A 87-d-old boy was brought for vaccination. He was second child of non-consanguineous parents. He was exclusively breast fed and thriving well. The child had received birth immunization and DTaP / HiB / IPV combination vaccine (1), OPV and HepB (2) at 6 wk.
On examination, the child was playful. Petechial spots were noted over the face and limbs. Otherwise general and systemic examination was normal.
Platelet count was 15000 / cu mm. Hemoglobin was 10.4 g/dl, total leucocyte count-13070/cu mm and differential count:P-23.5,L-72.3, M-3.2, E -0.9, B-0.1. Coagulation profile, LFT, RFT and TORCH titres were normal. Peripheral smear showed normal RBCs, lymphocytosis and marked thrombocytopenia (hence no comment on platelet morphology). Mother’s platelet count was 2.4 lakhs. HIV status was negative. Bone marrow aspiration showed normal megakaryopoeisis. A diagnosis of acute immune thrombocytopenic purpura (ITP) was made.
Intra venous immunoglobulin was given 1 g/kg body weight. Platelet count after 24 h was 75000/cumm. Repeat peripheral smear showed normal platelet morphology. The child was discharged without steroids. The platelet count was 5.4 lakhs after one wk and 2.7 lakhs after 4 wk. The child has received subsequent doses of vaccines and remains well.
ITP is typically a disease of 2-4 y old children [1]. Hashemi A et al, in a study of 72 cases of thrombocytopenia in children below 2 y found that 66 % had ITP, 2 had Wiskott Aldrich syndrome and 4 had Fanconi anemia [2]. Ramyar A and Kalanthari N retrospectively reviewed the chart of 202 pediatric patients with ITP. Of these, 96 were 24 mo of age or younger [3].
ITP should be considered in the differential diagnosis of thrombocytopenia even in infants. The principles of management are same as that for older children. Live viral vaccines should be administered after 3 mo of IVIG administration [4].
References
Scott JP, Montgomery RR. Idiopathic thrombocytopenic purpura. In: Kleigman, Behrman, Jenson, Stanton eds. 19th ed. Kliegman: Nelson Textbook of Pediatrics. Philadelphia, USA: Elsevier; 2011.
Hashemi A, Kargar F Souzani A, Hazar N . Acute immune thrombocytopenic purpura in infants. Iranian J Pediatr Hematol Oncol. 2011;1:104–8.
Ramyar A, Kalantari N. Clinical features and treatment response of immune thrombocytopenic purpura in infants. Acta Medica Iranica. 2007;45:510–2.
IAP Committee on Immunization. Immunization in special situation. IAP guide book on immunization, Mumbai: Print Throb Creation; 2011. pp. 151.
Acknowledgments
The authors would like to thank Dr. Sumati Manjunath, Consultant, Pediatrics, a private practioner, who promptly identified thrombocytopenia and referred the child and Dr. Krishnaratnam, Hemato Oncologist, who was consulted during case management.
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Venkat Ramanan, P., Prasath, T.S.A. & Kishore, T. Thrombocytopenia in an Infant. Indian J Pediatr 80, 521 (2013). https://doi.org/10.1007/s12098-012-0860-3
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DOI: https://doi.org/10.1007/s12098-012-0860-3