VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

A pediatric case of acute immune thrombocytopenia following influenza A infection Kirstie Mundok, OMS-III, Lindsay Tjiattas-Saleski, DO, MBA, FACOEP Spartanburg Regional Healthcare System and Edward Via College of Osteopathic Medicine, Spartanburg, SC

Abstract # CBR-14




• The patient was transferred to another facility and admitted to the pediatric hematology-oncology floor for two days where she had serial CBCs. • Her hemoglobin dropped to 6.3 two days after her transfer along with persistent oral/nasal bleeding. Due to this she received two platelet transfusions and packed red blood cells during her admission. • The patient received a total of two doses of IVIG 1g/kg, to which she did not respond. • She began prednisolone 2mg/kg twice daily four days after her initial presentation, improving her platelet count to 187,000. At this time, she was weaned to prednisolone once daily, which she continued for 16 more days. • Two weeks after finishing prednisolone the patient’s platelet count remained normal and her symptoms were completely resolved. • There have been other reported cases of ITP following influenza infection, however this association seems to be infrequent in the literature. • Most pediatric patients will recover within three to six months of presentation, and 10-20% of children will develop chronic ITP. • Mortality is rare in children with acute ITP. • This case was atypical because of the significantly low platelet count and need for blood transfusions due to a low hemoglobin. A typical CBC in ITP would show isolated thrombocytopenia with normal white blood cell and hemoglobin levels 8 . • This case is serves as a reminder that the relationship between viral illnesses and ITP exists and should be added to the differential if a patient presents with similar symptoms.

• A 3-year-old Hispanic female with no past medical history presented to the emergency department (ED) with her mother who reported recurrent epistaxis and scattered ecchymosis for the last four days. She noted that the patient spit up a blood clot prior to their arrival to the ED. • Mother reported a cough and intermittent fevers for the past week, stating that the patient’s highest temperature at home was 102F. • Mother denied any history of bruising or easy bleeding. She denied any family history of cytopenia or hematological disorders. • The patient was up to date on childhood immunizations but had not received an influenza vaccination this year. • Mother denied changes in oral intake, abdominal pain, vomiting, or diarrhea. • Physical examination was remarkable for blood noted to bilateral nares, palatal petechiae in the mouth and under the tongue (Figure 1), ecchymosis to inside of cheeks, and scattered ecchymoses and petechiae to her bilateral lower extremities and back (Figure 2). • There was no cervical, supraclavicular, or axillary lymphadenopathy on exam. No conjunctival pallor was noted. • The annual incidence of ITP in children is estimated to be around 8.1 per 100,000 persons, peaking between 2-5 years old and during the winter and fall seasons 1,2 . • 2/3 of children with acute ITP will have an infectious illness a few days to a few weeks prior to the thrombocytopenia 3 . • Various research indicates an association of acute ITP with Epstein-Barr virus (EBV), cytomegalovirus (CMV), hepatitis virus, and HIV 4 . • At least 80% of children diagnosed with acute ITP will make a complete recovery within a few days to weeks with or without treatment, others may go on to develop chronic ITP 3 . • Intracranial hemorrhage (ICH) is a rare but possible complication of acute ITP even if the patient has received treatment. Persistent platelet counts less than 10x10 9 /L is reported to be the main risk factor for ICH 5 . • Treatment options for ITP include intravenous immunoglobulin (IVIG), corticosteroids, platelet transfusion, and splenectomy 2 . Case

Figure 1. Palatal petechiae similar to patient presentation 6 .

Figure 2 . Scattered ecchymosis similar to patient presentation 7 .


1. Weycker D, Hanau A, Hatfield M, Wu H, Sharma A, Bensink ME, Chandler D, Grossman A, Tarantino M. Primary immune thrombocytopenia in US clinical practice: incidence and healthcare burden in first 12 months following diagnosis. J Med Econ . 2020 Feb;23(2):184-192. 2. Nugent, D.J. Childhood immune thrombocytopenic purpura. Blood Reviews 16, 27-29 (2002). 3. Rand, M.L., Wright, J.F. Virus-associated idiopathic thrombocytopenic purpura. Transfus. Sci. 19:3, 253-259. 4. Zhong Wu, Jin Zhou, Xiaoxia Wei, Xin Wang, Yongbin Li, Bing Peng & Ting Niu (2013) The role of Epstein-Barr virus (EBV) and cytomegalovirus (CMV) in immune thrombocytopenia, Hematology , 18:5, 295-299. 5. Elalfy, M.S., Eltonbary, K.Y.E.M., El Ghamry, I.R. et al. Intracranial hemorrhage in primary immune thrombocytopenia (ITP): 20 years’ experience in pediatrics. Eur J Pediatr 180, 1545 – 1552 (2021). 6. Blereau, RP. Palatal petechiae. Consultant , 45:12 (2005). 7. Hernaez, F, Hernaez AM, Blankas-Hernaez N. Idiopathic thrombocytopenic purpura [published online December 19, 2018]. Consultant360. +FPN 4XRFS 2* (MNQIMTTI NRRZSJ YMWTRGTH^YTUJSNF (QNSNHFQ UWJXJSYFYNTS FSI RFSFLJRJSY 8ZIFS / 5FJINFYW

• Viral respiratory panel was positive for influenza A and negative for influenza B, RSV, and SARS-COV-2. • Complete blood count (CBC) showed significant thrombocytopenia with a platelet count of 4x10 3 / μ L (normal: 150-450x10 3 / μ L) and mild normocytic anemia with a hemoglobin of 10.0 (normal: 11.0-13.7g/dL). • Complete metabolic panel, prothrombin time, and INR were within normal limits. • Flow cytometry showed no monoclonal B-cell population or abnormal T-cell population, and no blasts were detected. • Peripheral smear showed marked thrombocytopenia without morphologic dysplasia or circulating blasts.

Thank you to this patient’s parents for allowing this information to be presented in the academic setting to further the education of healthcare providers. Acknowledgements


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