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Barak G, Demmler-Harrison G, Rossetti L, Tubman VN, Walimbe AS, Asaithambi R. Progressive Thrombocytopenia, Splenomegaly, and Abnormal Tone in an Infant With Growth Faltering. Pediatrics 2024; 154:e2023064048. [PMID: 38864107 DOI: 10.1542/peds.2023-064048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/13/2024] [Accepted: 02/20/2024] [Indexed: 06/13/2024] Open
Abstract
A 4-month-old full-term female presented with growth faltering associated with progressive feeding difficulty, rash, abdominal distension, and developmental delays. She was found to have disconjugate gaze, abnormal visual tracking, mixed tone, bruising, and splenomegaly on examination. Initial workup was notable for thrombocytopenia and positive cytomegalovirus (CMV) immunoglobulin G and immunoglobulin M antibodies. She initially presented to the infectious diseases CMV clinic, where she was noted to have severe malnutrition, prompting referral to the emergency department for hospital admission to optimize nutrition with nasogastric tube feeding and facilitate additional evaluation. An active CMV infection with viruria and viremia was confirmed, but elements of her presentation and workup including brain magnetic resonance imaging were not consistent with isolated CMV infection. To avoid premature diagnostic closure, a multidisciplinary workup was initiated and ultimately established her diagnosis.
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Affiliation(s)
- Gal Barak
- Texas Children's Hospital, Houston, Texas
- Baylor College of Medicine, Houston, Texas
| | | | - Linda Rossetti
- Texas Children's Hospital, Houston, Texas
- Corewell Health Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Venée N Tubman
- Texas Children's Hospital, Houston, Texas
- Baylor College of Medicine, Houston, Texas
| | - Ameya S Walimbe
- Texas Children's Hospital, Houston, Texas
- Baylor College of Medicine, Houston, Texas
| | - Rathi Asaithambi
- Texas Children's Hospital, Houston, Texas
- Baylor College of Medicine, Houston, Texas
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Abstract
Meropenem is a broad-spectrum carbapenem widely used to treat both Gram-positive and negative bacterial infections, including extended-spectrum beta-lactamase-producing microbes. We describe the occurrence of thrombocytopenia and hypersensitivity in a boy receiving intravenous meropenem for intra-abdominal sepsis secondary to perforated appendicitis. The patient developed a pruritic maculopapular rash with occasional petechiae, associated with severe thrombocytopenia, after 7 days of meropenem administration. Investigations for other causes of thrombocytopenia, including possible line sepsis, were unfruitful, and the thrombocytopenia did not resolve until cessation of meropenem. Drug-induced reactions should be considered in children receiving meropenem who present with a rash and thrombocytopenia.
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Affiliation(s)
- Joanna Cachia
- Department of Paediatrics, Mater Dei Hospital, Msida, Malta
| | - Paul Torpiano
- Department of Paediatrics, Mater Dei Hospital, Msida, Malta
| | - David Pace
- Department of Paediatrics, Mater Dei Hospital, Msida, Malta
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Ozdin M, Cokluk E, Yaylaci S, Koroglu M, Genc AC, Cekic D, Aydemir Y, Karacan A, Erdem AF, Karabay O. Evaluation of coagulation parameters: Coronavirus disease 2019 (COVID-19) between survivors and nonsurvivors. ACTA ACUST UNITED AC 2021; 67Suppl 1:74-79. [PMID: 34406297 DOI: 10.1590/1806-9282.67.suppl1.20200816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aims to investigate and compare the coagulation parameters of coronavirus disease 2019 (COVID-19) patients with mortal and nonmortal conditions. METHODS In this study, 511 patients diagnosed with COVID-19 were included. Information about 31 deceased and 480 recovered COVID-19 patients was obtained from the hospital information management system and analyzed retrospectively. Whether there was a correlation between coagulation parameters between the mortal and nonmortal patients was analyzed. Descriptive analyses on general characteristics of the study population were performed. Visual (probability plots and histograms) and analytical methods (Kolmogorov-Smirnov and Shapiro-Wilk test) were used to test the normal distribution. Analyses were performed using the SPSS statistical software package. RESULTS Out of 511 patients, 219 (42.9%) were females and 292 (57.1%) were males. There was no statistically significant difference between males and females in terms of mortality (p=0.521). In total, the median age was 67 (22). The median age was 74 (13) in the nonsurvivor group and 67 (22) in the survivor group, and the difference was statistically significant (p=0.007). The D-dimer, prothrombin time, international normalized ratio, neutrophil, and lymphocyte median age values with p-values, in the recovered and deceased patient groups were: 1070 (2129), 1990 (7513) μg FEU/L, p=0.005; 12.6 (2.10), 13.3 (2.1), p=0.014; 1.17 (0.21), 1.22 (0.19), p=0.028; 5.51 (6.15), 8.54 (7.05), p=0.001; and 0.99 (0.96), 0.64 (0.84), p=0.037, respectively, with statistically significant differences. CONCLUSIONS As a result of this study, D-dimer, prothrombin time, and international normalized ratio increase were found to be associated with mortality. These parameters need to be closely monitored during the patient follow-up.
