Preceptor:

Case
Presentation
Immune
Thrombocytop
enic
Purpura

dr. Ulynar Marpaung, Sp.A

Presenter:
Brenda Karina

(1102010052)
Pediatric Department
Raden Said Soekanto Hospital
Yarsi Medical University
Period July 18th 2016 September 24th
2016

IDENTITY
Patient
Name
: An. P.A.S
Birth date
: October 1st 2015
Age
: 10 months
Gender
: Male
Adresss
: Jl. Batu Ampar V No.11 Kramat Jati
Nationality
: Indonesia
Religion
: Islam
Date of admission
: July 31st 2016
Date of examination
: August 3rd 2016

Parents

Father

Mother

Name

Mr.A.T.

Mrs.Y

Age

37 years old

34 years old

Job

Employee

Housewife

Nationality

Indonesia

Indonesia

Religion

Islam

Islam

Education

High school
High school
(graduate)
(graduate)
Jl. Batu Ampara V No.11 Kramat Jati

Address

Anamnesis
The anamnesis was taken on August 3rd 2016, by alloanamnesis
(from patients mother and grandmother)
Chief complain :
Black diarrhea since six days before admission to the hospital.
Additional complain :
Pink Urine since three days before admission to the hospital,
Appearance of redspot on the right ear, arms and legs since
two days before admission to the hospital.
Ginggival bleeding since one day before admission to the
hospital.

History of Present
Illness
A 10 months old boy came to Raden said
Sukanto Police Center Hospital emergency
room suffering from black diarrhea since six
days before admission to the hospital. This
complains also followed by pink urine since
five days before admission to the hospital,
and since two days before admission
appeared redspots on the right ear, arms
and legs.

History of Present Illness (2)

That black diarrhea happened 6 times a day,

contained with a little of waste, mucous, watery, and
amount a half of glass for each bowel. And then,
there were also pale face and faint body. That
complains did not follow with nosebleed, fever,
abdominal pain, cough and cold before.

History of Present Illness (3)

The next day black diarrhea happened, patients
mother brought him to RS Bhakti Yudha, and he had
hospitalization for 4 days there. In that hospital,
patient received therapy 2x200cc whole blood
transfusion, 3 units of trombocytes, Omeprazole
2x0,5cc intravena, Carbapenem 500mg. In 4th day of
hospitalization, patient had gingival bleeding so the
next day patient referenced to RS Polri.

History of Present Illness (4)

On the days of hospital admission, patient condition

is compos mentis and didnt have adding other
complains, even less than before, pink urine and
gingival bleeding did not happen anymore, Black
diarrhea still appeared 1 time at the hospital,
increasing desire to eat and did not faint.

History of Present Illness (5)

Previously the child had a story that 2 weeks

before hospital admission, patient got Measles
immunization. In the family, there is no
member of the family get suffer from disease
like patient.

History of Past Illness

Pharyngitis
Bronchitis
Pneumonia
Morbili
Pertussis
Varicella
Diphteria
Malaria
Polio
Enteritis

Bacillary dysentry

Amoeba dysentry

Diarrhea

Thyphoid

Worms

Surgery

Brain concussion

Fracture

Drug reaction

Allergic History
The patient didnt have cows milk allergy.
The patient didnt have asthma, allergic
rhinitis, and atopic dermatitis.
The patient didnt have allergy to medicine.
The patient didnt have allergy to dust, pollen,
etc.

Birth history
Mothers pregnancy history
The mother routinely checked her pregnancy to the hospital. She
denied any problem noted during pregnancy.
Childs birth history
Labor : hospital
Birth attendants : doctor
Mode of delivery : pervaginam
Gestation
: 9 months
Infant state
: healthy
Birth weight : 2950 grams
Body lenght : 49 cm

Development History
First dentition

: 6 months

Psycomotor development

Mental status : Normal

Conclusion: Growth
factor and development
status is still in
the normal limits and was
appropriate according to
the
patients age

Head up : 1 month old

Smile
: 1 month
Laughing : 1-2 month old
Slant
: 2,5 months old
Speech initiation: 5 month
old
Prone podition : 5 month old
Sitting : 6 month old
Crawling : 8 months old

History of eating
Breast milk :
exclusively 6 months
Formula milk :
bebelac
Fruit and vegetables :
apple, banana,
carrot, brocolli,
spinach, potatoes,
papaya

IMMUNIZATION
HISTORY

Immunizat Frequency
ion
Hepatitis B 3 times

Time

Polio

4 times

0,2,4,6
months old

BCG

1 time

1 month old

DPT

3 times

2,4,6
months old

Hib

3 times

2,4,6
months old

Measles

1 time

9 months
old

0,1,6
months old

Family history
There are no
significant
illnesses or chronic
illnesses in the
family declared.

