Low Platelet Count Can Cause Serious Bleeding
Question: We were traveling through the Maritimes recently when our four-year-old son got sick. He developed a red rash over his body. Within two days, the rash spread to his arms and legs, and he started getting bruises everywhere. Otherwise he was not sick, and continued to be very active. We went to an emergency room and was told that he had an allergic reaction. A nurse gave him an injection into his thigh to control the allergy, but he bled for a long time from the needle site and developed a big bruise afterwards. The following day, he started bleeding inside his mouth. We thought he was going to die. We took him to another emergency room, and after some blood tests, we were told that his platelet count was very low. The doctor gave him prednisone for several days. His platelets gradually increased and returned to normal within about one week. We are very glad that he is better. We want to know more about this obscure medical condition, and wonder whether he will get it again.
From your description, your son has a medical condition called idiopathic thrombocytopenic purpura (ITP). The word idiopathic means we don’t know the exact cause of this condition, although we know a lot about what happens, and how to treat it.
ITP is an uncommon medical condition. It occurs roughly about 5 in every 100,000 children every year. As a result, some family doctors may never have seen ITP during their training or in their practice. As a result, some doctors may not recognize this medical problem when they see one.
Most of the time, ITP happens to perfectly healthy children after what appears to be a mild virus infection. Within one to two weeks following the infection, these children develop a red rash on their body. These red spots are called petechiae.
Sometimes they can develop bruises as well as nose bleeds and bleeding inside the mouth. The most dangerous complication, although fairly rare, is bleeding into internal organs and the brain. These usually happen when a person with ITP gets into an accident.
Children with ITP have less platelets in their blood. There are three kinds of blood cells. Red blood cells have a red pigment called hemoglobin that carries oxygen to every cell in the body. White blood cells help us to fight infections. Platelets are much smaller blood cells that plug up broken blood vessels and stop bleeding. Normal platelet count in healthy people varies between 150 to 400.
Children with ITP produce abnormal antibodies following certain viral infections. These antibodies stick to platelets which are then destroyed by the spleen, resulting in reduced platelet count. If the platelet count stays above 50, there is no bleeding because the remaining platelets are enough to stop any bleeding.
However, if platelet count drops below 50, especially if it is below 20, the chance of bleeding increases. The lower the count, the higher is the danger of bleeding. Small bleeding under the skin leads to red spots called petechiae. This can happen anywhere in the body. Larger bleeds into soft tissues result in bruises. Injection of medicine into the muscle is not recommended because this can result in a blood clot in the muscle called hematoma.
The most important advice that parents need is this: watch the child carefully to avoid injury, especially to the head. The reason is obvious: injury results in bleeding. If the platelets are low, the bleeding can endanger a child’s life. Therefore, these children should not play contact sports or involve in activities where the chance of injury is relatively high while their platelet count is low. However, we must allow these children to stay reasonably active.
These children also should not receive pain and fever medications that contain aspirin and ibuprofen. Both of them can affect platelet function. If the number of platelets is already low, anything that affects their function will just make things so much worse, and bleeding can occur much more easily.
Treatment of ITP is more controversial now than ever before. Some specialists believe that these children should be observed only unless when serious bleeding occurs in their internal organs or in the brain. The reasoning is that although these children have less platelets in their blood, the ones that are there are essentially normal and they can plug up any broken blood vessels and prevent serious bleeding.
Other specialists feel that leaving children with very low platelet count without treatment poses an unreasonable risk, in case if they get into situations where they can get injured. Many choose to treat if the platelet count is below 20, and definitely if it is below 10, where the risk of bleeding into the brain becomes much higher.
There are several ways one can treat ITP. The simplest way is to use a medicine called prednisone. This is a steroid that can be given by mouth. Most advise using a relatively high dose for 4 to 7 days. With such a short course, the side effects are very minimal, and it can raise the platelet count fairly quickly.
A faster, but much more expensive way, is to use immunoglobulin intravenously. This generally works faster than prednisone, but tend to have a few more side effects. There is also the extremely small chance of infection because immunoglobulins are made from pooled human blood.
With or without treatment, most children will recover completely within a few months. If low platelet count continues for more than 6 months, by definition, the child has chronic ITP. Chronic ITP is a different medical condition. There is no way to tell the difference at the beginning. These children have the tendency to produce abnormal antibodies against their own platelets continuously. They do require additional tests to make sure that they don’t have any other underlying medical conditions.
Most of the time, children with chronic ITP don’t require treatment. If they need surgery, it may be necessary to give them intravenous immunoglobulin to increase the platelet count for a short time to prevent severe bleeding during and after surgery, or if they are involved in serious accident. However, immunoglobulin’s effect doesn’t last very long.
The only effective treatment for chronic ITP is removal of the spleen. When platelets are coated with antibodies, they are removed from circulation and destroyed by the spleen. If the spleen is removed, the platelets can survive for longer time and platelet count can return to close to normal level.
In recent years, this surgery can be performed with ‘minimal invasive’ technique. The surgeons can do the operation through a few small holes in the abdomen, therefore reducing the amount of tissue injury and post-operative pain, as well as shortening the length of recovery after surgery.
Although removal of spleen can normalize platelet count, it can also lead to serious and sometimes fatal infection. Our spleen is a very important organ that helps us fight infections. Therefore much discussion should take place before making this decision.
I hope you have better understanding of your son’s condition after reading this column. Your doctor should follow him with blood tests to make sure his platelet count stays within the normal range in the next few months.