Guidelines on the diagnosis of primary immune thrombocytopenia in children and adolescents: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2012

Are accessory spleen screening and resection in refractory immune cytopenia an effective strategy or a waste of resources?

Splenectomy remains an effective treatment for refractory immune cytopenia (RIC), which encompasses immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA). Accessory spleens (AS) have been described without identifying specific risk factors. We retrospectively analyzed patients with RIC after splenectomy who underwent splenic scintigraphy (SS) at our institution. Seventy-one patients were included. Sixty-two patients had ITP, five had AIHA, and four had Evans syndrome. Seventy-five percent (n = 53) were women. Eleven patients (15.5%) had an AS detected by SS. A complete response (CR) to first-line steroids (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.37-24.14, p = 0.017) and the absence of Howell-Jolly bodies (HJB) in peripheral blood smear (PBS) (OR 11.37, 95% CI 2.70-47.85, p = 0.001) were found to be risk factors. Patients with both elements had a higher rate of AS (83.3%) when compared to those with one or no factors (p < 0.001). Eight patients (73%) underwent an accessory splenectomy: seven (87.5%) achieved a CR, and none had perioperative complications. The presence of HJB in PBS changed from 25 to 87.5% after accessory splenectomy. We recommend the search for an AS via SS in patients with RIC due to ITP, who had a CR to corticosteroids and the absence of HJB in PBS. Accessory splenectomy is a safe and effective procedure.

A multicenter retrospective analysis on therapeutic plasma exchange in immune thrombocytopenic purpura

Immune Thrombocytopenia (ITP) is an autoimmune disease characterized by thrombocytopenia and skin and mucosal bleeding. In patients with an indication for treatment, corticosteroids, intravenous immunoglobulin (IVIg) and anti-D are recommended as the first line, while splenectomy, thrombopoietin receptor agonists or rituximab are recommended second line options. Approximately 10 % of adult patients with ITP fall into the chronic refractory ITP group. Therapeutic plasma exchange (TPE) has generally been tested in patients with refractory ITP, who have failed to respond to conventional treatments, in case of bleeding or prior to surgical interventions. It has been stated that elimination of the antibodies that are held responsible in the pathogenesis of the disease has an effective role in the treatment. In this article, we present the results of 17 patients, who underwent TPE for refractory ITP, together with the literature data.

Fibrinolytic therapy in newborns with superior vena cava syndrome. Case report

Introduction: Superior vena cava syndrome is described as the obstruction of blood flow through the superior vena cava. The literature reports that the incidence of this pathology varies from 1 case in every 650 inhabitants and 1 case in every 3 100 inhabitants. Since this condition is very rare in the pediatric population, no clear figure has been reported regarding its incidence in children. The use of a central venous catheter in newborns is a risk factor for this condition, as it may cause a thrombus due to the inflammatory reaction against the device. Therefore, it is necessary to initiate anticoagulation management and remove the catheter.Case presentation: Premature male newborn, (31.4 weeks gestation), with acute respiratory distress syndrome, early neonatal sepsis, pneumonia, necrotizing enterocolitis on 2 occasions, intestinal obstruction due to adhesions and intestinal volvulus. At 90 days of age, he presented thrombosis of the superior vena cava without involvement of the jugular and subclavian vein junction in the right atrium. Anticoagulant management was started, but given his unfavorable evolution, a multidisciplinary medical board was held to assess the risks, benefits, and treatment options in this age group. It was decided to start intracavitary tissue plasminogen activator treatment associated with mechanical thrombectomy and angioplasty of the superior vena cava. Due to the difficulty of conducting clinical trials in this population and the rates of major bleeding complications obtained with thrombolytic therapies, there is very little information available on the use of tissue plasminogen activator in newborns. For this reason, alteplase is seldom considered as the therapy of choice. However, in patients with life-threatening thrombosis, such as the present case, the results obtained in adults could be extrapolated in search of a favorable outcome.Conclusions: Fibrinolytic therapy is a way to reduce the size of the thrombus, but it dramatically increases the risk of bleeding; consequently, these patients must be strictly monitored. In pediatric populations, due to the diameter of the blood vessels, thrombectomy is difficult to perform; additionally, recurrent thrombosis and the need for transfusion of blood products are frequent.