Idiopathic thrombocytopenic purpura (ITP) or immune thrombocytopenic purpura is a disease characterized by low platelet count (<150,000/L) caused by autoantibody-mediated

platelet destruction and the absence of other causes of thrombocytopenia

 Acute

primary ITP is more common in children 2-8 years of old More frequency in females then male

Unknown etiology factor Hypersplenism Food or drugs intoxication (eg: acetosal, PAS, qina dll) Chemistry substantions Physical substantions Koagulation Defficienci DIC Autoimmune Post viral infection ( 50%)

acute

chronic

ITP is caused by specific platelet autoantibodies binding to the platelets. The IgG autoantibody-coated platelets undergo accelerated clearing after binfing Fc receptors expressed on tissue macrophages

 History Acute or chronic onset Bleeding complain Physical examination Skin : petechiea, eccymosis, purpura

Hemorrhagic vesicles or bullae may be seen in

the oral cavity and other mucosal surfaces. Gingival bleeding and epistaxis Gastrointestinal beleeding (hematemesis, melena) and in the genitourinary tract ICH rare Mild splenomegali 1-3 % case

Blood routine
Specific : Thrombocytopenia

Peripheral blood smears

show low numbers of normal-sized platelets,

occasionally also giant platelets, erythrocytes and leukocytes have a normal morphology Anemia normocytic or microcytic hypocromic depend on blood loss may occur.

The bone marrow ( rare to evaluate)

is usually normal or shows increased

megakaryocytes

diagnosis of ITP is still arrived at by a process of exclusion, by eliminating other causes of thrombocytopenia

Rumpel-leed (+) Prothombin consumption time became shorter

Acute ITP
Observation self-limiting disorder that

resolves spontaneously Corticosteroids Thrombocyt complement transfusion (< 10.000/uL)

Chronic
Corticosteroid Immunosuppressant (6-merkaptopurin,

cyclofosfamid) Splenectomi

Indicate to patient resistent with combination corticosteroid and immunosuppresant There is no spontaneous recovery in 6 month corticosteroid therapy Contraindication : patient < 2 years old

Immunoglobulin IV (IgIV) Immunoglobulin anti D Danazole Dapsone Combination of immunosuppressive and chemotherapy

In acute ITP, prognosis depend on primary disease. 90 % can recovery spontaneous. Chronic ITP have a poor prognosis

A girls, 6 month old, lives in Pekanbaru, came to Arifin Achmad Hospital in March18th 2013
chief complain: reddish spots appear a whole of body since 2 days before hospitalize

2 days before admition to the hospital, patients mother realize that reddish spots was appear a whole of the patients body . firstly the spots appears on the arm then its appears too on the face, chest, stomach, and legs. Reddish spots also found on the tip of the tongue and inner lips. The spots do not disappear with emphasis. Fever (-), vomit (-), diarrhea (+), frequencies was 3 times, color of the stool is greenish, bloody stool (-), mucus (-), nosebleed (-), gingival bleeding (-). Patient looks active and alert.

4 days before admission to the hospital, mother complained patient stool was black and soft, firstly the stool was black and then passed blood from anal. Then patient start diarrhea, 7 times, the color was black but there wasnt blood. Patient didnt irritability and no tenderness, fever (-).

3 weeks before admission to hospital patient got cough and influenze . Wet cough, but the sputum cant be passed. The mother didnt take her daughter to hospital. Fever (-), breathlessness (-), vomit (-), diarrhea (-), otalgia (-), irritability (-)

No similar complaint before

No similar illness with patient No bleeding problem in family

Children born just months, spontaneous birth assisted by midwives, burst into tears. Birth weight 3000 grams. Herbs (-), Smoking (-) Radiation (-) Alcohol (-)

Food and drink history Normally

Immunization: Patients are immunized from birth BCG (+), Polio (+), Hepatitis B (+)

History of mental growth

Patient smiling by the Pasien tersenyum saat diajak bermain ci luk ba Patient can sitting Normal

General appearance: moderate illness Awareness: Allert Nutritional state is good

PULSE RR T

126 x/min

32 x/min
36,60 C

Head : Normochepaly, Hair : black, strong Eyes : conjunctiva: not anemic (-/-), sclera : jaundice (-/-), pupil : isochors (2mm/2mm) light reflex : + / + Ears : in the normal limit, ear wax (-/-) Nose : discharge(-), bleeding (-)

Mouth
Lip Mucus membrane

Palate
Tongue Teeth

: cyanosis (-), wet(+), : Wet (+), petechie(+) : intact : petechie(+) on the tip of tounge :-

Neck
Lymph nodes

Stiff neck

: enlarged (-) :-

Thorax Lungs

Inspection

(-) Palpation : cant to evaluate Percussion : sonor/sonor Auscultation : vesicular (+/+), wheezing (-/-), ronchi (-/-)

: symmetrical movement , retraction

Heart

Inspection Palpation Percussion

sinistra

: ictus cordis invisible : ictus cordis palpable (+) : Sinistra : SIC 5 linea axilaris anterior
Dextra : linea sternalis dextra

Auscultation : Heart sound I & II regular, gallop (-),

murmur (-)

 Abdomen Inspection : flat, venectation (-)

Palpation

: supel (+), no pain in palpation, liver 1/3-1/3, splenomegali (-) Percussion : tympani Auscultation : bowel sound (+) normally.