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Affiliation(s)
- Mehmet Ozdin
- Sakarya University Education and Research Hospital, Medical Biochemistry Laboratory - Sakarya, Turkey
| | - Erdem Cokluk
- Sakarya University Education and Research Hospital, Medical Biochemistry Laboratory - Sakarya, Turkey.,Sakarya University Education and Research Hospital, Department of Medical Biochemistry -Sakarya, Turkey
| | - Selçuk Yaylaci
- Sakarya University Faculty of Medicine, Department of Internal Medicine - Sakarya, Turkey
| | - Mehmet Koroglu
- Sakarya University Faculty of Medicine, Department of Medical Microbiology - Sakarya, Turkey
| | - Ahmed Cihad Genc
- Sakarya University Faculty of Medicine, Department of Internal Medicine - Sakarya, Turkey
| | - Deniz Cekic
- Sakarya University Faculty of Medicine, Department of Internal Medicine - Sakarya, Turkey
| | - Yusuf Aydemir
- Sakarya University Faculty of Medicine, Department of Pulmonology - Sakarya, Turkey
| | - Alper Karacan
- Sakarya University Faculty of Medicine, Department of Radiology - Sakarya, Turkey
| | - Ali Fuat Erdem
- Sakarya University Faculty of Medicine, Anesthesiology and Reanimation - Sakarya, Turkey
| | - Oguz Karabay
- Sakarya University Faculty of Medicine, Department of Infectious Disease and Clinical Microbiology - Sakarya, Turkey
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Gurion R, Siu A, Weiss AR, Masterson M. Use of Recombinant Factor VIIa in a Pediatric Patient With Initial Presentation of Refractory Acute Immune Thrombocytopenic Purpura and Severe Bleeding. J Pediatr Pharmacol Ther 2012; 17:274-80. [PMID: 23258971 DOI: 10.5863/1551-6776-17.3.274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Severe bleeding in acute immune thrombocytopenic purpura (ITP) is rare but can cause significant complications to the patient. Here we report the case of a pediatric patient with acute ITP and hematuria refractory to anti-D immune globulin, high dose intravenous immunoglobulin G, and high dose steroids. Her hematuria was successfully treated with recombinant factor VIIa (rFVIIa). While further investigation on the use of rFVIIa in ITP is warranted, this case report contributes to the pediatric literature for its use during the course of an initial presentation of ITP with hemorrhagic complications.
