ITP Bleeding Case Powerpoint Presentation

ITP BleedingCase Powerpoint Presentation

1. Pediatrics ITP, Bleeding, and Child abuse

2. Immune Thrombocytopenia (ITP) 01

3. Definition of Thrombocytopenia Platelet count <150,000/ μ L Often found incidentally or during bleeding/bruising work-up Immune-mediated processes are the most common causes in children

4. ITP Most common cause of  isolated thrombocytopenia  in children Peak age:  2–5 years Sudden bruising, petechiae, or mucosal bleeding Often post-viral or post-vaccine, but many cases idiopathic Primary ITP:  No associated systemic disease Secondary ITP:  Associated with SLE, HIV, CVID, ALPS, drugs By Duration: Newly diagnosed: <3 months Persistent: 3–12 months Chronic: >12 months

5. Pathogenesis Autoantibodies (IgG) against GP IIb/IIIa, Ib /IX, etc. Antibody-coated platelets → macrophage clearance (mainly spleen) Antibodies may also impair megakaryocyte function Involvement of  T-cell cytotoxicity  and  immune dysregulation (Tregs/B-cells)

6. Epidemiology Annual incidence:  1–6.4/100,000 children Underdiagnosed due to asymptomatic or mild cases Peak:  2–5 years , minor secondary peak in adolescence

7. Clinical Presentation Healthy-appearing child with: Sudden petechiae, purpura, bruising ± mucosal bleeding (epistaxis, oral, GU, GI) Often preceded by viral illness or MMR vaccination Systemic signs absent  (no fever, bone pain, hepatosplenomegaly)

8. Bleeding Severity Most have mild mucocutaneous bleeding 40% have mucosal bleeding Serious bleeding: ~3% Intracranial hemorrhage (ICH): <1% High risk if platelets <10,000/ μ L

9. Diagnostic evaluation CBC with differential Peripheral blood smear Reticulocyte count Direct antiglobulin test Immunoglobulin levels Further tests if atypical findings

10. Diagnostic Criteria Platelets <100,000/ μ L Normal CBC, normal smear No systemic symptoms Diagnosis of exclusion Note:  Antiplatelet antibody testing not helpful (low sensitivity/specificity)

11. Differential Diagnosis Malignancies (ALL, lymphoma) Infections (EBV, HIV, CMV) Autoimmune diseases (SLE) Bone marrow failure syndromes DIC, TTP, HUS Drug-induced thrombocytopenia Inherited thrombocytopenia

12. Management Observation for mild/no bleeding Treat if: Platelets <10,000/ μ L Mucosal or life-threatening bleeding First-line: IVIG, anti-D (if Rh+), or steroids Reserve platelet transfusions for emergencies

13. Severe Bleeding Management Platelet transfusions:  10–30 mL/kg bolus IVIG + Steroids ± anti-D Add  TPO-RA (romiplostim)  to sustain counts Consider ICU admission for ICH or GI hemorrhage

14. Disease Course 80–90% recover in 3–6 months 10–20% → chronic ITP (>12 months) Risk factors for chronicity: Older age No preceding infection Less severe thrombocytopenia at diagnosis Insidious onset

15. Chronic ITP: Management Avoid contact sports, NSAIDs Monitor labs and menstrual bleeding First-line: IVIG, steroids If recurrent/severe: TPO-RAs preferred Rituximab  if autoimmune-associated Splenectomy  rare (reserved, due to lifelong risks)

16. Prognosis 30% spontaneous remission by 2 years 50% remission by 5 years Severe bleeding <10% over 5 years Younger age = better prognosis

17. Bleeding in Children 02

18. Approach to Pediatric Bleeding Begin with a  focused history Follow with  targeted physical exam Order  baseline labs  based on findings Use structured tools like  bleeding assessment scores

19. Focused History Onset and frequency of bleeding Triggering events (trauma, surgery, dental work) Type of bleeding: mucosal vs deep tissue Past medical history, meds, supplements Family history  of bleeding disorders Possible  child abuse  in unexplained bruising

20. Bleeding Assessment Tools ISTH Bleeding Assessment Tool (BAT) Score ≥3 → further evaluation needed Helps quantify symptoms and guide testing Use when the history is unclear or symptoms vague

21. Child Abuse Considerations Pattern and location of bruises inconsistent with history Multiple stages of healing Delay in seeking care Consider abuse in any atypical bruising without coagulopathy

22. Initial Lab Work-Up CBC + Platelet count Peripheral smear Prothrombin time (PT) Activated partial thromboplastin time ( aPTT ) Fibrinogen Von Willebrand panel : VWF antigen VWF activity Factor VIII level

23. Diagnostic Approach Use initial lab results to narrow causes Algorithm-based evaluation is recommended Examples: ↓ Platelets: consider ITP, leukemia, DIC Normal platelets + ↑PT/ aPTT : consider factor deficiencies Normal PT/ aPTT + mucosal bleeding: think VWD

24. Further Testing Based on initial findings, consider: Coagulation factor assays (VIII, IX, XI, XIII) Platelet function testing (e.g., aggregation studies) Antiphospholipid antibodies Thrombin time (TT), factor XIII activity Fibrinolysis evaluation (e.g., D-dimer, euglobulin clot lysis time)

25. Child Abuse 03

26. Definition Injury inflicted upon a child by a caregiver or parent Legal and cultural definitions may vary Key:  Inflicted , not accidental trauma

27. Epidemiology Thousands of injuries and deaths annually worldwide High risk of repeated harm if not intervened Early recognition = lifesaving Most common in  children under 5 years

28. Approach to Suspected Abuse Keep abuse in  differential diagnosis  of any unexplained injury Carefully assess: History : inconsistency, delay in care Physical exam : patterned injuries, fractures Involve  child protection teams  when possible Report  any suspicion to child services

29. Risk Factors (Contextual, Not Diagnostic) Young age Household history of abuse Family stress, poverty, isolation Caregiver mental illness or substance use Race or socioeconomic status  should NOT  be used to guide suspicion

30. Red Flag History for Abuse Injury inconsistent with developmental stage Vague or changing history Delay in seeking medical attention Recurrent injuries with no clear cause Explanation not matching injury severity

31. Red Flag History for Abuse

32. Red Flag Physical Exam Findings Bruises in non-mobile infants Patterned or clustered bruises Burns (e.g., immersion, cigarette) Retinal hemorrhages Multiple fractures in various healing stages Genital or perianal injuries

33. When to Pursue Full Work-Up Presence of any red flag history or exam finding Use institutional abuse protocol (lab + imaging) Refer to child protection team or abuse specialist Transfer if specialized services are not available

34. Screening Recommendations ED/urgent care:  Routine screening for <5 years recommended Increases detection Reduces missed cases Use  validated tools Requires institutional commitment and team collaboration

35. Primary Care Limitations Universal screening not yet supported by evidence Rely on clinical vigilance + family dynamics assessment Incorporate abuse awareness into developmental visits

36. Thank You!