Idiopathic thrombocytopenic purpura in children

Clinical and laboratory predictors of chronic immune thrombocytopenia in children: a systematic review and meta-analysis

Childhood immune thrombocytopenia (ITP) is a rare autoimmune bleeding disorder. Most children recover within 6 to 12 months, but individual course is difficult to predict. We performed a systematic review and meta-analysis to identify predictors of chronic ITP. We found 1399 articles; after critical appraisal, 54 studies were included. The following predictors of chronic ITP in children, assessed in at least 3 studies, have been identified: female gender (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.04-1.31), older age at presentation (age ≥11 years; OR 2.47, 95% CI 1.94-3.15), no preceding infection or vaccination (OR 3.08, 95 CI 2.19-4.32), insidious onset (OR 11.27, 95% CI 6.27-20.27), higher platelet counts at presentation (≥20 × 10(9)/L: OR 2.15, 95% CI 1.63-2.83), presence of antinuclear antibodies (OR 2.87, 95% 1.57-5.24), and treatment with a combination of methylprednisolone and intravenous immunoglobulin (OR 2.67, 95% CI 1.44-4.96). Children with mucosal bleeding at diagnosis or treatment with intravenous immunoglobulin alone developed chronic ITP less often (OR 0.39, 95% CI 0.28-0.54 and OR 0.71, 95% CI 0.52-0.97, respectively). The protective effect of intravenous immunoglobulin is remarkable and needs confirmation in prospective randomized trials as well as future laboratory studies to elucidate the mechanism of this effect.

Bleeding severity as an important outcome in childhood immune thrombocytopenia

Over the years pediatric hematologists have continued to debate whether pharmacotherapy or clinical observation should be employed as initial management in childhood immune thrombocytopenia (ITP). Delineating the fundamental elements of heterogeneity in bleeding manifestations in childhood ITP has proven to be a complicated task. Efforts to classify the impact of hemorrhage in ITP based on platelet count have been problematic. Factors beyond relying on a laboratory measurement as a surrogate marker of disease severity need to be considered. What is needed to better guide therapeutic decision-making is a clinically relevant and evidence-based measure of bleeding severity. In this special supplement, the history of therapeutic management in ITP and prior attempts to grade or quantify hemorrhage will be reviewed.

Demographic data, natural history, and prognostic factors of idiopathic thrombocytopenic purpura in children: a multicentered study from Argentina

BACKGROUND

Demographics, outcome, and management of idiopathic thrombocytopenic purpura (ITP) in children present differences between countries. Although several factors influence outcome, it is impossible to predict at diagnosis which patients will have acute or chronic disease. High rates of spontaneous remission in chronic ITP have been reported.

PROCEDURE

Data concerning 1,683 patients with ITP diagnosed from 1981 to date are presented; outcome was evaluated in 1,418 children.

RESULTS

Remarkable presenting features were an incidence peak in the first 2 years of age and male predominance in patients <24 months of age. Three age groups with different recovery rates (P < 0.001) were established (2-12 months: 89.8%; 1-8 years: 71.3%; 9-18 years: 49.0%). Platelet count <10 x 10(9)/L and history of previous illness were associated with higher remission rates only in patients >12 months of age. The score developed by the NOPHO Group showed a predictive value of 83.9% for acute ITP. Spontaneous remission between 6 months and 11 years from diagnosis was achieved by 107 of 325 (32.9%) non-splenectomized children with chronic ITP, and in 44.9% of them between 6 and 12 months from diagnosis.

CONCLUSIONS

Age and score were main prognostic factors. Infants <1 year of age are a special group with a brief course and very high recovery rate that are not influenced by other prognostic factors. Definition of groups based on age and scoring could be useful to establish differential management guidelines. The cut-off value to define chronic ITP should be changed to 12 months.

Recurrent idiopathic thrombocytopenic purpura in childhood

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) is a common haematological disease during childhood, that usually has a benign course; however, literature on the recurrent form of the disease (rITP) is limited.

PROCEDURE

rITP was characterized by intermittent episodes of thrombocytopenia (TP) followed by periods of recovery, unrelated to therapeutic intervention. We retrospectively reviewed features of patients with rITP, diagnosed and systematically followed up at our center, during the period 1975-2004.

RESULTS

Forty-eight of 795 children with ITP (6.0 %) presented with rITP. The majority of patients (68.8%) had only one recurrence, whereas only one patient had four. A time interval between two episodes longer than 3 months (up to 96) was identified in 2/3 of episodes and <3 months in 1/3. The initial episode and the first recurrence mostly shared features of acute ITP; however, 22.9% of the episodes appeared with a chronic self-limited course. Bleeding manifestations were rare (18.6% of episodes) and mild, and they tended to occur in severely thrombocytopenic patients, mainly at the onset of the initial episode; intracranial hemorrhage (ICH) occurred in a toddler with short duration thrombocytopenia. Intravenous gamma globulin (IVIG) or corticosteroids were administered in 24.5% of episodes. None of the patients needed splenectomy.

