oa Epidemiological And Clinical Feature of Newly Diagnosed Childhood Immune Thrombocytopenic Purpura in Qatar

Background

ITP (Immune thrombocytopenic purpura) is the most common bleeding disorder in childhood. It is usually a self-limiting disorder, and most patients recover spontaneously without serious complication. The clinical features of ITP have remained unchanged over the past few decades but there have been many recent changes in management strategies as evidenced by the new international guidelines on the management of childhood ITP. We wanted to study our pediatric inpatient population in Qatar who were admitted with acute ITP over the last 5 years for their presenting features and the management strategies adopted by our pediatricians, most of the these decisions in our institution are in conjunction with the pediatric hematology team. This study would also serve as baseline data, which could be used to compare changes in trends of management in the future.

Methods

This was designed as a retrospective descriptive study. We included previously healthy, newly diagnosed ITP, aged 0 to 14 years, admitted to the pediatric inpatient unit, in Hamad General Hospital, Doha, Qatar from January 2008 to January 2014. Patients with a pre-existing chronic medical illness, including hematological conditions and those that were later diagnosed to have conditions other than ITP, were excluded. Data was collected from the patient's medical records using a specially designed data collection sheet that was used to gather the all the relevant patient related details including demographics, presenting signs and symptoms, investigations, treatment and outcome. The study was approved by the Medical Research Center at Hamad Medical Corporation.

Results

80 patients fulfilled the inclusion criteria with a male to female ratio of 1.1: 1. (38.3%) of the patients were in the 2–5 year age group, which reflects the peak incidence of ITP in children as per literature, (13.8%) of the patients were below the age of 12 months and (16.3 %) were above the age of 10.(34.3%) of the patients were Qatari Nationals, while the rest of them were expatriates residing in Qatar.

(40.5%) reported flu-like symptoms before the presentation of the illness. Most of the parents (>80%) denied any history of known hematological disease in their families.

The platelet counts at admission to the pediatric ward were as follows: (80%) of patients had a platelet count f 20,000 or less, (11.3%) from 21,000 to 35,000, while the rest of the patients had platelet counts between 36,000 to 100,000. The most common clinical features reported were spontaneous sub-cutaneous bruising in (77.5%) of patients, followed by oral mucosal petechial rash in (38.8%), fever in (28.8%), epistaxis in (16.3%), gum bleeding in (7.5%). 3 patients needed observation in the pediatrics intensive care unit due to life threatening bleeding, one of whom had intracranial bleeding.

The treatment modalities used in our patient population were as follows: Intravenous immunoglobulin (IVIG) alone in (86.3%), a combination of IVIG and steroids in (6.3%) and steroids alone (1.1%). Only 5 patients (6.3%) were managed by observation alone, 4 of these patients had platelet counts above 20,000 and none had any significant bleeding clinically. The most common IVIG dosing used was 1 gram/kg/day for 2 days. (28.7%) of our study population was prescribed a second dose of IVIG by their treating physician. The vast majority (74.3%) did not experience any adverse reaction after IVIG treatment. However, (10.8%) had fever, (8%) had vomiting and headache. 2 patients were clinically suspected of aseptic meningitis, post IVIG therapy, based on the treating physician's assessment. In terms of the length of stay in hospital, majority of the children (83.8%) were hospitalized for 1 to 5 days.

At follow up, (66%) children had recovered with normal platelet counts within 1 year from the date of diagnosis, while (34%) had progressed to chronic ITP, which is defined as the persistent thrombocytopenia, lasting beyond 1 year.

Conclusion

Our study showed that the clinical features of Acute ITP in Qatar were similar to those reported from various parts of the world. However, the percentage of chronic ITP was higher in our study population than that quoted in literature. Management decisions in our center, like in many centers around the world, were often based on the physician's clinical judgement, rather than the current established international guidelines.