History of disease in
other family
member
There is no one
living around their
home known for
having same
condition as the
patient.

Social and
economic history
house size: 20 m
x10m
1 door at the
front side,1 toilet
near the kitchen
and 2
bedrooms.there
are 4 windows
inside the house.
Hygiene:
Take a bath twice
a day
changes clothes
everyday
Bed sheets
changed every
two weeks.

PHYSICAL EXAMINATION
(AUGUST 3 rd 2016)
General status
General condition : compos mentis
Awareness : compos mentis
Pulse
: 109 x/min,regular, full, strong
Breathing rate : 24 x/min
Temperature
: 36,80C

Antropometry status
Weight :8,4 kg
Height :69 cm
Nutritional status based NCHS
(National center for health
statistic) year 2000
X

WFA (Weight for age) :

8,4/9,6 x 100% = 87,5 %
HFA (Height for age) :
69/73 x100% = 94,5 %
WFH(Weight for height) :
8,4/8,6 x 100% = 97,7 %

Head to Toe Examination

Head to Toe Examination (2)

Head to Toe Examination (3)

Neurological Examination
Meningeal Nuchal
rigidity
sign

Kernig sign
Lasegue sign
Brudzinski 1
Brudinski 2

Motoric Examination

Motoric Examination (2)

Autonom Examination
Defecation

Normal

Urination

times daily)

Sweating

Normal
times daily )
Normal

1-2

4-5

Laboratory Investigasion
Haematology & Clinic Chemistry
30th July 2016
Haematology

Results

Normal Value

Haemoglobin

13,4

13-16 g/dL

Leukocytes

12.700

5,000 10,000/L

Hematocrytes

38

40 48 %

Trombocytes

5.000

150,000 400,000/L

Erythrocytes

4,98

4 5 million/L

Clinic Chemistry

Results

Normal Value

Sodium

137

135-145 mmol/l

Potassium

3,8

3,8-5,0 mmol/l

Chloride

104

98-106 mmol/l

Hematology

Laboratory
Investigasi
on
Complete
Hematolog
y 31st July
2016

Results

Normal Value

Haemoglobin

11,9

13-16 g/dL

Leukocytes

11.400

5,000 10,000/L

Hematocrytes

32

40 48 %

Trombocytes

18.000

150,000 400,000/L

Basophil

0-1%

Eosinophil

1-3%

Stick

2-6%

Segment

36

50-70%

Lymphocytes

57

20-40%

Monocytes

2-8%

Differential Count Leucocytes

Erithrocytes Sedimentation 10

<15 mm/hour

Rate (LED)
Erithrocytes

4,50

million/ul

Serology/Immunology (Anti Dengue IgG-IgM)

IgG

Negative

Negative

IgM

Negative

Negative

Working Diagnosis

WORKING DIAGNOSIS
ITP

MANAGEMENT
IVFD KAEN 3B 10 tpm makro
Transfusion TC 4 unit/days
Inj. Cefotaxime 2x400 mg
Inj. Transamine 3x15mg

PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam
Quo ad sanactionam : dubia ad bonam

FOLLOW UP
July 31st 2016 - August
th
4 2016

Follow Up Day 1

Follow Up Day 2

Follow Up Day 3

Follow Up Day 4

Follow Up Day 5

Immune
Thrombocytopenic
Purpura
(ITP)
Literature Review

Definition

ITP, Immune Thrombocytopenic Purpura, is an

acquired bleeding disorder in which the immune
system destroys platelets, blood cells that play a
vital role in primary hemostasis. Individuals with ITP
develop thrombocytopenia with a platelet count below
the normal range generally defined as less than
150,000 cells/mm3.

