Occult Hemorrhage in Egyptian Children with Immune Thrombocytopenia

Abstract

Immune thrombocytopenia (ITP) is a hematological disorder characterized by a reduced number of circulating platelets and an increased risk of bleeding. The platelet count is most often used to assess disease status and response to therapy; however, bleeding is the most clinically important outcome because it has a direct impact on morbidity, mortality, quality of life and treatment decisions (Neunert et al., 2015). In children, ITP typically presents in otherwise healthy patients, often resolving spontaneously or following therapy within 6–12 months of diagnosis. However, approximately 20%–25% of children with newly diagnosed ITP ultimately develop chronic disease (Jung et al., 2016). Bleeding manifestations in patients with (ITP) range from mild skin bruises to life-threatening intracranial hemorrhage (ICH). Severe bleeding is distinctly uncommon when the platelet count is >30 × 109/L and usually only occurs when the platelet count falls <10 × 109/L. Based on estimates from clinical studies, ITP registries and administrative databases, the frequency of ICH in patients with ITP is ~0.5% in children and 1.5% in adults (Arnold, 2015). Four sites of occult hemorrhage deserve special attention, ie, microscopic hematuria which can be detected by urine analysis , fecal occult blood can be detected by stool analysis, retinal hemorrhage detected by fundus examination, and silent (subclinical) intracranial hemorrhage (ICH) can be detected by MRI (Flores and Buchanan 2013). ICH is the most devastating complication of ITP in children, and prevention of ICH is the primary goal of ITP treatment. However, the great majority of patients with ITP, even those with very low platelet counts, do not experience severe bleeding .and ICH occurs in less than 1 in 100 children with ITP (Psaila et al., 2009). After ICH, hemosiderin-containing deposits stored in macrophages and glial cells cause focal changes in the magnetic resonance (MR) signal due to their magnetic properties. Such “brain microbleeds” appear dark on T2-weighted spin-echo sequences, appearing enhanced when relying on gradient-echo sequence. Studies in adults with unruptured cerebral aneurysms or hypertension have shown that brain microbleeds can be detected as early as 3 weeks and for as long as 18 months after the onset of localized hemosiderin deposition (Flores and Buchanan, 2016).