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DBATEC AgeInfancy1-3y/o Inherited? Acquired Antecedent illnessNoViral illness Abnormal facies/anomalies Yes: 25-50%No RBC Adenosine Deaminase HighNormal.

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Presentation on theme: "DBATEC AgeInfancy1-3y/o Inherited? Acquired Antecedent illnessNoViral illness Abnormal facies/anomalies Yes: 25-50%No RBC Adenosine Deaminase HighNormal."— Presentation transcript:

1 DBATEC AgeInfancy1-3y/o Inherited? Acquired Antecedent illnessNoViral illness Abnormal facies/anomalies Yes: 25-50%No RBC Adenosine Deaminase HighNormal MCVHighNormal (?high in recovery) Hgb FHighNormal (?high in recovery

2 Differences: DBA and TEC  DBA may be considered premalignant syndrome Laughing: Pediatric Boards

3 Both DBA and Fanconi Anemia can have: Thumb abnormalities, urogenital defects, severe anemia DBA will typically be ISOLATED ANEMIA

4 Think about it  12 month old Severe anemia (Hbg 3) Recent viral illness Reticulocytosis  TEC in recovery phase

5 Question 5  Name the syndrome which is characterized by microangiopathic hemolytic anemia caused by a giant hemangioma.  A: Stendhal Syndrome  B: Kasabach-Merritt Syndrome  C: Capgras Syndrome  D: Cotard Syndrome

6 Kasabach-Merritt Syndrome  Giant hemangioma Serves as trap for platelets Localized consumptive coagulopathy ○ Risk for DIC Bone marrow is normal  Tx: Address hemangioma Support with transfusions

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8 Leukemoid Reaction  Differentiated from leukemia by B.M. Biopsy  Leukocyte alkaline phosphatase (LAP) Increased in leukemoid reaction  Down Syndrome Transient leukemoid reaction as neonate 20-30% of these: leukemia in 1 st 3 yrs of life

9 Reilly (Alder-Reilly) Bodies  WBC metachromatic prominent granules Stained with toluidine blue  Pathognomonic for Hurler syndrome

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11 Question 6 A previously healthy 4 year old girl is seen for petechiae and diffuse bruises. She is anxious but afebrile, alert and not in any distress. She is noted to have bleeding from the gums and moderately severe epistaxis. Lab studies reveal: Hgb 12.5; WBC 7 with a normal diff; platelets 4000. Part of the initial management would include..... A. Immediate bone marrow exam for suspected leukemia B. Blood cultures and IV antibiotics C. Careful PE, review of the smear and consideration of IVIG therapy D. Type and cross match and infusion of FFP E. Emergency splenectomy following platelet transfusion

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13 Bleeding Disorders Disorders of PlateletsCoagulopathies  Mucocutaneous bleeding  Purpura  Petechiae  Ecchymoses  Deep tissue bleeding  Joint bleeds

14 Bleeding Disorders  Bleeding in either may be Trauma Surgery Hematuria Guaiac-positive stools Menorrhagia CNS bleeding  Epistaxis More likely to be nose picking, dry mucous membranes or rarely HTN

15 Bleeding Disorders  Evaluation CBC c diff Platelet count PT PTT Bleeding time or closure time

16 Platelet Disorders  Isolated Thrombocytopenia Idiopathic or immune thrombocytopenias Hypersplenism DIC Consumption ○ Intracardiac defect or bypass Washout from exchange transfusion Local microangiopathic disease ○ HUS Local thrombosis ○ Renal vein thrombosis

17 Platelet Disorders  ITP Look at the smear! Large platelets = platelet destruction Hx ○ Recent viral infection Tx ○ IVIG ○ Anit-D antibody Only if pt is Rh positive ○ Splenectomy when unresponsive Bone marrow ○ When unresponsive

18 Platelet Disorders  Isoimmune Thrombocytopenia in the Newborn Fetal platelets cross the placenta into maternal circulation Maternal IgG produced against the platelet antigen Suspect when ○ Maternal platelets normal Risk ○ Cephalohematoma ○ Bleeding from umbilicus ○ ICH Tx ○ Washed maternal platelets ○ IVIG

19 Platelet Disorders  Decreased production = decreased or absent megakaryocyte precursors TAR syndrome ○ Thrombocytopenia-absent radius Amegakaryocytic thrombocytopenia ○ Leukemoid reactions ○ CHD ○ FTT In both conditions, thrombocytopenia resolves with age

20 Platelet Disorders  Qualitative or functional platelet disorders Normal number and clotting studies but poorly functioning platelets First ask for history of... ○ Drug exposure ○ Uremia ○ Hypothyroidism ○ Hyperbilirubinemia ○ IBD Von Willebrand disease

21 Question 7 A 16 month old boy is brought to the ER with persistent crying and refusal to move his right arm. The history is negative for fever and trauma. Past history is significant for bleeding from his circumcision and easy bruising. PE shows boggy, tender swelling of the right elbow with marked decrease in ROM. The Hb is 11.2; WBC, plts and inflammatory markers are normal. You plan would be.... A. Obtain a skeletal survey to r/o child abuse B. Admit the patient for evaluation of a bone tumor C. Request an orthopedic consultation for aspiration of the elbow joint. D. Obtain a FH, PT, PTT, factor assay and consider factor replacement therapy E. Close monitoring of the patient w/o intervention for the presumptive diagnosis of HSP

