Immune thrombotopenia (ITP) is the most common thrombocytopenia bleeding disorder in childhood and is characterized by simple thrombocytopenia, while the other two lines of blood cells are normal. The disease is more common in children aged 2 to 5 years, and is often presented with a "needle-like" rash on the skin.
In the following case, the child has needle-like petechiae and ecchymosis all over the body, is it ITP? Or is there something else?
Case after
The child, female, 3 years old and 2 months old, came to the clinic for 2 days because of the discovery of petechiae and ecchymosis throughout the body. The condition is roughly as follows: 2 days ago, there were needle-like petechiae and ecchymosis scattered on the back, back to the limbs, chest, and face, accompanied by 1 nasal bleeding, the amount was small, the rash gradually increased, there was no other discomfort, and he came to the hospital for treatment.
Physical examination:
Body temperature 36.8 °C, pulse 110 beats / min, breathing 25 times / min, SPO298%, weight 14 kg, face, chest, back, limbs can be seen scattered in needle-like petechiae, ecchymosis, left forearm visible 2 cm× 1.5 cm hematoma, tenderness, 4 cm × 2 cm hematoma in the posterior lumbar sacrumb, tenderness. Ecchymos may be seen on the mucosa of the palate, and pinprick-like bleeding spots may be seen in the gums and tip of the tongue.
If the child has needle-like petechiae + ecchymosis, there is no other discomfort, what will be the cause?
Hurry up and check the blood:
The prothrombin time >200 seconds, the activated partial thromboplastin time was 181.20 seconds, the blood scale: hemoglobin 118.0 g/L, platelet count 433×109/L, blood group: Rh (D) + positive, type A, liver function, reticulocyte count, D-dimer did not see obvious abnormalities.
Case Summary:
There was no history of taking drugs in previous physical examinations, acute bleeding disorders, prothrombin time (PT), activated partial thromboplastin time (APTT) were significantly increased, platelets, liver function, reticulocyte count, D-dimer, and inflammatory indicators were not significantly abnormal.
Obviously, according to the preliminary examination results, consider the coagulation dysfunction caused by certain factors, common persistent hemorrhagic coagulation disorders, such as thrombocytopenia, oral anticoagulants, sepsis, acute poisoning, liver function impairment, severe trauma, etc.
The child had no obvious clinical signs and symptoms of infection, denied trauma, checked blood to show platelets, liver function, and inflammatory indicators were not abnormal, and also denied the history of taking anticoagulant drugs, excluding thrombocytopenia, oral anticoagulants, sepsis, liver function damage, and severe trauma, and the possibility of acute poisoning was the greatest.
Ask for medical history, there is a suspected environmental condition of exposure to rat poison in the child's home, and it is considered that the coagulation dysfunction caused by the child's exposure to rat poison is highly likely.
Subsequently, the family said that there was a rodenticide in the family, which was bromovirin, the English common name brodifacoum, the ingredient was "Dalong", and the second generation of anticoagulant rodenticide. Give symptomatic treatment and draw blood to the judicial department for examination, oral report that the blood poison analysis of the child can see the rodenticide ingredients!
Image source: Network
Of the many types of rodenticides, anticoagulants are the most commonly used dosage forms. As mentioned above, the bromine rat spirit (the ingredient is "Dalong") is one of them, which is a long-acting anticoagulant, also known as "super warfarin", and the same type is bromopyrrolone and chlordiapron.
Rat dosage forms include: grain bait, small pills, paste, tracking powder, wax blocks, etc., more commonly grain bait, the shell is dyed with bright color to remind humans to avoid contact.
When poisoning caused by rat feeding or human ingestion, contact, etc., the onset of the disease does not occur immediately (it can occur within a few hours when a large number of contacts). Because anticoagulants need to work by inhibiting vitamin K-1,25 oxyoxy reductase, the original vitamin K is not affected, and affects the subsequent production of vitamin K and vitamin K-dependent coagulation factors II., VII., IX., X. and the like.
Moreover, coagulation disease occurs only when the activity of coagulation factors drops below 30% of the normal value, a process that usually takes 24 to 48 hours to change symptoms and laboratory results.
Major laboratory test changes: prolonged PT, elevated International Normalized Ratio (INR), decreased prothrombin levels. Platelets and hemoglobin are not abnormal (massive bleeding or hemorrhagic anemia may occur during multiple blood tests).
Lessons learned
Acute intoxication, particularly anticoagulant poisoning, should be considered after clinical exposure to unexplained skin ecchymosis and/or bleeding symptoms (acute bleeding disorders emphasized here, rather than chronic), after exclusion of thrombocytopenia, oral anticoagulants, sepsis, liver function impairment, severe trauma, and decreased congenital coagulation factors.
When a child comes to the clinic, it is often more than 48 hours away from contact with rat poison, and it is particularly important for us to ask about the history of exposure to anticoagulant rodenticide in addition to improving blood routine, biochemical and coagulation function tests, which is also an important basis for disease diagnosis. If the history of exposure to rodenticide cannot be followed up and the likelihood of acute poisoning is highly clinically considered, blood can also be drawn for testing of rodenticide components to assist in diagnosis.
In addition, diagnostic treatment with vitamin K1 (5 to 10 mg) may also be considered if prothrombin time is significantly improved in 24 to 48 hours, and anticoagulant poisoning may also be considered.
Treatment, if the symptoms are more severe, if necessary, plasma or prothrombin complex can be transfused to correct coagulation dysfunction, vitamin K1 can be given to continue treatment after discharge, weekly coagulation function testing, according to the different half-life of the rodenticide, vitamin K1 course of about 1 to 8 months, premature discontinuation of the drug may have repeated bleeding.
【Reference】
Expert group for the diagnosis and treatment of acute hemorrhagic coagulation dysfunction. Expert Consensus on diagnosis and treatment of acute hemorrhagic coagulation dysfunction (2020).Chinese Journal of Emergency Medicine.2020.29(6)
ZHU Jihong. Bleeding of unknown origin: Diagnosis and treatment of anticoagulant rodenticide poisoning. The 13th National Conference on Resuscitation and Poisoning Academic Paper Exchange Meeting of emergency medicine branch of Chinese Medical Association.2009
Jiang Ting, Wang Weiwei, Li Chunyu, et al. Clinical characteristics of anticoagulant and rodenticide poisoning in a family of six[J].Chinese Journal of Health Emergency Electronics.2016,(2).129-130.
Luo Changchun. Clinical analysis of anticoagulant rat poisoning in children[J].Medical Dietary Therapy and Health.2018,(12)
Source: Pediatrics Channel of the Medical Professions
Edited by: Yeah Reviewer: Xiao Ran