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Affiliation(s)
- Reut Gurion
- Division of Pediatric Rheumatology, University Hospitals Case Medical Center, Rainbow Babies & Children's Hospital, Cleveland, Ohio
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Stiakaki E, Perdikogianni C, Thomou C, Markaki EA, Katzilakis N, Tsirigotaki M, Kalmanti M. Idiopathic thrombocytopenic purpura in childhood: twenty years of experience in a single center. Pediatr Int 2012; 54:524-7. [PMID: 22647082 DOI: 10.1111/j.1442-200x.2012.03606.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder with a variable clinical course. METHODS A retrospective analysis was carried out of ITP patients presenting to a pediatric hematology-oncology department during a period of 20 years, with a focus on treatment and outcome. RESULTS One hundred and twenty-four cases were recorded (mean patient age, 8.4 years). Forty-nine children (39.5%) had platelet counts <10,000/µL at diagnosis. No episode of severe bleeding was observed. Peak incidence was observed during spring and summer. Respiratory infections proceeded in 58% of cases. Treatment consisted of i.v. immunoglobulin (IVIG) in 93 children at four dosing schedules. Sixteen children received corticosteroids, 10 children received anti-D immunoglobulin and 14 received no treatment. Recovery was observed in 67% of children on IVIG and in 50% on anti-D globulin. Eight patients did not respond initially and received corticosteroids. Three children with refractory thrombocytopenia received anti-CD20 (rituximab). Fourteen children (11%) had persistent/chronic disease. In 10 of them recovery was observed in 13 months-8 years. Splenectomy was performed in six children with resistant/chronic disease. CONCLUSION ITP has a benign course in the majority of cases. Anti-D globulin can effectively be used as an alternative first-line treatment. Rituximab can successfully be used in refractory cases, while splenectomy has currently limited indications.
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Affiliation(s)
- Eftichia Stiakaki
- Department of Pediatric Hematology-Oncology, University of Crete, Heraklion, Crete, Greece
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Hematology and Oncology in Critical Illness. PEDIATRIC CRITICAL CARE STUDY GUIDE 2012. [PMCID: PMC7178863 DOI: 10.1007/978-0-85729-923-9_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This chapter will focus on a variety of hematologic issues pertinent to the care of critically ill children. This is an area of intense research with the pathophysiology underlying these clinical conditions becoming progressively better understood. This improved understanding has resulted in new therapeutic strategies that are being assessed in multicenter clinical trials. The chapter will begin by describing the incidence and pathophysiologic significance of anemia in the pediatric intensive care unit (PICU) providing a differential diagnosis of the many conditions that may present with anemia in this setting. The chapter will next consider disseminated intravascular coagulation (DIC) focusing on the pathophysiology of a condition that has been associated with much morbidity and mortality. The underlying conditions predisposing to DIC will be detailed as well as a number of treatment options that have been implemented in clinical trials. In addition to DIC, thrombocytopenia may be caused by a number of other clinical conditions important to the pediatric critical care provider. The clinical and prognostic significance of thrombocytopenia will be addressed and a focused differential diagnosis will be provided. Thrombotic disorders are becoming increasingly recognized in children and are a particular concern for the pediatric intensivist. The epidemiology of thromboembolism in children will be reviewed focusing on the conditions most commonly associated with these thromboses. Finally, a chapter on hematologic issues in the critically ill child would not be complete without a discussion of sickle cell disease. Acute chest syndrome, one of the most frequent complications of sickle cell disease resulting in the need for intensive care services, will be discussed in detail.
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Bryant N, Watts R. Thrombocytopenic syndromes masquerading as childhood immune thrombocytopenic purpura. Clin Pediatr (Phila) 2011; 50:225-30. [PMID: 21098529 DOI: 10.1177/0009922810385676] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Immune thrombocytopenic purpura (ITP) is the most common cause of thrombocytopenia in children and adolescents. However, there are a number of other diagnoses that are often mistaken for ITP. A 10-year retrospective chart review was performed at the Children's Hospital of Alabama to characterize ITP. Initially, 492 patients who had the coded diagnosis of ITP (ICD 287.3) were identified. However, 83 (17%) of patients were found to have alternative diagnoses on chart review. Of the 83 patients, 13 patients (3%) represented coding errors or study classification errors. The 70 remaining patients (14%) had an alternative explanation for their thrombocytopenia, consisting of 31 different diagnoses. The most common diagnoses were familial thrombocytopenia (10%), systemic lupus erythematosus (9%), hypersplenism (9%), neonatal alloimmune thrombocytopenia (7%), Wiskott-Aldrich syndrome (7%), or systemic infection (6%). In total, 16 of the patients (23%) were ultimately diagnosed with one of a number of congenital syndromes with concurrent thrombocytopenia. Although this review confirms that most children with thrombocytopenia are diagnosed with ITP, 14% of the study population manifested other diagnoses. The clinician evaluating a child with thrombocytopenia must keep an open mind about the possible diagnosis and perform a comprehensive and thoughtful evaluation based on the clinical picture. ITP must be a diagnosis of exclusion as misdiagnosis in a child with thrombocytopenia may have a significant impact on morbidity and mortality.
