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You are seeing an 8-year-old boy for prolonged nosebleed last night and this morning. Last night it happened on the right nares, and this morning on the left nares. Dad is a nurse and held pressure until the bleeding stopped, and there is currently no bleeding. Exam shows temp 37.5, HR 90, RR 24, BP 94/56. Exam is negative for lymphadenopathy, hepatosplenomegaly, or pallor. There is a small amount of dried blood in the left nares. His parents did not notice any rash, but on exam with the patient undressed you notice a few petechiae on the ankles and across the lower abdomen. There are no purpura. Laboratory values are: WBC 10.3, diff 40% polys, 45% lymphs, 8% monos; Hgb 13, Hct 39, Platelets 1. Lytes, LFTs, BUN/Cr, are all normal. There are no inpatient beds available, so management will begin in the ED.
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March 4, 2024 at 10:05 pm
D) Intravenous immune globulin
The patient has a typical presentation for immune thrombocytopenic purpura (ITP). There are no other cell lines abnormal on the CBC, and no exam signs concerning for malignancy, so bone marrow biopsy is not indicated. Platelet transfusions are only used to treat ITP in the case of life-threatening bleeding. The mainstays of pharmacotherapy for ITP are IVIG; anti-D immune globulin can be used instead in Rh+, DAT negative patients; or, methylprednisolone is sometimes used as an adjunct or as sole therapy when a rapid rise in platelet count is not essential. The bleeding has stopped, so nasal packing is not indicated. The petechiae are from thrombocytopenia and not concerning for non-accidental trauma.