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Petechiae and Gingival Bleeding: ITP Beyond the Boards

Treatment of ITP has 2 major focuses: bleeding control and increasing platelet levels. Bleeding control follows direct local pressure or packing pending on the site as would be done for non-thrombocytopenic patients. One recent case series has shown the potential for improved homeostasis with the use of intravenous tranexamic acid (TXA) in ITP patients with active bleeding.8 Platelet transfusion should be considered in any significant bleed, especially in the setting of platelet counts less than 30,000/L. Transfusion should not be initiated in patients without active bleeding, regardless of platelet count...

Initial treatment should include IV methylprednisolone (40mg in adults)…

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 Briefs: ITP- Peds

Therapy is directed towards the immune response and includes intravenous immune globulin (IVIG), systemic corticosteroids, and/or Anti-Rho(D) immune globulin. Despite treatment 1/5 children will have a chronic course (>6 months). Interestingly, there also appears to be a slight increase in the month and a half following MMR vaccination.

 Therapeutics: Platelet Coagulopathy Fixes with ITP, TTP and DIC

The goal of initial treatment is to prevent significant bleeding, not to normalize the platelet count. Based on the 2019 International Consensus Report on ITP, treatment is stratified based on the patient’s bleeding severity and their risk of bleeding, not the platelet level...

Articles of Interest

EM@3AM: Idiopathic Thrombocytopenic Purpura

Preferred first line therapy. Prednisone 1mg/kg/day PO, or methylprednisolone 15mg/kg/day IV if not PO tolerant (switch to prednisone as soon as able, typically by day 4). Classically have used long course (21 days prednisone followed by taper). Some evidence that high dose dexamethasone (40mg/day for 4 days) confers similar benefit without long term steroid risks.

Peds - ITP – Immune Thrombocytopenia Purpura

75-80% enter remission within 6 months (parents want to know this).

UMEM Educational Pearls

Suspect ITP in patients with isolated thrombocytopenia on a CBC without other blood-line abnormalities. Abnormality in other blood-line warrants consideration of another diagnosis (e.g., leukemia).

Resources

Core EM

Corticosteroids: Prednisone (0.5 – 2.0mg/kg/day) or Dexamethasone (40 mg/day). Intravenous Immunoglobulin (IVIG) may be used as alternate first line therapy if steroids are contraindicated. Usual dose 1g/kg.