Would we do everything the same way?

SETH’S Checkup STORY

ITP in a 4-Year-Old Boy Who Recovered Without Specific CBC Blood Test Treatments

The start of my life-changing events was March 2007

Seth was taken to the Emergency room when he was 4 years old. He had bruises that covered his body. The bruises had been notable for about two weeks and started only where he usually had them, such as on his shins. His parents grew concerned, however, when they continued and appeared on his arms and back. When he developed “little red spots” all over his body, the family took him to the local emergency room.

Emergency rooms have a long waiting time.

It was late in the day when they took him to the crowded emergency room and had to wait for test results. When the results came back, a complete blood count (CBC) showed that Seth had few platelets. Seth’s parents were told that based on his labs and physical exam. This was “possibly leukaemia” and to take him immediately to the emergency room at the Children’s Hospital.

When Seth arrived at the Children’s Hospital, it was now midnight, and he still had to undergo more CBC exams and laboratory Complete blood Count tests by the new doctors. His parents waited without a clear anaemia diagnosis and feared the worst.

“We feared that this was leukaemia and that Seth would die,” his Dad recalls.

Fortunately, when the laboratory tests came back, the only thing wrong with Seth was an extremely low platelet CBC Blood Count Test (3,000; normal is over 150,000) and nothing else. Seth was diagnosed with ITP. I was told to follow up in the haematology clinic in the morning. The doctors spoke with the haematologist on call and decided it was not necessary to give Seth any medicine since he had no major bleeding.

Seth visited the haematology clinic in the morning for an Anaemia Blood Laboratory test. He had no new bleeding, although he was still covered in bruises. His platelet count was 6,000, and his blood looked normal under the microscope except for a few platelets. CBC Blood test results showed that he had a normal red and white cell count.

Multiple Exams were needed to identify the actual issue.

Upon supination, Seth’s anaemia blood test showed no enlargement of his liver, spleen, or lymph nodes. Seth did indeed have ITP. There was no evidence of leukaemia either on the examination or in the laboratory data. The doctors spent a lot of time during that visit reviewing the diagnosis of ITP with Seth’s family and talking about the treatment options available for a boy like him. 

The parents received an informational booklet about ITP that described the diagnosis of ITP from anaemia blood tests and a series of other diagnostic measures. It also had important information on things to avoid when the platelet count is low, like aspirin and ibuprofen, which can decrease the functional ability of the few circulating platelets, roughhousing, and contact sports. Reasons to call the doctor were outlined, along with the staff’s appropriate phone numbers.

All this information was useful in reassuring the family and providing education.

However, the family still feels that the best thing was the doctors’ time reviewing all the possible treatment options with them. They knew they would have to keep him from roughhousing at home and give him options for more “quiet activities,” but they thought this was best for him.

Nursey School at a Young Age

Seth continued attending his regular nursery school, and the parents reviewed the diagnosis and restrictions with the teachers. His Dad stated, “Boys will be boys. Care and explaining his condition to everyone (family members, friends, and school staff) was important.

I was very, very protective at first. Seth acted perfectly normal when he was diagnosed with ITP. So it was hard for him to understand why we would restrict him from certain activities. He said, ‘I feel fine, Dad, I’m OK!’.” Despite how good he felt, he was restricted from bike riding.m Playground activities, roughhousing with his brother, and recess during preschool.

Light Symptoms can be deceiving. The underlying issue can be very serious.

Seth’s platelet Complete Blood count was measured again in one week and then every couple of weeks and continued to be low. Despite this, he had only mild bruising and no serious bleeding, such as nosebleeds or bleeding from his gums. The family stood by the decision to avoid Anaemia Blood Tests and further medication and watch him. He did so well that we established a return appointment in one month. But he was lost to follow-up.

Seth returned 1 month later for a Complete Blood Count check-up and, much to everyone’s delight, had a normal platelet count of 243,000. So Seth has had a full recovery from his ITP with watchful waiting as his treatment.

Seth is now a healthy six-year-old boy active in baseball and tennis.

He is doing well in school. Because of his diagnosis, he learned about hospitals and what they do. Looking back on his CBC Testing experience, his Dad said, “He had no side effects and did well. This is why I’m glad ITP can be treated. Close monitoring rather than medication worked.” The family says that they would have done everything the same way again.

Seth Update: February 2011

Seth continues to do well and has not required any further visits to our clinic or treatment for his ITP. The family knows that they can always call us if they notice that he starts bruising or bleeding again, but fortunately, this has not happened. Seth is now a healthy and active boy who only sees his doctors for regular checkups.

Comments by Dr Cindy Neunert

Seth’s CBC Blood Test story illustrates the natural course of most cases of ITP in children. ITP is one of the most common disorders, bringing children to the attention of a pediatric haematologist. The majority of children with ITP will have bruising and petechiae like Seth, but more significant bleeding is uncommon.

The disorder can be alarming when children are first seen because of the underlying fear that the child has leukaemia or is at risk for serious bleeding. In Seth’s case, he was transferred to the Children’s Hospital for an evaluation in the middle of the night.

His parents recall the fear that their whole life would change.

Seth’s case also illustrates several points about the management of children with ITP. First, the diagnosis of ITP can be made by physical exam, which involves evaluating the blood under a microscope. This requires an experienced physician, one who is experienced in diagnosing ITP in an emergency room.

In most cases, a bone marrow examination to rule out leukaemia or cancer is not needed if everything else is normal. Seth’s parents felt comfortable because the doctors spent a lot of time with them explaining the diagnosis and management options.

Children often don’t know they are sick. They need us more.

Seth is a delightful little boy who, despite having ITP, was completely unaware that he was “sick”. Like most children with ITP, what Seth needed was time. Most children will recover and never have any further problems after several months. It took Seth longer than most to recover. The most recent fast CBC blood test showed that his ITP “disappeared” in the end. In my experience, ITP will completely resolve in most children Seth’s age within approximately 6 to 8 weeks.

He is now a youngster who is doing great and enjoying all of his normal activities. He is full of energy and keeps his parents busy. Seth has a very small chance (1-2%) of having another episode of ITP and is not at risk for other blood disorders or cancers because of his ITP. Unlike adults, most children Seth’s age with ITP usually resume their normal childhood activities and have only memories of visiting the hospital.

Seth Update for 2011:

Seth’s ongoing CBC Blood test story highlights an important fact about ITP in children. Full recovery from ITP occurs in most children, and recurrence is rare. Full recovery requires documentation that the platelet has risen to the normal range without recent medication. Even in children with ITP who seem to recover quickly, we request another platelet Complete Blood count six months following diagnosis to be certain that all is well. Once we had documented two normal platelet counts, we felt comfortable that the children should not have more trouble with ITP. 

Current events and setbacks

Most of the time, the cause of the new episode is unknown, just like the cause of the initial event. Likely, these are not separate events. Rather, these patients had borderline thrombocytopenia. But some or much of the time, without bleeding, brought them back to the doctor.

We are currently trying to study this at our centre. We do this by following children who have resolved ITP. Suppose we study them long to see if the platelet counts go below normal.

Cases where a person has apparent acute ITP as a child. And such can develop a recurrence 20 or 30 years later. And even in rare cases where pregnant women had ITP during childhood. They can give birth to babies with temporary thrombocytopenia.