CONCLUSION

rITP is a rare, mild, self-limited type of ITP, although ICH may occur in a profoundly TP child. Recurrence may occur close or far apart to a previous isolated TP episode. The duration of episodes varies considerably from patient to patient and from episode to episode in the same patient. The pathogenesis of rITP still remains unclear.

Prevalence of elevated antithyroid antibodies and antinuclear antibodies in children with immune thrombocytopenic purpura

The prevalence and significance of autoantibodies found at the time of diagnosis of childhood ITP were studied to correlate their presence with risk for development of chronic ITP. Children presenting with acute or chronic ITP to The James Whitcomb Riley Hospital for Children between July 1993 and September 1994 were tested at study entry and followed for the presence of antithyroid antibodies (ATA), antinuclear antibodies (ANA), Coombs' reactivity, and anti-human immunodeficiency virus (HIV) antibodies. Grouped data were evaluated for significance using Fisher's exact t-test. Thirty-one patients were enrolled in the study with a median age of 8 years (range 17 months-16 years) and male-to-female ratio of 1:1.8. Forty-two percent of these children had an acute course of ITP, and 58% of children had a chronic course of ITP. Of children with acute ITP, three (23%) of the patients had an acute nonplatelet autoantibody detected. Of the children with chronic ITP, six (33%) of the children had at least one abnormal antibody value. Five children (16%) tested positive for ATA: 2 children with acute ITP and 3 with chronic ITP. Five children had positive ANA, and of these children, 4 (80%) had chronic ITP. Sixty-seven percent of patients testing positive for autoantibodies were female, and 67% of all patients were 12 years of age or older. Three patients, 1 with acute ITP and 1 with chronic ITP, had insignificant abnormal thyroid function tests (these children had minimally elevated T3 with otherwise normal thyroid function, and none of these children had autoantibodies). No patients included in the study tested positive for HIV. Our results suggest that patients with acute ITP who also have other autoantibodies may be more likely to develop chronic ITP than those lacking these autoantibodies. Larger studies are needed to determine whether the presence of ATA or ANA is predictive of clinically significant autoimmune disease.

The pros and cons of drug therapy for immune thrombocytopenic purpura in children

This article discusses the pros and cons of drug therapy for immune thrombocytopenic purpura in children.

Childhood chronic immune thrombocytopenic purpura: unresolved issues

Chronic immune thrombocytopenic purpura (ITP), defined as a platelet count of below 150 x 109/L persisting for more than 6 months from onset of illness, occurs in approximately 20% to 25% of children with acute-onset ITP. A small subset of these patients (approximately 5%) will manifest symptomatic, severe thrombocytopenia (platelet counts <20 x 109/L) at 1 year or longer following diagnosis, and may require splenectomy. Complete/partial response rates following splenectomy in children with primary chronic ITP are of the order of 70% to 75%; response rates are lower in children with secondary ITP and those with complex autoimmune cytopenias (e.g., Evans syndrome). Laparoscopic splenectomy is increasingly preferred over open splenectomy. Patients should be immunized with the pneumococcal, Haemophilus type b and meningococcal vaccines before splenectomy; the duration of postsplenectomy antibiotic prophylaxis using penicillin or an equivalent antibiotic is controversial but should be at least until 5 years of age and for a minimum of 1 year postsplenectomy. Some experts advocate life-long antibiotic prophylaxis. Treatment of postsplenectomy failures is a challenge; partial/complete remission rates are low, and multimodality therapy may be more efficacious than monotherapy. The presence of an accessory spleen should be sought and removal considered if present. The role of newer treatment modalities such as anti-CD 20 remains to be established.

Low-dose versus high-dose immunoglobulin for primary treatment of acute immune thrombocytopenic purpura in children: results of a prospective, randomized single-center trial

PURPOSE

To investigate the efficacy and side effects of two different intravenous immunoglobulin (IVIG) dose regimens for the initial treatment of childhood acute immune thrombocytopenic purpura (ITP).

METHODS

Thirty-four consecutive patients with a clinical diagnosis of acute ITP and a platelet count below 20x10(9)/L were randomized to receive either 1 g/kg body weight (n=17; group A) or 0.3 g/kg body weight (n=17; group B) IVIG per day for 2 consecutive days (total dose 2 g/kg and 0.6 g/kg).

RESULTS

Fifteen of the 17 patients (88.2%) in group A and 13 of the 17 patients (76.5%) in group B achieved a platelet count of more than 20x10(9)/L within 72 hours. The increase in platelet counts on day 2 and 3 was more pronounced in the high-dose group. Two patients in the high-dose group and four in the low-dose group were non-responders. Chronic disease occurred in three patients receiving 2 g/kg IVIG and in five patients receiving 0.6 g/kg IVIG. Side effects of IVIG administration were more common in the high-dose group.

