Severe Hemorrhage in Chinese Children With Immune Thrombocytopenia

Risk factors for skin, mucosal, and organ bleeding in adults with primary ITP: a nationwide study in Japan

Bleeding manifestations in primary immune thrombocytopenia (ITP) range from skin petechiae to life-threatening intracranial hemorrhage (ICH). However, the relation between these various bleeding manifestations and the platelet count in ITP remains poorly characterized. Using a nationwide database of patients with ITP during the years 2005 to 2014 (10 years) in Japan, we analyzed 19 415 adult patients newly diagnosed with ITP, including 222 with ICH. The frequency of skin purpura was 64.8%, and this increased linearly with thrombocytopenia without a specific platelet count threshold. In contrast, mucosal bleeding (epistaxis and gingival bleeding) and organ bleeding (melena, hematuria, and ICH) increased exponentially with thrombocytopenia at a platelet count threshold of 10 to 15 × 109/L. Age showed a much weaker correlation than platelet count with skin and mucosal bleeding. However, the incidence of organ bleeding increased exponentially above 60 years of age. Multivariate analysis showed that the presence of mucosal bleeding was a risk factor for occurrence of melena and hematuria but not for ICH. The frequency of ICH was 1.1% and risk factors for ICH were age ≥60 years (odds ratio [OR], 3.09; 95% confidence interval [CI], 2.13-4.47; P < .001), platelet count <10 × 109/L (OR, 2.96; 95% CI, 2.11-4.15; P < .001), and the presence of hematuria (OR, 1.56; 95% CI, 1.04-2.35; P = .033). The relation between ICH and platelet count varied with age. This large-scale analysis of risk factors for bleeding in ITP has revealed distinct characteristics of skin, mucosal, and organ bleeding in adult patients with newly diagnosed ITP, thus indicating those who are at a high risk of severe organ bleeding.

Pediatric ITP: is it different from adult ITP?

Immune thrombocytopenia (ITP) has historically been thought to occur in 2 distinct forms: childhood ITP and adult ITP. This division is based largely on the presumption that childhood ITP is often benign and self-limited, whereas ITP in adults tends to be more chronic and difficult to treat. Although data exist to justify a different approach to the diagnosis and treatment in young children and the elderly, ITP in older children, adolescents, and younger adults is likely to share more similar pathology. This article will highlight the most recent data describing the natural history, diagnostic approach, management strategies, and disease-related outcomes in children and adults with ITP. These data reveal many unexpected similarities between the 2 groups, while confirming some of the more well-described differences. Discussion of these findings aims to highlight similarities and differences between ITP in children and adults, which will underscore important areas of future research and/or changes in management guidelines.

ACVIM consensus statement: Support for rational administration of gastrointestinal protectants to dogs and cats

The gastrointestinal (GI) mucosal barrier is continuously exposed to noxious toxins, reactive oxygen species, microbes, and drugs, leading to the development of inflammatory, erosive, and ultimately ulcerative lesions. This report offers a consensus opinion on the rational administration of GI protectants to dogs and cats, with an emphasis on proton pump inhibitors (PPIs), histamine type-2 receptor antagonists (H2 RAs), misoprostol, and sucralfate. These medications decrease gastric acidity or promote mucosal protective mechanisms, transforming the management of dyspepsia, peptic ulceration, and gastroesophageal reflux disease. In contrast to guidelines that have been established in people for the optimal treatment of gastroduodenal ulcers and gastroesophageal reflux disease, effective clinical dosages of antisecretory drugs have not been well established in the dog and cat to date. Similar to the situation in human medicine, practice of inappropriate prescription of acid suppressants is also commonplace in veterinary medicine. This report challenges the dogma and clinical practice of administering GI protectants for the routine management of gastritis, pancreatitis, hepatic disease, and renal disease in dogs and cats lacking additional risk factors for ulceration or concerns for GI bleeding. Judicious use of acid suppressants is warranted considering recent studies that have documented adverse effects of long-term supplementation of PPIs in people and animals.

