Abstract
Idiopathic thrombocytopenic purpura is a condition frequently encountered in childhood. Extensive literature currently exists on its etiology and management. Petechiae, ecchymoses and epistaxis are the usual manifestations of this condition, originating from the autoimmune destruction of platelets. Bleeding may occur spontaneously from any mucosal membrane. While bilateral hemotympanum has yet to be documented as a possible complication of this condition, immediate impact on the child’s hearing will require appropriate follow-up.
Keywords: Bilateral hemotympanum, Hemotympanum, Idiopathic thrombocytopenic purpura
Abstract
Le purpura thrombopénique idiopathique est une maladie courante pendant l’enfance. De nombreux documents scientifiques portent sur son étiologie et sur sa prise en charge. Les pétéchies, les ecchymoses et l’épistaxis en sont les manifestations habituelles, causées par la destruction auto-immune des plaquettes. Une hémorragie de la muqueuse peut survenir spontanément. L’hémotympan bilatéral n’a encore jamais été documenté comme complication possible de cette maladie, mais son effet immédiat sur l’ouïe de l’enfant exige un suivi pertinent.
CASE PRESENTATION
A 22-month-old boy presented after a one-week history of increased bruising. It was noticed after an upper respiratory tract infection of one-week duration. His symptoms included rhinitis, fever, anorexia and cough, but had completely resolved one week later when propensity to bruising became evident. The child was previously healthy with no recent history of nonsteroidal anti-inflammatory drug use or chronic illness. The emergency room visit was delayed because of fear on the part of the parents that they would be accused of physical abuse.
The patient was transferred to the Centre hospitalier de Val-d’Or, Quebec, after a complete blood count at a local community health centre revealed a platelet count of 7×109/L. On examination, the patient was an active young boy with multiple frontal hematomas and numerous ecchymoses on his tibias, buttocks and upper limbs. Petechiae were also present below his eyes and on his hands and feet. The remainder of the physical examination was unremarkable. The laboratory findings were repeated, and his platelet count reached a nadir of 3×109/L; he was found to be mildly anemic (hemoglobin 106 g/L). The patient’s leukocyte levels were in the normal range.
He was rapidly started on intravenous immunoglobulins at 1 g/kg. A first dose was given over 6 h the night of admission, and a second dose was given 24 h later. The platelet response was slow, rising only to 8×109/L after the first intravenous immunoglobulin infusion, and rising to 16×109/L after the second dose. The treatment was well tolerated. However, his hospital course was complicated by gingival bleeding on the second day of admission. Furthermore, on the third night of hospitalization, he experienced epistaxis from the right nostril, which lasted for less than 10 min and resolved with compression. On the fourth day, his platelet count was up to 32×109/L. His parents, however, noted that he was touching his ears, especially the right one, more than usual.
On examination, both tympanic membranes were dark, a contrast compared with the admission examination. A ear, nose and throat consultation was requested, and the diagnosis of bilateral hemotympanum was confirmed. The cause was attributed to spontaneous bleeding in both middle ears because the epistaxis was unilateral and limited in time. There was no previous history of ear infections, such as chronic otitis media. His parents were reassured that the condition was self-limiting, and that his hearing capacity was only affected for a short period of time. The patient was discharged home with follow-up by a paediatrician and an otorhinolaryngologist.
DISCUSSION
Idiopathic thrombocytopenic purpura (also known as autoimmune thrombocytopenic purpura of childhood) is a condition characterized by thrombocytopenia, resulting from antiplatelet antibodies (immunoglobulin G or M). Once bound by the antibodies, the platelets are subsequently trapped by the reticuloendothelial system. It usually occurs one to four weeks after a viral infection. It must be distinguished from other hematological diseases including leukemia, idiopathic aplastic anemia or autoimmune disease (eg, systemic lupus erythematosus). Treatment is not necessary because it is self-limited, except in severe thrombocytopenia. Treatment options include gammaglobulins or steroids (1).
The classical presentation includes petechiae, ecchymoses and epistaxis. Spontaneous bleeding can occur from any site, especially mucous membranes (2). However, bilateral hemotympanum is not a frequent finding. The existing literature reports bilateral hemotympanum in cases of skull fractures and in hematological conditions such as leukemia. Other known causes include nasal packing, retrograde hemorrhage secondary to epistaxis or blunt trauma to the head. No current reports exist in the literature regarding this presentation in idiopathic thrombocytopenic purpura. Considering the immediate impacts of hemotympanum on a child’s hearing, and documentation for future follow-up and examination, we recommend that tympanic membranes be routinely examined in children with idiopathic thrombocytopenic purpura. A ear, nose and throat consultation may be warranted for appropriate follow-up.
REFERENCES
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