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You are evaluating a 5-year-old girl brought in for a prolonged nosebleed. The nosebleed happened this morning and lasted 15 minutes despite the parent applying appropriate continuous pressure. The child two other nosebleeds that lasted 5 minutes each earlier this week. On careful exam you notice a few petechiae on her upper chest and lower legs. Other than dried blood in her nares, she has no other abnormal physical exam findings (no lymphadenopathy, organomegaly, purpura, pallor). She has had no fever, malaise, weight loss, or bone pain. Her CBC shows a platelet count of 18,000 but the remainder of the CBC and the peripheral smear are normal.
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December 2, 2025 at 12:18 pm
D) Administration of IVIG or anti-D immunoglobulin
The patient’s presentation is consistent with immune thrombocytopenia (ITP). Peak ages for pediatric ITP are 2-5 years and adolescence, but ITP can occur at any age. Patients typically present with mucocutaneous bleeding and/or petechiae. Serious bleeding such as intracranial hemorrhage (ICH) is rare but can be life-threatening. Head CT would only be performed if the patient had findings concerning for ICH such as severe headache or altered mental status. Platelet transfusions are used in cases of life-threatening bleeding but not in minor bleeding. The epistaxis has stopped, so nasal packing is not indicated. There are no CBC, smear, or history / physical exam findings concerning for malignancy, and bone marrow biopsy is not routinely recommended for ITP. Patients with no or very minor bleeding and few petechiae may not be treated initially at all, but rather undergo close monitoring. This patient has moderate risk bleeding because of the prolonged epistaxis episode. Treatment of pediatric ITP in the case of moderate risk but not critical bleeding is typically IVIG, anti-D IG (only for Rh+ DAT neg patients with intact spleens), or oral glucocorticoids.