Genitalia: Extremity:

girl, in the normal limit

warm acral, CRT < 2, edema (-)

Neurologist states
Physiologic reflex : (+) normal Pathologic reflex : (-)

Dermatology
Region

lips Efflouresensi : petechie (+), ekimosis ( +) Penyebaran : generalisata

: a whole of body, tounge, tip of

Blood examination (March 18th 2013) Hb : 10,9 gr/dl Ht : 31,8 % Leukocyte : 15.300 /uL Thrombocyt : 6.000 /uL Blood examination (March 19th 2013) IgG anti dengue : non reaktive IgM anti dengue : non reaktive

Urine (March 18th 2013) Macroscophic : light yellow, clarity :

clear Micro : Eritrosit : 0 1/LBP Leukosit : 23/LBP Sel epitel : 4 6/LBP Urine chemistry : Protein (-) ,Glukosa : (-)

Feces

(March 18th 2013)

: 1

Macroscophic : greenish, mucous (-),

blood (-) Micro : Eritrosit : 0/LBP, Leukosit 2/LBP, worm (-)

March 18th 2013

March 23th 2013

March 25th 2013

Hb

10,9 gr/dL

9,1 gr/dL

9,3 gr/dL

Ht

31,8 %

25,6 %

28,1%

Leukocyte

15.300/ mm

7.300/ mm

15.400/ mm

Thrombocyt

6.000/mm

42.000/mm

113.000/mm

HISTORY
Reddish spot on whole body Fever (-)

Physical examination
Petechiea (+), eccymosis (+) on the whole of

body, conjungtiva and mucousa

Laboratory
Thrombocytopenia

Acute of Idiopathic Thrombocytopenic Purpura

Dengue Hemoragic Fever Measless

Bedrest
Pharmacotherapy:
Methil prednisolon 3 x 4 mg (pulv) Thrombocyt Complemen Tranfusion 4 unit

Dietary 936 ccal

Bonam

March 22th 2013 S: reddish spot on a whole of body (-), fever (-), diarrhea (+), 1 times, colour of stool yellow, blood (-), mucous (-), epistaxis (-), vomit (-), patien active and alert, good appetite O : moderate illnes HR : 126 x/minute RR : 32 x/ minute T : 36,7 C Conjungtiva anemic (-/-) Dermatologist : Location: a whole of body, conjungtival, lip mucousal Effloresensi : petechiae, eccymosis, A : acute ITP P : Ceftriaxone IV 2x200mg Paracetamol drop 2 x 165 mg

March 23th 2013 S: reddish spot on a whole of body (-), fever (-), diarrhea (+), colour of stool yellow, blood (-), mucous (-), epistaxis (-), vomit (-), patien active and alert, good appetite O : moderate illnes HR : 124 x/minute RR : 30x/ minute T : 36,5 C Conjungtiva anemic (-/-) A : acute ITP P : Metil Prednisolon 3 x 4mg

March 24th 2013 S: reddish spot on a whole of body (-), fever (-), colour of stool yellow, blood (-), mucous (-), epistaxis (-), vomit (-), patien active and alert, good appetite O : moderate illnes HR : 126 x/minute RR : 32x/ minute T : 36,7 C Conjungtiva anemic (-/-) A : acute ITP P : Metil Prednisolon 3 x 4mg

March 21th 2013 S: reddish spot on a whole of body (+), fever (-), diarrhea (+), 2 times, colour of stool greenish, blood (-), mucous (), epistaxis (-), vomit (-), patient active and alert, good appetite O : moderate illnes HR : 125 x/minute RR : 32 x/ minute T : 36,7 C Conjungtiva anemic (-/-) Dermatologist : Location: a whole of body, conjungtival, lip mucousal Effloresensi : petechiae, eccymosis, A : acute ITP P : Ceftriaxone IV 2x200mg Paracetamol drop 2 x 165 mg Thrombocyt transfusion 2 unit

March 22th 2013 S: reddish spot on a whole of body (+), fever (-), diarrhea (+), 2 times, colour of stool greenish, blood (-), mucous (), epistaxis (-), vomit (-), patien active and alert, good appetite O : moderate illnes HR : 124 x/minute RR : 29x/ minute T : 36,9 C Conjungtiva anemic (-/-) Dermatologist : Location: a whole of body, conjungtival, lip mucousal Effloresensi : petechiae, eccymosis, A : acute ITP P : IVFD RL 10 tpm (micro) Metil Prednisolon 3 x 4mg Thrombocyt transfusion 2 unit

March 23th 2013 S: reddish spot on a whole of body (+), fever (-), diarrhea (+), 2 times, colour of stool greenish, blood (-), mucous (), epistaxis (-), vomit (-), patien active and alert, good appetite O : moderate illnes HR : 125 x/minute RR : 30x/ minute T : 36,9 C Conjungtiva anemic (-/-) Dermatologist : Location: a whole of body, conjungtival, lip mucousal Effloresensi : petechiae, eccymosis, A : acute ITP P : IVFD RL 10 tpm (micro) Metil Prednisolon 3 x 4mg Thrombocyt transfusion 2 unit

March 25th 2013 S: reddish spot on a whole of body (-), fever (-), colour of stool yellow, blood (-), mucous (-), epistaxis (-), vomit (-), patien active and alert, good appetite O : moderate illnes HR : 126 x/minute RR : 30x/ minute T : 36,6 C Conjungtiva anemic (-/-) A : acute ITP P : Metil Prednisolon 3 x 4mg

anamn esis

Reddish spots a whole of body Fever (-) Melena (+) Cough (+)

Physical examin ation

Petekie (+), ekimosis (+) Splenomegali (-)

Laborat ory Finding

Trombocytopenia (6.000/uL) Hb : 10,9 gr/dL IgM dan IgG anti dengue

March 18th 2013

March 23th 2013

March 25th 2013

Hb

10,9 gr/dL

9,1 gr/dL

9,3 gr/dL

Ht

31,8 %

25,6 %

28,1%

Leukocyte

15.300/ mm

7.300/ mm

15.400/ mm

Platelet

6.000/mm

42.000/mm

113.000/mm