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Affiliation(s)
- Nichole Bryant
- Greenville Health System and University Medical Group, Greenville, SC, USA
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Kato K, Kobayashi C, Katayama Y, Moriyama N, Shiono J, Kudo K, Koike K, Aoki K, Fujisawa K, Okada M, Matsumoto M, Fujimura Y, Tsuchida M. Forty-two-day-old boy with acute idiopathic thrombocytopenic purpura. Pediatr Int 2010; 52:485-7. [PMID: 20723123 DOI: 10.1111/j.1442-200x.2010.03037.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Keisuke Kato
- Division of Pediatrics, Ibaraki Children's Hospital, Futaba-dai, 3-3-1, Mito, Ibaraki 311-4145, Japan.
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Park SM, Lee JH, Lee KS. von Willebrand Disease in Childhood Chronic ITP. THE KOREAN JOURNAL OF HEMATOLOGY 2008. [DOI: 10.5045/kjh.2008.43.4.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Sun Min Park
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ji Hye Lee
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kun Soo Lee
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
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Miale TD, Wong JYC, Ahmed I, Wagman LD. Multimodal management, including precisely targeted irradiation, in a severe refractory case of Evans syndrome. Pediatr Blood Cancer 2006; 47:726-8. [PMID: 16933267 DOI: 10.1002/pbc.20976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A challenging case of acute autoimmune thrombocytopenia (ITP) which evolved into a chronic refractory case of Evans syndrome over a period of more than 23 years is presented and may illustrate current therapeutic dilemmas now perplexing patients and clinicians. Newer modalities are being developed and their eventual role in the scheme of clinical management remains to be established. While this development unfolds, highly targeted radiotherapy was applied in this case to reduce platelet uptake by a refractory recurrent splenule with the goal of stabilizing the platelet count until promising investigational thrombopoietic agents or other newer, less toxic therapies might become available for wider application.
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MESH Headings
- Adult
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/radiotherapy
- Anemia, Hemolytic, Autoimmune/surgery
- Disease Management
- Female
- Humans
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/radiotherapy
- Purpura, Thrombocytopenic, Idiopathic/surgery
- Radiotherapy/instrumentation
- Radiotherapy/methods
- Recurrence
- Severity of Illness Index
- Splenectomy
- Syndrome
- Thrombocytopenia/drug therapy
- Thrombocytopenia/surgery
- Treatment Outcome
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Affiliation(s)
- Thomas D Miale
- Pediatric Hematology-Oncology Section, Fort Sanders Regional Medical Center, Knoxville, Tennessee 37950-0642, USA.
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Holterman AXL, Adams KN, Seeler RA. Surgical Management of Pediatric Hematologic Disorders. Surg Clin North Am 2006; 86:427-39, x. [PMID: 16580932 DOI: 10.1016/j.suc.2005.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Ai-Xuan L Holterman
- Department of Surgery, Division of Pediatric Surgery, University of Illinois at Chicago, 840 South Wood Street, M/C 958 Chicago, IL 60612, USA.
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Johnson LH, Gittelman M. Management of Bleeding Diathesis: A Case-Based Approach. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2005. [DOI: 10.1016/j.cpem.2005.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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