22 Coagulopathies  Deficiency in factors  Causes Decreased production ○ Genetic defects ○ Acquired conditions Overutilization of factors  Testing PT ○ Extrinsic and common PTT ○ Intrinsic and common Make sure you check age related values

23 Coagulopathies  Hemophilia A (VIII) and B (IX) X-linked recessive ○ Males Prolonged PTT Variable degrees of deficiency and disease Mild ○ 5-30% factor activity ○ Bleeding with surgery or major trauma Moderate ○ 1-5% factor activity ○ Localized hemorrhage in response to trauma Severe ○ <1% factor activity ○ Spontaneous soft tissue hemorrhages or bleeding with minor trauma

24 Coagulopathies  Hemophilia Presentation ○ Birth Circumcision ○ 12-18 months Increased mobility and bleeding with minor trauma ○ Most commonly affected systems Musculoskeletal -Hemarthroses -Soft tissue bleeding with intramuscular hematomas CNS Urinary

25 Coagulopathies  Hemophilia Secondary hemophiliac arthropathy ○ Knees ○ Elbows ○ Ankles Contractures Painful arthritis Compartment syndrome ○ Intramuscular bleeding

26 Von Willebrand Disease  Most common heritable bleeding disorder  Bleeding time or closure time is increased with or without an increase in the PTT  Most are AD  Most are asymptomatic and found incidentally  If symptomatic Abnormal mucosal bleeding ○ Frequent epistaxis ○ Menorrhagia

27 Von Willebrand Disease  What does VWF do? Responsible for the adherence of platelets to damaged endothelium Required for normal Factor VIII function  Types I and III ○ Quantitative ○ I is most common II ○ Qualitative

28 Von Willebrand Disease  Testing Von Willebrand factor antigen Von Willebrand factor ristocetin cofactor activity Factor VIII levels  Treatment DDAVP ○ Causes release of factor stores from platelets and endothelial cells ○ Quantitative Factor replacement ○ Donor blood products ○ Qualitative

29 Acquired Disorders  Inhibitors Testing ○ Mix patients plasma with normal plasma ○ PT or PTT will fail to correct Example ○ Lupus anticoagulant Actually predisposes to thrombosis ○ 10% of patients with Lupus ○ Also acquired after some medications or other infectious organisms ○ Persists for months

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31 Thrombosis  Disruption in the balance of procoagulant and antithrombotic factors  Rare in children Infants and adolescents  Incidence increasing Due to use of indwelling lines

32 Thrombosis  Increased risk Retardation of blood flow ○ Severe dehydration ○ Immobilization Endothelial damage ○ Indwelling catheters Family history Past history of thrombosis Recurrent spontaneous abortions Thrombosis during pregnancy Nephrotic syndrome

33 Thrombosis  Protein C Vitamin K dependent Inhibits procoagulant factors Va and VIIIa Decreases clot formation  Protein S Cofactor required for anticoagulant activity of protein C  Deficiency of either leads to clot formation

34 Thrombosis  Antithrombin III Inhibitor ○ Complexes with thrombin, factor Xa and factor IXa Deficiency lead to loss of inhibition and thrombosis  Paroxysmal Nocturnal Hemoglobinuria Rare Cells with an increased sensitivity to complement Leads to ○ Abdominal and back pain ○ Chronic intravascular hemolysis ○ Intermittent hemoglobinuria ○ Diffuse venous thrombosis

35 Thrombosis  Factor V Leiden Mutations lead to protein C resistance ○ Can’t degrade procoagulant factors  Factor II prothrombin gene variant Increased factor II  Methylene tetrahydrofolate reductase (MTHFR) gene mutation Thermolabile variant Increased plasma homocyteine levels  Genetic testing may be done Not affected by anticoagulants

36 Question 8 An infant you are seeing in the newborn nursery is born with hypoplastic thumbs and some abnormal skin pigmentation. You suspect that the patient may have Fanconi’s anemia. What test should confirm the diagnosis? A. Chromosomal analysis B. Bone Marrow Biopsy C. CBC with peripheral smear D. CBC with reticulocyte count E. CBC with diff

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38 Pancytopenia  Definition Reduction in all three formed elements of the blood  Results from a number of disease processes Bone marrow failure Depressed marrow function and increased cellular destruction

39 Aplastic Anemia  Insult to the bone marrow Drugs Toxins Solvents Radiation Autoimmune Postinfectious Idiopathic ○ 50%  Bone marrow failure  Death from infection or bleeding unless there is an intervention

40 Fanconi Anemia  Autosomal recessive  Signs Pancytopenia ○ Marrow hypoplasia Congenital anomalies ○ Abnormal skin pigmentation ○ Growth retardation ○ Skeleton Absent or hypoplastic thumb ○ CNS ○ GU  Testing Fragility of the chromosomes ○ Breaks, gaps and rearrangements  Treatment Frequent transfusions Bone marrow transplant


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