CONCLUSIONS

The present study showed that platelet counts increased more rapidly after high-dose IVIG administration within the first 72 hours, although a platelet count of more than 20x10(9)/L can be achieved also with low-dose IVIG in most children with acute ITP. For patients with very low platelet counts, doses higher than 0.6 g/kg seem, therefore, to be more effective.

Intracranial hemorrhage in immune thrombocytopenic purpura: a retrospective analysis

PURPOSE

To ascertain characteristics of children with immune thrombocytopenic purpura (ITP) and intracranial hemorrhage (ICH).

METHODS

The authors identified 75 published cases of ICH in children with ITP by review of the literature from 1954 to 1998. Data pertaining to the ICH was recorded for age, gender, time from diagnosis of ITP (to ICH), platelet count, head trauma or arteriovenous malformation, concomitant medications, associated infections, other bleeding manifestations, prior treatment, and outcome. RESULTS Sixty-two cases represented 6 months to 20 years of age; 65% of patients were female. The median time from the diagnosis of ITP to ICH was 32 days (range 0 days to 8 years). Fifty of 69 ICH cases (72%) occurred within 6 months of diagnosis, but only 7 (10%) occurred within 3 days of diagnosis. The platelet count was less than 10000/microL in 71.4% of the cases. Treatment prior to the ICH was primarily steroids but also included intravenous immune globulin (IVIG), splenectomy, and others (interferon, azathioprine, or vincristine). There was no difference in mortality of patients before (56%) or after (54%) 1980.

CONCLUSIONS

A very low platelet count appears permissive but not sufficient for ICH to occur in children with ITP. ICH occurs more commonly in acute ITP but can occur years after diagnosis. A significant number of patients develop an ICH despite having already initiated steroid treatment of ITP.

Serum immunoglobulin levels at onset: association with the prognosis of childhood idiopathic thrombocytopenic purpura

Between 1981 and 2000, 87 patients with new diagnoses of idiopathic thrombocytopenic purpura (ITP) were admitted to the pediatric department of Kobe City General Hospital or Nishi-Kobe Medical Center. The patients' clinical records were analyzed for the relationships of disease outcome to serum immunoglobulin levels and other factors, including sex, onset age, and initial platelet counts. The disease of 22 patients became chronic, and of the 65 patients with an acute form of the disease, 27 exhibited levels of immunoglobulin G (IgG), IgA, or IgM above the 97.5% confidence limits of the age-matched control subjects. However, only 2 patients with the chronic form of the disease showed elevated serum immunoglobulin levels. The presence of antecedent specific viral infections was also associated with the acute disease form. In predicting the prognosis of childhood ITP, high serum immunoglobulin levels at initial presentation can be considered a good prognostic marker for the acute form of the disease.

Acute immune (idiopathic) thrombocytopenic purpura in childhood

Acute immune (idiopathic) thrombocytopenic purpura (ITP) in childhood is most commonly a self-limiting condition with unexplained onset and resolution. In cases of severe thrombocytopenia, or situations where the condition persists beyond 6 months, treatment may be required to minimize the danger of life-threatening intracranial hemorrhage. Nonsurgical treatment options include corticosteroids, intravenous gammaglobulin (i.v.Ig), or anti-D. Specific indications, benefits, and limitations of these modalities are discussed, with recommendations for future directions in therapy.

Novel approaches to refractory immune thrombocytopenic purpura

Chronic immune thrombocytopenic purpura (ITP) is an organ-specific autoimmune bleeding disorder in which autoantibodies are directed against the individual's own platelets, resulting in increased Fc-mediated platelet destruction by macrophages in the reticuloendothelial system. Although ITP is primarily mediated by IgG autoantibodies, the production of these autoantibodies is regulated by the influence of T lymphocytes and antigen-presenting cells (APC). There is evidence that enhanced T-helper cell/APC interactions in patients with ITP may play an integral role in IgG antiplatelet autoantibody production. New therapies may improve platelet production, decrease platelet antibody production, and decrease monocyte function and/or B-cell and T-cell activities. Understanding these cellular immune responses in ITP may lead to the development of more specific immunoregulatory therapies for the management of this disease.

Ethnicity and environment may affect the phenotype of immune thrombocytopenic purpura in children

Little is known about the influence of environmental and ethnic factors on the epidemiology of immune thrombocytopenic purpura (ITP). Therefore we compared the initial presentation and condition after 6 mo in 90 Vietnamese and 89 German and Swiss children with newly diagnosed ITP. Data from the two cohorts were collected within the same time period. No differences in age and sex were observed between the Asian and European cohorts, but significant differences between initial platelet count, the occurrence of dry versus wet bleeding symptoms, and infection preceding the onset of ITP were found. Children who had chronic ITP also differed with respect to platelet count and postinfectious state, but not initial bleeding type. In addition, chronic ITP occurred more often than expected with a male to female ratio of 1.2 in Vietnam and 2 in Germany and Switzerland. The data support the potential influence of environmental or ethnic factors on the different aspects of ITP, and point to the need for further epidemiologic investigations.

