G548(P) Retinal and intracranial haemorrhages – underlying haematological pathology or non-accidental injury

Abstract

Aims To investigate the cause of multiple unexplained retinal and intracranial haemorrhages – underlying haematological pathology or non-accidental injury Method We report the case of a 2 year old girl who had presented to the paediatric assessment unit with petechiae and was diagnosed with immune thrombocytopenic purpura, however a week later she was reviewed with evidence or new and old retinal haemorrhages following a scheduled appointment with an ophthalmologist due to developmental delay. Her mother called the hospital concerned about the haemorrhages however then did not attend the paediatric assessment unit until the following day. Why had she not attended despite her concerns? Results Once the patient had been assessed in addition to the retinal haemorrhages she was found to have multiple petechiae which were increasing in number. Her mother reported a similar episode of possible petechiae a few months previously in an otherwise healthy looking child. A repeat set of blood test showed persisting thrombocytopenia with a macrocytic anaemia with normal haematinics. Following discussion with a tertiary hospital, 2 doses of intravenous immunoglobulins and a platelet transfusion were given however the patient remained thrombocytopenic. Why was this patient resistant to therapy? Table 1. Due to the persistent thrombocytopenia and new onset neutropenia, on the advice of the tertiary hospital, central nervous system imaging was carried out which showed multiple foci of intraparenchymal haemorrhage, was this a missed case of NAI? Following transfer to the tertiary hospital the patient underwent a bone marrow biopsy which was consistent with bone marrow failure the aetiology of which is currently being investigated. A literature search (Pubmed) of retinal haemorrhages as the presenting finding in bone marrow failure has revealed no reported cases in paediatrics, however there were 114 cases of intracranial haemorrhage reported in children with ITP with 30 cases identified as having trauma the leading cause of the haemorrhage.