 hours/IV. Advice: Urinalysis and urine culture. Advice from Hemato-Oncology Division on March 1st 2011: Advice: Post transfusion full blood count, Coombs test, indirect and direct bilirubin level, and reticulocyte. His parents still not give a permission to perform the lab tests due to financial problem.

20

S: Bloody urine (-), Fever (-), Headache (-) O: Consciousness CM. T: 36.9C. BW: 7,7 kg. BL: 68,5 cm. BW/BL: 92,7%. Head Face: petechiae (+). Eye: light reflex (+/+), isochoric pupil, pale inf conj palp (-/-). Ear and nose : normal and stor cells (+) in his gums. No lymph node enlargement. SF, no retraction. HR: 120 bpm, regular, no murmur. RR: 22 tpm, regular, no rhonchi/crackles. Soft and tenderness, peristaltic (+) normal. No liver and spleen enlargement. Petechiae (+). Pulse: 120 tpm, regular, adequate pressure/volume CRT < 3. BP: 90/50mmHg. Petechiae (+). Male, within normal limit DD: - ITP+ susp. UTI. - ATP + susp. UTI. - Haematuria ec. Coagulation disorder. -IVFD D5% (20 gtt/i)

Neck Chest Abdomen Extremities Anogenital A:

P:

-Cefotaxime inj. 450mg/12 hours/IV.

- Transamin inj. 100mg/8 hours/IV - Breast milk diet ad. Libitum
21

Laboratory Finding (March 2nd 2011) Examination Units Result Normal value

Hematology : Complete blood count (CBC): Haemoglobin Erythrocyte Leucocyte Haematocrit Platelet MCV MCH MCHC RDW Neutrophil Lymphocyte Monocyte Eosinophil g% 10/mm % fL pg g% % % % % % 6.40 2.57 19.70 76.70 24.90 32.50 12.50 17.30 71.20 10.40 0.90 10,7-17,1 3,75-4,95 6,0-17,5 38-52 217-497 93-115 29-35 28-34 14,9-18,7 37-80 20-40 2-8 1-6
22

10/mm 11.29 10/mm 66

Advice from Hemato-Oncology Division on March 2nd 2011: Advice: BMP Parents were not ready to give a permission to perform the procedure. Patient was discharged from the hospital on March 2nd 2011 due to financial problem.

23

Teory

Case

People with ITP often have bruises or petechiae. Spontaneous bleeding such as nose bleeds, bleeding gums and small red/purple pinpoint spots in the mouth, blood in urine and bowel movements.

the patient has petechiae and bruise in his extremities, face, and abdomen. He also has bleeding gums and blood in urine

24

Teory

Case

Diagnosis : clinical presentation the platelet count often does not require a bone marrow examination. Full blood count was needed to rule out other conditions that may cause similar symptoms to ITP

Diagnosis: clinical manifestations (petechiae, bruise and spontaneous bleeding). From the laboratory findings, (low platelet count with normal RBC and WBC)
25

Teory

Case

Bone marrow examination was needed in diagnose of ITP to rule out an infiltrative disorder (leukemia), an aplastic process (aplastic anemia) and other disorder.

The physician has advised parents to perform bone marrow examination to rule out the DD, but the patients parents was not agree due to financial problem

26

Teory

Case

The direct Coombs' test is used to detect antibodies that are already bound to the surface of RBCs. The indirect Coombs' test looks for unbound circulating antibodies against a series of standardized RBCs.

In this case, the Coombs test was recommended by the physician, but it was not performed and result was unknown.

27

Teory
Most children do not need any treatment unless they have severe bleeding, and most children improve whether or not treatment is given. Therapy is seldom indicated for patelet counts > 30.000/mm3. For clinical bleeding or severe thrombocytopenia (platelet count < 20.000/mm3), therapeutic options include prednisone, IVIG or IV anti-D (WinRho SD), and splenectomy

Case

This patient was given supportive treatment with: IVFD D5% 20 gtt/i. Injection of Cefotaxime 450mg/12 hrs/IV Injection of Transamin 100 mg/8 hrs/IV Transfusion 2 units of FFP, & 1 unit of thrombocyte breast milk diet is given ad libitum

28

It has been reported a case of childhood ITP in a 5 months old baby. The diagnosis was established based on clinical manifestation and laboratory findings. The treatment was administered symptomatic treatment.

29

30