Chronic childhood idiopathic thrombocytopenic purpura

Childhood idiopathic thrombocytopenic purpura (ITP) is a largely trivial disorder from which over 95% of children sooner or later recover spontaneously, and for most of whom the risks of unnecessary or ineffective therapy are arguably greater than those of the untreated disease. There are, however, a few patients who continue to have very low platelet counts and remain symptomatic for many months or years. They are rare, and they present difficult management problems. Splenectomy is probably the most effective treatment but is also the most dangerous and is not always successful. It is also irreversible. Most other regimens are either ineffective, unacceptably toxic, or both. Planning management for an individual patient requires a realistic risk:benefit appraisal, a process that is impeded by inadequate epidemiological data and a scarcity of large-scale randomized clinical trials. International collaborative studies may help in the future.

Approach to the investigation and management of immune thrombocytopenic purpura in children

Childhood immune thrombocytopenic purpura (ITP) is typically a benign, self-limiting disorder occurring in young (<10 years of age) previously healthy children. More than 80% of such children enter a complete sustained remission within a few weeks to a few months of initial presentation, irrespective of any therapy given. The major concern is the small but finite (0.1 to 0.9%) risk of intracranial hemorrhage, which occurs in children with very low platelet counts (<20 x 10(9)/L), and is the justification for treatment to increase the circulating platelet count. Effective treatment strategies are single-dose intravenous immunoglobulin G (IVIgG; approximately 1 g/kg) and medium to high-dose corticosteroids, administered orally or parenterally. The necessity for initial bone marrow aspiration and hospitalization continues to be debated. In children with chronic ITP, defined by persistence of thrombocytopenia for > or =6 months, splenectomy should be considered for the relatively small subgroup with symptomatic, severe thrombocytopenia who have either failed an adequate trial (> or = 12 months) of primary therapy (IVIgG, intravenous anti-D, corticosteroids) or are intolerant of such therapy. Laparoscopic splenectomy is preferred over open splenectomy. Children who fail to respond to splenectomy ( < or = 20% of cases) should be evaluated for the presence of accessory spleens; their management is often difficult and must be individualized. In severe refractory cases, second-line therapies (such as azathioprine or vinca alkaloids) need to be considered. Secondary ITP in children is relatively rare and is sometimes associated with other autoimmune cytopenias (Evan's syndrome, ITP with autoimmune neutropenia). These cases often respond poorly to conventional medical therapies and response rates to splenectomy are considerably lower than in children with primary chronic ITP.

Elective splenectomy in children with idiopathic thrombocytopenic purpura

PURPOSE

The aim of this study was to review the safety and efficacy of elective splenectomy in children with idiopathic (immune) thrombocytopenic purpura (ITP).

METHODS

The authors reviewed the medical records of children with ITP treated with elective splenectomy at Children's Medical Center of Dallas since 1961. Indication for splenectomy was symptomatic thrombocytopenia unresponsive to medical management.

RESULTS

Thirty-eight evaluable patients who had elective splenectomy for ITP were identified. Twenty-one (55%) were girls and 17 (45%) were boys. Twenty-two had splenectomy since January 1990. Age at diagnosis ranged from 6 months to 15.9 years (median 9 years), and age at splenectomy ranged from 3.6 to 16.4 years (median 11.8). Laparoscopic splenectomy was performed in 11 patients. No patient died and only one (2.6%) had postoperative hemorrhage. There were no other complications related to surgery. No cases of postsplenectomy sepsis were observed. At follow-up ranging from 1 month to 19.9 years (median 2.1 years), 29 patients (76.3%) had a normal platelet count (>150 x 109/L) and 4 (10.5%) had a platelet count between 50 and 150 x 109/L. Only two of the five (13.2%) remaining patients who continued to have a platelet count less than 50 x 109/L had hemorrhagic manifestations necessitating intermittent therapy with corticosteroids.

CONCLUSION

Laparoscopic or open splenectomy is a safe and effective procedure for children with chronic or refractory ITP and should be considered when medical management fails or causes excessive toxicity.

