Bleeding child: diagnostic approach: SAQ

Part A (10 marks)

a) What is the most likely diagnosis, and which two features of the presentation confirm that this is a primary-hemostasis (platelet-type) rather than a coagulation-type problem? (3 marks) ^[1]

The most likely diagnosis is immune thrombocytopenia, suggested by the sudden onset of petechiae and bruising in an otherwise well child one to two weeks after a viral illness, with isolated severe thrombocytopenia and no blast cells on the film. The two features confirming a primary-hemostasis problem are the petechial, mucocutaneous bleeding pattern, which is immediate and superficial, and the isolated thrombocytopenia with a normal prothrombin and activated partial thromboplastin time, excluding a coagulation-factor deficiency. ^[1]

b) Which single investigation is essential before any corticosteroid therapy is considered, and why? (3 marks) ^[3]

A peripheral blood film reviewed for blast cells is essential, together with the haemoglobin and white cell count, to exclude acute lymphoblastic leukaemia. Treating suspected immune thrombocytopenia with steroids before excluding leukaemia can mask the diagnosis and delay definitive chemotherapy. The absence of additional cytopenias, blasts, hepatosplenomegaly, and lymphadenopathy supports immune thrombocytopenia, but the film must be confirmed before treatment. ^[3]

c) Outline the immediate management priorities for this child. (3 marks) ^[4]

A well child with immune thrombocytopenia and only skin bleeding can be observed with a clear safety-net and early review, because most acute immune thrombocytopenia resolves spontaneously. Treatment with corticosteroids or intravenous immunoglobulin at 0.8 to 1 g per kg is reserved for significant bleeding, a very low count with risk features, or an urgent need to raise the count. Avoid intramuscular injections and invasive procedures. The family must be safety-netted to present immediately with head injury, severe headache, or any significant bleeding, because intracranial haemorrhage is the catastrophic risk. ^[4]

d) Why is the bleeding assessment tool useful in the initial evaluation of a child with bruising, and when should it be applied? (1 mark) ^[1]

The bleeding assessment tool quantifies whether the bleeding is truly abnormal, separating pathological bleeding from normal childhood bruising far better than clinical impression, and it should be applied before expensive tier-two tests are ordered. ^[1]