Epidemiology
The annual incidence of ITP is about 3 to 8 cases per
100,000 children with a peak in the two to five year age
group. It should be noted that this is an underestimate as the
documented numbers are dependent on the development of
bleeding symptoms.

Pathophysiology
Immunologic Mechanism
The most common mechanism involved in ITP is
development of antiplatelet antibody through the
activation of B-lymphocytes.
These antibodies are most
frequently directed against platelet glycoproteins, such as
glycoprotein IIb/IIIa (the fibrinogen receptor).

Pathophysiology
Proposed mechanism of immune
dysregulation in ITP.
a) T cells are activated, induce antigenspecific expansion of B cells. The B cells
in turn produce autoantibodies with
specificity for glycoproteins expressed on
platelets and megakaryocytes.
b) Circulating platelets bound by
autoantibody are removed by Fc
receptors predominantly by splenic
macrophages.
c) Autoantibodies also reduce the
capacity of megakaryocytes to
produce platelets.

Immune Thrombocytopenic
Pathophysiology
Purpura
Infection Trigger
In the pediatric age group the temporal
relationship between development of acute
ITP and a recent (within 2 to 3 weeks)
infectious illness or immunization is quite
striking and is reported for approximately
60% of cases.

Classification
Acute ITP: healing < 6 months
Chronic ITP: trombocytopenia persistent > 6
months

Clinical Manifestation

Diagnosis
1.
2.
3.
4.

Blood count and evaluation of peripheral smear

Blood typing and direct Coombs testing
Bone marrow evaluation
Immunoglobulin quantitation

Differential Diagnosis
Post tranfussion purpura
Disseminated Intravascular Coagulation
Wiskott-Aldich syndrome
Dengue Haemmoragic Fever
Thrombocytopenia-Absent Radius (TAR) syndrome
Neonatal alloimmune thrombocytopenia

Treatment
1. Supportive
. Avoid post traumatic bleeding
. Avoid of using drugs that modify trombocytes
2. Pharmacology
. Corticosteroid
. IVIG (Intravenous Immune Globulin )
. Rituximab
. Thrombopoietin receptor agonists (TPO-RA)
3. Surgery
. Splenectomy

Complication
Corticosteroids
are
accepted
as
conventional treatment of ITP. However, long
term corticosteroid administration can lead to
many undesirable effects. Among them are
hypertension, hyperglycaemia, Cushing's
appearance, myopathy and increased
susceptibility to infection.

Thank You

REFERENCES
1. Blanchette M, Freedman J. The History of Idiopathic Thrombocytopenic Purpura (ITP).
Transfusion Science 1998;19:231-6.
2. Kuhne T, Buchanan G, Zimmerman S, Michaels L, Kohan R, Berchtold W, et al. A prospective
comparative study of 2540 infants and children with newly diagnosed idiopathic
thrombocytopenic purpura (ITP) from the intercontinental childhood ITP study group. The
Journal of Pediatrics 2005;146:151-2.
3. Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al. International
consensus report on the investigation and management of primary immune thrombocytopenia.
Blood 2009;115:168-86.
4. Wilson D. Acquired platelet defects. In: Nathan D, Orkin S, Look A,Ginsburg D, eds. Nathan
and Oski's Hematology of Infancy and Childhood. 6 ed. Philadelphia: WB Saunders;
2003:1597-44.
5. Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold D, et al. Standardization of
terminology, definitions and outcome

REFERENCES
6. American Society of Hematology. Guideline on the Evaluation and Management of
Immune Thrombocytopenia (ITP). 2011
7. Riley, Roger S. Idiopathic Thrombocytopenic Purpura (ITP). 2006
8. Spring. Immune Thrombocytopenia (ITP): A New Look at an Old Disorder. Indiana
Hemophilia and Trombosis Centre. 2010
9. Setyoboedi, Bagus. Idiopatik Trombositopenik Purpura pada Anak (Patofisiologi,
Tatalaksana serta Kontroversinya). Juni 2014
10. Behrman RE, Kliegman R, Nelson WE. Hematologi-Onkologi Anak. Jakarta:
Badan Penerbit IDAI; 2005. h. 236-. 47. 2.