Treatment options for chronic immune (idiopathic) thrombocytopenia purpura in children

Immune (idiopathic) thrombocytopenic purpura (ITP) in children is usually acute and self-limiting, but may become chronic in 10% to 30% of patients. Salient issues in the treatment of childhood chronic ITP (cITP) include the following: the choice of immunomodulatory agent; the child's desire for unrestricted physical activity; interventions to avoid or defer splenectomy; and, finally, choosing when (and how) to perform splenectomy. Treatment for children with cITP during childhood usually is extrapolated from that for acute ITP. Treatment with pooled intravenous immunoglobulin (IVIg) and anti-D immunoglobulin often gives an acute response followed by a predictable decay of platelet count. Corticosteroids usually lead to a platelet increase; however, the associated adverse effects of chronic usage are generally unsatisfactory for most children and adolescents. With pulsed, high-dose corticosteroids, a durable platelet response is the exception, not the rule. More aggressive immunosuppression is usually reserved for patients who are symptomatic and refractory to the above treatments, Including splenectomy. Although the estimated success rate ranges from 70% to 90%, the long-term outcome of splenectomy in children with cITP in not well described. In addition, the risk of fatal postsplenectomy infections is significant. A familiar initial strategy among pediatric hematologists thus involves deferral of splenectomy with the reasonable possibility of spontaneous recovery. Corticosteroids, anti-D, and IVIg are effective, temporizing medical alternatives to splenectomy in treating cITP in children. Quality-of-life measurements in children with cITP may help to stimulate the development of new approaches.

Immune thrombocytopenic purpura ITP

Immune thrombocytopenic purpura ITP is characterized by early platelet destruction due to an imbalanced immune response. In acute ITP, a transient increase of HLA-DR molecules has been detected while in individuals with chronic ITP, in addition, increased serum concentrations of IL-2 and other cytokines reflecting in vivo T-cell activation have been observed. Clinically, the hemorrhagic manifestation of ITP rather than the platelet count should define the indication for active intervention. In a staging system a patient with stage III has bleeding signs and platelet counts below 10 or 20 x 10(9)/L and needs treatment, a patient with stage II should be treated on an individual level (prevention of bleeding) and a patient with stage I (no bleeding, platelet count above 50 x 10(9)/L) should be observed only.

The spectrum of Evans' syndrome

Eleven patients (10 boys, one girl) with Evans' syndrome with a median follow up time of 8.0 years were evaluated retrospectively. Six patients had either persistent hepatosplenomegaly or generalised lymphadenopathy, or both. In five patients, an increase in lymph node and/or spleen size was observed during the exacerbations of cytopenias. Seven patients had quantitative serum immunoglobulin abnormalities at the time of presentation. There were associated systemic manifestations in nine patients. Various forms of treatment were used with mixed results. Four patients died from sepsis and haemorrhage; four had complete recovery--two after splenectomy. These findings show that Evans' syndrome is a heterogeneous disorder with significant morbidity and mortality. High incidence of quantitative serum immunoglobulin abnormalities, lymphoid hyperplasia, and associated systemic manifestations suggest that Evans' syndrome may represent a stage of a more broad spectrum, generalised immune dysregulation.

Current controversies in the management of idiopathic thrombocytopenic purpura during childhood

Both acute and chronic ITP in children are generally benign conditions. Few patients develop serious complications or long-term sequelae. Therefore, most patients require little or no specific therapy. IVIG or high-dose steroids may benefit some patients who have evidence of clinical bleeding, and splenectomy may be of value in patients with chronic ITP whose lives are altered by low platelet counts or bleeding. It is difficult to predict which patients are at risk for the development of ICH, and severe hemorrhage is not always curtailed by prior or concomitant therapy. The decision to treat a child with ITP should be based on the entire clinical picture rather than on the platelet count alone.

Intracranial haemorrhage in idiopathic thrombocytopenic purpura. Paediatric Haematology Forum of the British Society for Haematology

A UK survey was carried out to discover the frequency, circumstances, and outcome of intracranial haemorrhage (ICH) complicating idiopathic thrombocytopenic purpura (ITP) of childhood. A questionnaire was circulated through the membership of the UK Paediatric Haematology Forum, and thence to local paediatricians and haematologists. It sought information on any child with ITP who had had an ICH during the 20 year period to January 1994. Fourteen instances were discovered, seven before 1984 and seven after. Six children survived the event with minimal or no sequelae, four without craniotomy. An immediately precipitating cause was noted in four; two had arteriovenous malformations and two suffered head injuries. The event occurred over two weeks from diagnosis in seven cases and over two months in five. All children were profoundly thrombocytopenic at the time of their intracranial bleed. By calculation the 14 children would have represented some 0.1% of the total with ITP during the period under review. ICH in childhood ITP may have a precipitating cause and is not necessarily fatal. There is no period of maximum risk, and it can occur at any time during the course of the illness when the platelet count is less than 10-15 x 10(9)/l. It is an extremely rare event and previous estimates of its incidence may have been too high.

