Background ITP is an acquired condition caused by Ig-G mediated platelet destruction. The aetiology is unknown, but there is often an infectious process that triggers this aberrant immune response. Laboratory investigations are associated with isolated thrombocytopenia, increased megakaryocytes and clinically petechiae on skin and/or mucous.
Presentation 4-year-old child, male, without significant pathological history, current illness shows insidious onset 1 month ago with multiple episodes of epistaxis. On the day of admission to hospital clinical examination reveals malaise, sick face, paleness with multiple petechial elements with tendency to generalise and multiple bruises. Laboratory investigations highlights thrombocytopenia-8000/ul, leukocytosis-14000/ul, positive CRP, elevated ESR, positive IgG antitoxoplasma, reactive IgM antitoxoplasma. Blood smear shows very rare platelet, isolated aspect of large platelet. Marrow count highlights megakaryocytes. Chest radiography shows diffuse peribronchial infiltrates. We initiated treatment with intravenous human immunoglobulin 400 mg/kg/day on 4 consecutive days, as well as antibiotic and symptomatic treatment. During hospitalisation, in day 3 our patient presents intense headache, vomiting, somnolence, raising the suspicion of an intracranial hypertension syndrome. Following neurological consultation, cranial MRI is recommended, and reveals a minimal hypoplasia of the lower cerebellar hemispheres, cisterna magna dilated, subacute maxillo-etmoido-sphenoidal inflammation, intracranial hypertension syndrome. EEG shows irritative aspect. We started depletion and steroid treatment, with favourable evolution and intracranial hypertension syndrome remission. Day 11 after admission, child presents maculopapular exanthema in the upper limb and thoraco-abdominal, intensely itchy, with a tendency to generalise, that rises the suspicion of an infectious-contagious disease but is was disproven after consultation. Subsequent course was to suspect an allergic cause and it was recommended to stop antibiotic and symptomatic medication, and introduce corticosteroid treatment, after that, the evolution was gradual favourable, reducing symptoms. Platelet count at hospital discharge was within normal limits.
Conclusions The particularity of our case is adding multiple diagnoses: ITP, sinusitis, pneumonia, toxoplasmosis, intracranial hypertension syndrome, cerebral malformation, allergic reaction.
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