History An 11-year-old boy without known underlying disease CC : Continuous bleeding at traumatic wound 9 days
Present history An 11-year-old boy was in his usual state of good health. 10 days PTA, he had a bicycle accident. He suffered from abrasions at his right elbow without bleeding. Film Rt. Elbow suggested a right supracondylar fracture of humerus. The fracture was fixed by using slab and arm sling. He got ibuprofen tid for relieving pain (10 days).
Present history 9 days PTA, he has had a continuous bleeding from his traumatic wound so the wound was dressed once daily. 3 days PTA, he was referred to provincial hospital for proper management. CBC : Hb 8.9 g/dl, Hct 28%, WBC11400/ul, (N73% L17% E14%) Plt 72,000/ul. The initial diagnosis was ITP Thus, he was refered to Siriraj hospital for further diagnosis and treatment.
History PMH: No history of abnormal bleeding. No previous hospitalization, no prior surgery. FH: 2 nd child. No family history of bleeding disorder. No family history of hereditary disease. No anticoagulant drug use.
Physical examination V/S : T 36.8 º c, RR 40/min, PR 96/min, regular, BP 100/56 mmHg BW 40.8 kg (P 75 ),Height 151.5 cm (P 90 ) GA : A 11-year-old Thai boy. good consciousness, mildly pale, no jaundice, Skin : no petechiae, purpura or ecchymosis
Physical examination HEENT : pharynx and tonsils not injected, TM intact both ears, no mucosal bleeding. RS : normal breath sounds, no adventitious sound CVS : normal S 1 &S 2, no murmur Abdomen : soft, no distension, active bowel sounds, no mass, liver& spleen not palpable, bimanual palpation negative
Physical examination NS : muscle power grade V all extremites, normotonia, no sensory deficit DTR 2+ all, no stiff neck Extremities: Rt arm: abrasion at medial side of right elbow, size 1x2 cm, active bleeding, swelling from elbow to fingers
Clinical Evaluation History taking Physical examination Laboratory Investigation Diagnosis and treatment Bleeding Patient Clinical Evaluation History taking Physical examination
Bleeding disorder Local vs. systemic defect Location: single vs. multiple sites Severity: Spontaneous? Appropriate to trauma? Hereditary vs. acquired disorder Onset Family history Underlying disease Medication Primary vs. secondary hemostatic disoder
Primary Hemostasis Platelet Adequate number Normal function Blood vessel von Willebrand factor vessel platelet
In this patient Local vs. systemic defect Location: single vs. multiple sites Severity: Spontaneous? Inppropriate to trauma Hereditary vs. acquired disorder Onset: 11 years old Family history: none Underlying disease: none Medication: Ibuprofen for 1 day Primary vs. secondary hemostatic disoder
Delayed Deep Deep ecchymosis, hematoma Rare Retroperitoneal Hematoma, hemarthrosis Immediate Superficial Petechiae, superficial ecchymosis Common Rare Onset Sites Skin Mucosal Others Secondary Hemostasis Primary Hemostasis
Clinical Evaluation History taking Physical examination Laboratory Investigation Diagnosis and treatment Bleeding Patient
Investigation CBC at Siriraj hospital: Hb 7.1g/dL, Hct 23%, MCV 81 WBC 8880 /mm 3, N 44.2%, L28.2%, Mo 7.7%, Eo19.4%, Ba 0.5% Platelet : 144,000/mm 3 CBC at provincial hospital, 9 day ago: Hb 8.9 g/dl, Hct 28%, WBC11400/ul, (N73% L17% E14%) Plt 72,000/ul.)
Investigation Interpretation of CBC : normochromic normocytic anemia Eosinophilia (>500/ ul) normal platelet count (150,000-400,000/ul) > 100,000/uL Bleeding unlikely < 20,000/uL ↑ risk for spontaneous bleeding
Investigation UA : pH 7, Sp.gr. 1.015, WBC 0-1/HPF, RBC 0 /HPF, Coagulogram: PT 13.5 sec aPTT 27.5 sec PT-INR 1.17 Interpretation of coagulogram: no significant prolongation of coagulogram
Bleeding Time: Interpretation Normal value* : 2-7 min: in this patient is >30min Prolonged bleeding time: Thrombocytopenia/ anemia (Hct < 20%) Hereditary platelet dysfunction von Willebrand disease Severe hypofibrinogenemia Blood vessels disorders Uremia Myeloproliferative disorders Medication: Aspirin, NSAIDs, other antiplatelets
Bleeding Time Screening test for platelet function –Increased yield in patient suspected of bleeding disorder Limitation - Operator dependent - Not very sensitive nor specific in general population - Poor predictor of surgical bleeding
Differential diagnosis 1. Acquired platelet dysfunction with Eosinophilia 2. von Willebrand Disease (vWD) 3. Drug induced platelet dysfunction
Diagnosis Acquired platelet dysfunction with Eosinophilia (APDE)
APDE A syndrome characterized by 1.Reversible spontaneous hemorrhagic diathesis. 2.Platelet: bizarre shape, varying in size, pale staining and poor granulation. 3.Eosinophilia First described by Mitrakul, 1975. “Allergic vascular purpura” or “Non-thrombocytopenic purpura with eosinophilia” Most common bleeding diathesis in children in Thailand (Suvatte, 1979).
Certain facts of APDE Clinical course can intermittently last from a few days to 1 year. Self-limiting course and spontaneous recovery within 6-12 months. Recurrence is apparently rare once resolved. No correlation among number of eosinophil, IgE level and severity of bleeding.
Diagnostic investigation 1.CBC: –normal plt count, decreased granules, pale giant plt and no aggregation. –eosinophilia 2.Prolonged bleeding time. 3.Normal coagulogram and clot retraction. 4.Abnormal plt aggregation test.
Treatment in APDE No specific treatment Treatment of parasitic infestation. Symptomatic and supportive treatment If severe bleeding occurred, platelet transfusion should be performed : 0.4-0.6 u/kg/dose of plt conc every 2-3 d as guided by bleeding time (Hathirat, 1982). Oral vitamin C supplement.
Treatment In this patient -Mebendazole (100) 1x2 oral x 3 days -Platelet transfusion 4 units x II -Ferrous sulfate 2x2 oral pc (4MKD) -Transamine (250) 2x3 oral pc -Counseling: –Reassure. –Avoid trauma (even minor) or operation.
Take-home message Always screen blood smear. APDE: –Most common bleeding disorder in Thai children. –Self-limited disease. –Rx: No specific treatment, just reassure. Parasitic eradication. Symptomatic Rx if required.