Chronic childhood idiopathic thrombocytopenia purpura: long-term follow-up

An understanding of the natural history of childhood chronic idiopathic thrombocytopenia purpura (ITP) could contribute to a rational therapeutic approach to its treatment, which remains controversial. In our retrospective study of 92 children with ITP, 22 had a chronic course and were followed for 3-14 years (median 8.6 years). Treatment, when indicated, was individualized: 4 patients (18.2%) did not receive any treatment, 14 (63.6%) received steroids only, while 4 (18.2%) were treated with steroids and one of the following: high-dose gamma globulin (4 patients), splenectomy (2 patients) or immunosuppressive therapy (2 patients). During follow-up, 14 patients (63.6%) achieved complete remission, 5 (22.7%) partial remission and only 3 (13.5%) remained severely thrombocytopenic, with minimal bleeding tendency. Eleven patients (50%) responded to the initial prednisone course (1-5 mg/kg/day), but showed a marked decrease in platelet count when steroids were tapered off. In view of the high rates of complete and partial remission and the mild course of the few non-responding patients, it is suggested that with adequate supportive therapy, follow-up problems and fatalities can be kept to a minimum. We believe that aggressive therapy, such as splenectomy, should be reserved for the rare symptomatic and severely thrombocytopenic patient.

Successful anti-D immunoglobulin therapy in refractory chronic idiopathic thrombocytopenic purpura showing reduction in thrombocytes even after splenectomy

An 8 year old female child was treated with steroid hormones, anabolic steroid hormones and high dose gamma-globulin therapy for 2 years since being diagnosed with idiopathic thrombocytopenic purpura at the age of 6 years. Treatment produced only transient efficacy, and thrombocytopenia persisted. A scintigram taken 2 years after the onset of the disease using [125I]-labelled heated auto red cells revealed accumulation of radioactivities in the spleen, and therefore splenectomy was performed. However, thrombocytopenia (10 x 10(9)/L) developed again 3 weeks after the operation, for which she was treated again with high dose gamma-globulin with only transient recovery. Then, anti-D immunoglobulin was injected intramuscularly at 250 micrograms per dose for a total of four doses and the platelet count was restored to the normal range. Since then her platelet count has been maintained higher than 200 x 10(9)/L for these 11 months. The scintigram taken after splenectomy showed an accumulation of radioactivities in the liver. After administration of anti-D immunoglobulin, transient subclinical hemolysis appeared. The mechanism whereby anti-D immunoglobulin exerts the efficacy described here may be considered to be by blockage of Fc receptors of macrophages, as is the case for high dose gamma-globulin therapy. However, since the recovery in the platelet count persisted, it appears that changes in the immune system other than the above described mechanism have contributed to the recovery.

A prospective, randomized trial of high-dose intravenous immune globulin G therapy, oral prednisone therapy, and no therapy in childhood acute immune thrombocytopenic purpura

Fifty-three children, aged 7 months to 14.4 years and with typical acute immune thrombocytopenic purpura and platelet counts < or = 20 10(9)/L, were randomly assigned to receive intravenously administered immune globulin G (IVIG), 1 gm/kg per day for 2 consecutive days (n = 19); orally administered prednisone, starting at a dose of 4 mg/kg per day, with tapering and discontinuation of corticosteroids by day 21 (n = 18); or no therapy (n = 16). Both IVIG and prednisone resulted in significantly fewer days with platelet counts < or = 20 x 10(9)/L in comparison with no therapy (median, 1 and 2 days vs 4 days; corresponding ranges, 1 to 20 and 1 to 11 days vs 1 to 132 days; p < 0.01). Reversal of clinically important thrombocytopenia assessed by the number of days taken to achieve a platelet count of > or = 50 x 10(9)/L was significantly faster in children randomly assigned to receive IVIG (median, 2 days; range, 1 to 34 days) than in those receiving prednisone (median, 4 days; range, 2 to 13 days; p < 0.001) or no therapy (median, 16 days; range, 2 to 132 days; p < 0.001). Because the risk of intracranial hemorrhage in children with acute immune thrombocytopenic purpura is highest in the group with severe thrombocytopenia, and appears to be restricted to children with platelet counts < or = 20 x 10(9)/L, these results support the use of IVIG or high doses of prednisone as initial therapy in children with acute immune thrombocytopenic purpura and severe thrombocytopenia (platelet counts < or = 20 x 10(9)/L).

Childhood idiopathic thrombocytopenic purpura: Experience at King Khalid University Hospital, Riyadh

Forty-nine children (30 boys and 19 girls) with idiopathic thrombocytopenic purpura (ITP) seen at King Khalid University Hospital (KKUH) Riyadh, during a 7-1/2 year period were retrospectively reviewed with regard to their clinical characteristics, management, and outcome. The age of onset of the disease ranged from 8 months to 11 years with a mean of 4.26 years. Twenty-seven cases presented as acute ITP while 22 cases presented as chronic ITP. The clinicopathological features and response to treatment of the cases were essentially similar to findings in other parts of the world. In a search for a predictor of chronic disease, the platelet counts at four weeks and three months after diagnosis were found to be a significant factor for prediction of chronicity of ITP. If the platelet counts are less than 100x10(9)/L during these periods, the risk of chronic ITP is increased and vice versa. There was, however, no correlation in our patients between duration of symptoms prior to presentation and outcome of the disease as has been reported by investigators in Europe and Australia.