Delayed Appearance of Cutaneous Lesions of Cutaneovisceral Angiomatosis (CAT) Leading to Misdiagnosis of Immune Thrombocytopenia

Cutaneovisceral angiomatosis with thrombocytopenia (CAT), also called multifocal lymphangioendotheliomatosis with thrombocytopenia (MLT), is a rare and newly described vascular malformation. Skin manifestations and thrombocytopenia are the hallmark of CAT/MLT, and visceral lesions are described. We report an infant with pulmonary hemorrhage, thrombocytopenia, and antiplatelet antibodies. There was no cutaneous involvement and the child was initially diagnosed with immune thrombocytopenia. Poor response to immune thrombocytopenia-directed therapy raised suspicion for an alternative diagnosis, and the ultimate diagnosis of CAT/MLT was made by lung tissue sampling. Unexpectedly, 2 years after resolution of pulmonary lesions and thrombocytopenia, the child developed typical cutaneous lesions.

Cystic adrenal lesions: focus on pediatric population (a review)

BACKGROUND AND AIM

The cysts may potentially affect any organ; adrenals cysts are rare. This is a review of the literature regarding adrenal cysts, focusing on children and young adults.

GENERAL DATA

Three major types have been described: pure cysts (endothelial, epithelial, and hemorrhagic or pseudocyst), parasitic (as hydatid) cysts and cystic part of a tumour (most frequent are neuroblastoma, ganglioneuroma, pheocromocytoma, and teratoma). The complications are: bleeding, local pressure effects; infection; rupture (including post-traumatic); arterial hypertension due to renal vessels compression. Adrenal hemorrhage represents a particular condition associating precipitating factors such as: coagulation defects as Factor IX or X deficiency, von Willebrand disease, thrombocytopenia; antiphospholipid syndrome; previous therapy with clopidogrel or corticosteroids; the rupture of a prior tumour. At birth, the most suggestive features are abdominal palpable mass, anemia, and persistent jaundice. Adrenal insufficiency may be found especially in premature delivery. The hemorrhage is mostly self-limiting. Antenatal ultrasound diagnosis of a cyst does not always predict the exact pathology result. The most important differential diagnosis of adrenal hemorrhage/hemorrhagic cyst is cystic neuroblastoma which is highly suggestive in the presence of distant metastases and abnormal catecholamine profile. The major clue to differentiate the two conditions is the fact that the tumor is stable or increases over time while the adrenal hemorrhage is expected to remit within one to two weeks.

CONCLUSION

Pediatric adrenal cysts vary from simple cysts with a benign behavior to neoplasia- related lesions displaying severe prognosis as seen in cystic neuroblastoma. A multidisciplinary team is required for their management which is conservative as close follow-up or it makes necessary different surgical procedures in cases with large masses or if a malignancy suspicion is presented. Recently, laparoscopic approach is regarded as a safe procedure by some authors but generally, open surgery is more frequent used compare to adults; in most cases the preservation of normal gland is advisable.

[Classification therapy in 405 children with immune thrombocytopenia]

目的

探讨儿童原发免疫性血小板减少症（ITP）分层治疗的疗效和安全性。

方法

2013年1月1日至2014年8月31日期间405例≤14岁新诊断ITP患者纳入研究。以PLT<20×10⁹/L或活动性出血为标准分为观察组和治疗组。观察组180例，男104例，女76例，中位基线PLT 46（20~89）×10⁹/L，中位随访时间20（12~31）个月；治疗组225例，男131例，女94例，中位基线PLT 11（1~19）×10⁹/L，中位随访时间22（12~32）个月。

结果

治疗组患者急性期一线治疗总有效[完全反应（CR）+有效（R）]率为80.44%（181/225）；观察组急性期148例（82.22%）符合CR或R标准。治疗组44例患者进入持续期，持续期内总有效率为34.09%（15/44），发病后1年总有效率为87.11%（196/225）；观察组32例患者进入持续期，13例（40.63%）符合CR或R标准，发病后1年共161例（89.44%）患者符合CR或R标准。治疗组29例进入慢性期，5例（17.24%）患者获CR或R；观察组19例患者进入慢性期，6例（31.58%）符合CR或R标准。年龄≥10岁是影响两组患者1年自愈或治疗无效的高危因素。本组患儿均未观察到严重出血、严重不良反应，无死亡病例。

结论

以PLT<20×10⁹/L或活动性出血作为儿童ITP分层治疗的指征是安全可行的。