dr.vasim
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12 yr old MALE comes with bruises all over body, Ecchymoses- limbs, purpuric rash generalized. Bleeding gums, temp.-normal, no discoloration of Urine or stools, no pains, no edemas, BP 110/70mmhg, no lymphadenopathy, hrt n lungs - normal, no organomegaly, no pains, peripherals cold, perfusion- normal, no CNS involvment.
In HX thers nothing much but lowgrade fever 10days back, cough which subsided after 3days.
No family Hx of bleeding diathesis, no congenital malformations, no h/o pregnancy problems or delivery problems.
normal urine output, anorexia- present since 3 days.
SO U R ALL WELCOME, TRY UR BEST, WITHOUT LABORATORY VALUES. IF U WANT, U CAN WRITE d.d. WITH LAB VALUES..
thnx ahead. GOOD LUCK.
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| bhagat
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Acute ITP
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| nisha
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I agree with ITP
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| sarika
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!.Acute ITP
2.May b Scurvy
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| dr.vasim
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ok.. even if I agree itz ITP .. give me some other DDs.. n if possible what wud b LAB values.
Thnx Pals.. U all r Gr8.
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| dr.vasim
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most probably u all r agreeing fr ITP coz of Hx of fever-10days back ?.. ok. Gd point.
but still wud appriciate more differentials.
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| drvic
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Besides, ITP one should consider:
1) henoch schonlein purpura
2) VonWillebrand Factor Def
3) Factor XIII def
4) Child Abuse (why not!)
5) Leukemia/lymphoreticular malignancy could still be a possibility....
6) any of the tick-borne diseases - RMSF and stuff
these are the ones that came to my mind immediately....will think of more and let you know....
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| dr.vasim
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gr8 buddy .. gr8 .. keep it up. I wish i can hv a mind like U. DRVIC
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| dr.vasim
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child abuse - PAINS +ve ..
tick borne disease - sm xtra symptoms r present n even organomegaly too.
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| drvic
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the differential diagnosis could be expanded/refined further if you can give details like
a) duration of bleeding symptoms in this child
b) any H/o similar symptoms in the past
c) any family history - especially maternal uncles with similar complaints for X-linked coagulopathies...
d) any history of bone pains
e) any history suggestive of malabsorption or cystic fibrosis - because that would lead to malabsorption of fat soluble vitamins, esp VITAMIN K - whose deficiency can cause bleeding symptoms....
my IM prof used to say - 80%of diagnoses can be made in clinical medicine by History alone, another 10% is contributed by examination, and the final 10% by investigations....we used to sneer at that remark as being too idealistic. but when u come into clinical medicine, you begin to realise how true it is...
the diff diagnoses come fast these days as i'm preparing for Step2CS, so i have to be really quick in formulating my D/D and explaining it to the SP in the limited time that i'll have..... wish me luck for my exam..
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| dr.vasim
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well Dear drvic, nice to know few thnz abt U. I really appriciate it. n first of all i wish U GOOD LUCK, frm the deeper corner of my hrt.
well in the Q, i already said, no family Hx, No skeletal pains/ or any other pains, no Edema or s.c. formations( hematomas), no previous Hx of similar attacks.
well as i said, 10days before mild/ lowgrade fever with cough, which subsided n then since 3 days the bruises, rashes, ecchymoses appeared. Otherwise the child was fine before that, no hx of recurent RTI, no Hx of malabsorption or anorexia.. but since the rash appeared ther is anorexia.
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| sarika
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is scurvy even a possibility in differential?..
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| dr.vasim
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Yeah Dear frnd .. even Scurvy is very GOOD DD
keep it up.. Im sory i didnt inform it earlier
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| dr.vasim
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* hint from Lab reports :
total decrease in Leaukocyte Count, PLTLT count 30,000/cmm, Hgb 10.5g/dL , normal Liver func. tests with Normal Clotting T n factors.
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| drvic
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aplastic anemia
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| dr.vasim
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good, but my Frnd.. there is picture of PANCYTOPENIA in aplastic Anemia..
here only TLC n Thrmbctpenia.. rest other r normall.. even neurtophils, Hgb.. mild decresed...
& no Hx of exposure to drugs, radiation, or chemicals.
but even then doing Bone aspiration will b helpful I hope..
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| dr.vasim
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anywez after giving FFP n packed RBC.. the TLC increased to 4000 n PLTLTS to 50,000. n at same time started Methylpredni., but seem no effect on pltlts
SO, drvic ? which r the books or material U refer ? i hop will b smart smday like U 
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| drvic
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well aplastic anemia has its own differential diagnoses - there are a number of congenital marrow failure syndromes....won't burden you with fancy names but just in case u wanna listen - here's the list:
Fanconi's Anemia
Dyskeratosis Congenita
Schwachman Diamond Syndrome
Amegakaryocytic thrombocytopenia
etc. etc. a few more very rare ones i can't remember....
i feel that all three cell lines are depressed here, because an Hb of 10.5 isn't normal either....and even if you attribute it to the entity called Physiologic Anemia of Infancy, where such Hb levels may be seen; but then, look at the age of the child. by this age the physiologic anemia of infancy has usually subsided and erythropoiesis has picked up, unless of course your child is severely nutritionally deprived as well...
and you said that TLC and platelets are already low....so that does make it a pancytopenia....
anyway even for a bi-cytopenia, a bone marrow aspiration and biopsy (esp if aplastic anemia is being considered, biopsy should be taken simultaneously to avoid doing a repeat procedure if the aspirate comes dry or inadequate...as it usually does in most cases of aplastic) because it may still be a malignancy...seen a few cases wheer child received steroids before doing BM and it alters the bone marrow picture totally, and hides the picture of malignancy from being shown clearly. therefore, before starting steroids in such cases one should be very sure of the diagnosis.......
but you haven't given platelet concentrates to your patient yet....even then, has your patient received platelet transfusions before?? if he/she has, there could be platelet antibodies which are eating up all that you are transfusing...it'll improve gradually with the methylpred that you've started....
do work up the child for Fanconi's coz its never suspected and never sought by most people. for that you'll need to do study of clastogen-induced chromosome breakage studies (esp with Mitomycin C)
hope this helps....
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| dr.vasim
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yeah Thnx a lot .. hv focused more than ENUF.. n I appriciate it.
well the thng is after 3-4 day of methyl predni. the pt. increased not only PLTLT to 4 lkahs, but even TLC too .. no new bruises, echh, or purpura, + diminishin the old ones..
Discharged him n asked to come back next week with new Hemogrm.
THNX a lot n if thers smthn new, will keep u UPDATED.
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