Infantile idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura (ITP) in childhood is a benign disease, as only 10% to 20% of the patients have a chronic course. A retrospective study of 57 ITP patients ranging in age from four months to two years revealed that 30% of them proceeded to chronicity. Unlike ITP in the general pediatric population, chronic infantile ITP was characterized by male predominance, a high frequency of preceding viral infections, and lack of responsiveness to any of the known modalities of treatment.

High-dose intravenous methylprednisolone for acute childhood idiopathic thrombocytopenic purpura

49 children with acute idiopathic thrombocytopenic purpura (ITP) were divided into non-treatment, oral prednisone (2 mg/kg), and high-dose intravenous methylprednisolone (HIVMP) treatment groups which consisted of 17, 16 and 16 children respectively. Platelet counts rose above 150,000/microliters over a 2-week period in 5 (29.4%) children in the first group, 5 (31.2%) in the second group and 15 (93.7%) children in the third group. Platelet counts reached the normal level in only 3 days in 11 (68.7%) children treated with HIVMP. Initially, antiplatelet antibodies (APA) were shown by the Handin and Stossel method in every patient. With normalization of platelet counts, the antibodies decreased but could still be detected in every case; antibody decrease was greater in the HIVMP group. With the exception of mild cushingoid appearance, none of the major corticosteroid side effects was observed in the treated children.

Use of intravenous gamma globulin in children and adolescents with idiopathic thrombocytopenic purpura and other immune thrombocytopenias

Approximately 85 to 90 percent of cases of idiopathic thrombocytopenic purpura (ITP) in children are of the acute, self-limited variety that generally occurs after a viral infection. The remaining 10 to 15 percent of children with this disorder have the chronic (autoimmune) type of ITP. For these patients, splenectomy is often the recommended treatment if severe bleeding occurs and platelet counts remain below 40,000/mm3. However, splenectomy has associated risks and the response to this surgery cannot always be predicted. Intravenous gamma globulin (IVIG) has proven useful as an alternative to splenectomy, especially in children who are considered too young for splenectomy or in those in whom there is no response to splenectomy. It should be noted that booster shots are frequently required and the patient's ITP may become refractory. IVIG may also be useful in preparing a child with ITP for splenectomy and in treating children or adolescents with ITP who have central nervous system or other serious hemorrhages. Although IVIG is not always effective in raising the platelet count, it does provide a very useful alternative method of treating this disorder.

The nontreatment of childhood idiopathic thrombocytopenic purpura

Despite the sudden and often alarming clinical manifestations of ITP, few patients in the pediatric age group develop serious complications or long-term sequellae. Conservative therapy, without use of pharmacologic or surgical intervention, is the most convenient, safe, and cost-effective approach in the vast majority of patients. There is a definite role for corticosteroids and IV gamma globulin in certain selected patients with both acute and chronic forms of ITP. Splenectomy may be of value in some chronically affected patients. Other forms of treatment are rarely if ever indicated. In summary, the best therapy for most children with ITP is no treatment at all.

In vitro effects of gammaglobulin (IgG) on human monocyte Fc receptor function. I. Effect on monocyte membrane-associated IgG and Fc receptor-dependent binding of antibody-coated platelets

Intravenous immunoglobulin (IV IgG) has been reported to be clinically beneficial for the treatment of immune thrombocytopenic purpura (ITP). The mechanism of effect still remains unknown. We examined the in vitro effects of two commercially available IV IgG preparations. Exposure of normal monocytes to IgG in vitro produced a significant increase in monocyte-bound IgG. Prior treatment of the commercial IgG preparations by filtration through a 0.2-micron Millipore filter or ultracentrifugation caused a dramatic decrease in IgG bound to the monocyte surface, indicating that IgG aggregates were responsible for this effect. Exposure of monocytes to IgG levels as high as 150 mg (Sandoglobulin) and 400 mg (Gamimune) did not result in a statistically significant inhibition of monocyte-platelet interaction as examined by a morphologic rosetting assay. Thus, despite the ability of IV IgG preparations to cause substantial increments in monocyte surface IgG, impairment of Fc receptor-mediated monocyte binding of antibody-coated platelets was not observed.

Periodontal manifestations of acute autoimmune thrombocytopenic purpura. A case report

Purpuric hemorrhages are usually the result of thrombocytopenia, but are also seen in vascular disorders such as vitamin C deficiency, Henoch-Schonlein purpura, and von Willebrand's disease. The progressive purpuric hemorrhages in the oral mucosae and skin in a case of acute autoimmune thrombocytopenic purpura (AITP) in a young adult are described. Localized hemorrhagic periodontal lesions of doubtful interpretation proved to be the first clinical signs of the underlying thrombocytopenia. The diagnosis is confirmed by finding thrombocytopenia with normal or increased numbers of megakaryocytes in the bone marrow. Treatment must be started before the onset of serious complications such as cerebral hemorrhages.

Treatment of acute idiopathic thrombocytopenia of childhood with intravenous infusions of gammaglobulin

Gammaglobulin treatment was given at a dose of 1 gm/kg/day intravenously in 29 patients with acute idiopathic thrombocytopenic purpura: 15 previously untreated, 10 resistant to steroids, and four who were steroid dependent. The average platelet increase in 24 hours was greater than 50,000/microliter; the average peak platelet count was 194,000/microliter. Eighteen of 25 patients required only one infusion; 10 of these 18 never required any additional (maintenance) therapy. Outcome in previously untreated and steroid-resistant patients was identical; however, previously untreated patients required only 1.8 gm/kg total dose of gammaglobulin, whereas steroid-resistant patients received 3.9 gm/kg. Only one steroid-dependent child of the 29 patients still requires maintenance therapy, at 6-week intervals. Toxicity was minimal. Cost was minimized by not admitting patients and by giving treatment in one visit, rather than five.

Acute idiopathic thrombocytopenic purpura

A 35-year-old man had hemorrhagic bullae of the buccal and sublingual mucosa as the first sign of acute idiopathic thrombocytopenic purpura. Twenty-four hours later the more typical cutaneous manifestations of petechiae of the lower extremities were present. Although it is unusual for the initial symptoms of this disease to be limited to the oral region, the physician and dentist should be keenly aware of the clinical appearance described in this article, as it may be the only clue of an underlying systemic disease.

Long-term follow-up study of 168 patients with immune thrombocytopenia. Implications for therapy

A total of 168 patients (90 adults, 78 children) with immune thrombocytopenia (ITP) and a median follow-up of 75 months were treated with a sequential regimen of corticosteroids (n = 125), splenectomy (n = 83) and immunosuppressives (n = 25). In 43 patients an observation period of a minimum of 1 month preceded the therapy. It is concluded that: (i) withholding therapy in the expectation of spontaneous recovery is at least in children justified in case of limited bleeding tendency; (ii) corticosteroids should be limited in adults to a maximum of 3 weeks and in children to a maximum of 6 weeks; (iii) if corticosteroids fail, splenectomy remains the therapy of choice, especially in patients aged less than or equal to 30 years, and should be performed within 6 months after diagnosis; (iv) after failure of the aforementioned forms of therapy, there is rarely a beneficial effect of treatment with azathioprine and vincristine; (v) no reaction to any form of therapy can be followed by an acceptable long-term outcome.

Intracranial hemorrhage simulating brain tumor in immune thrombocytopenic purpura

A 6-year-old girl with signs of a space occupying lesion had a CT scan compatible with a brain tumor. A preoperative hemogram revealed thrombocytopenia which was later proved to be due to ITP. Intracranial bleeding can rarely be the first manifestation of ITP. Early recognition of this situation aided by serial CT follow-up may lead to an improvement in the handling of these patients.

Platelet-associated immunoglobulin G in childhood idiopathic thrombocytopenic purpura

Platelet-associated IgG was studied in children with acute and chronic ITP and in patients with thrombocytopenic SLE, using the microtiter solid-phase radioimmunoassay. Of the children with acute ITP, 85% had elevated PAIgG levels. The degree of elevation of PAIgG at onset of disease did not correlate with the development of chronicity. Of the children with acute ITP, clinically and hematologically indistinguishable from the rest, 15% had normal PAIgG values. All of 22 children with chronic ITP had elevated PAIgG values. Although there was good correlation between the platelet count and the PAIgG value in children with chronic ITP, the association was not as striking in those with acute ITP; thus, factors in addition to the level of PAIgG may contribute to the thrombocytopenia in the latter group. Patients with SLE and thrombocytopenia had higher values of PAIgG than would be predicted from the platelet count; the PAIgG value is probably not the only factor determining the degree of immune thrombocytopenia.

Immunosuppressive treatment of idiopathic thrombocytopenic purpura in children

Eleven children with symptomatic idiopathic thrombocytopenia were treated with immunosuppressive agents. Ten children received cyclophosphamide; 1 was given azathioprine. Only 1 child produced a full response, and 6 subsequently needed splenectomy which was curative. It is concluded that immunosuppressive treatment is ineffective in childhood thrombocytopenia and that splenectomy remains the treatment of choice for the rare case which fails to settle spontaneously or respond to corticosteroids.