Diagnosis Of Immune Thrombocytopenic Purpura Research Articles

A Case of Investigation and Diagnosis of Immune Thrombocytopenic Purpura After Vaccination of COVID-19 Inactivated Vaccine

A Case of Investigation and Diagnosis of Immune Thrombocytopenic Purpura After Vaccination of COVID-19 Inactivated Vaccine

Red blood cell distribution width is a useful biomarker to predict bleeding and thrombosis risks in patients with immune thrombocytopenic purpura.

Bleeding and thrombosis are common complications during immune thrombocytopenic purpura (ITP) treatment. There is a strong need to predict bleeding and thrombosis risks before ITP treatment to optimize therapy and appropriately manage these complications. We performed a retrospective cohort study of 120 patients with primary ITP to identify a biomarker to predict bleeding and thrombosis. We compared blood test results at diagnosis between patients with and without bleeding or thrombosis episodes. The standard deviation of red blood cell distribution width (RDW-SD) differed significantly between those with and without bleeding and between those with and without thrombosis, leading us to identify it as a variable representative of risk. RDW-SD was significantly associated with patient age and with histories of several vascular diseases. Multivariate regression analyses showed that RDW integrated several variables associated with vascular risks. RDW-SD was significantly associated with difficulty with corticosteroid discontinuation (hazard ratio [HR], 2.22, p=0.01), incidence of bleeding (HR, 2.75, p< 0.01), incidence of thrombosis (HR, 2.67, p< 0.01) and incidence of infection (HR, 1.78, p=0.04). The RDW-SD value at the time of ITP diagnosis is a useful biomarker to predict the risks of bleeding, thrombosis, and other complications.

Egyptian Pediatric Guidelines for the Management of Children with Isolated Thrombocytopenia Using the Adapted ADAPTE Methodology-A Limited-Resource Country Perspective.

Thrombocytopenia is a prevalent presentation in childhood with a broad spectrum of etiologies, associated findings, and clinical outcomes. Establishing the cause of thrombocytopenia and its proper management have obvious clinical repercussions but may be challenging. This article provides an adaptation of the high-quality Clinical Practice Guidelines (CPGs) of pediatric thrombocytopenia management to suit Egypt's health care context. The Adapted ADAPTE methodology was used to identify the high-quality CPGs published between 2010 and 2020. An expert panel screened, assessed and reviewed the CPGs and formulated the adapted consensus recommendations based on the best available evidence. The final CPG document provides consensus recommendations and implementation tools on the management of isolated thrombocytopenia in children and adolescents in Egypt. There is a scarcity of evidence to support recommendations for various management protocols. In general, complete clinical assessment, full blood count, and expert analysis of the peripheral blood smear are indicated at initial diagnosis to confirm a bleeding disorder, exclude secondary causes of thrombocytopenia and choose the type of work up required. The International Society of Hemostasis and thrombosis-Bleeding assessment tool (ISTH-SCC BAT) could be used for initial screening of bleeding manifestations. The diagnosis of immune thrombocytopenic purpura (ITP) is based principally on the exclusion of other causes of isolated thrombocytopenia. Future research should report the outcome of this adapted guideline and include cost-analysis evaluations.

Immune Thrombocytopenic Purpura (ITP) as a Complication of COVID-19: A Case Report

Immune thrombocytopenic purpura (ITP) is a condition that can occur either spontaneously or as a secondary complication of preexisting disorders, often associated with viral infections. In the context of COVID-19, hematological manifestations, including thrombocytopenia, have been observed and linked to increased mortality rates among severely infected patients. Presented here is a case study of a 70-year-old man who recovered from COVID-19 but subsequently developed ITP. The severity of his thrombocytopenia exceeded what is typically observed during COVID-19 infections, leading to a diagnosis of ITP. Treatment with steroids and intravenous immunoglobulin (IVIG) was initiated based on specialist recommendations, resulting in an adequate response.

The diagnostic accuracy of mean platelet volume in differentiating immune thrombocytopenic purpura from hypo-productive thrombocytopenia: A systematic review and meta-analysis.

Thrombocytopenia is defined as a decreased number of platelets in the circulating blood as a result of hypo-proliferation in marrow or peripheral destruction of platelets. Several diagnostic methods have been proposed to discriminate the underline cause of thrombocytopenia. Recent studies showed that mean platelet volume (MPV) could be used for differential diagnosis of immune thrombocytopenic purpura (ITP). Thus, we aimed to investigate the diagnostic accuracy of MPV for differential diagnosis of ITP from hypo-productive thrombocytopenia. This study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines (PRISMA). The study protocol was registered on PROSPERO with the reference number CRD42023447789. Relevant published studies that were published up to April 10, 2023, in peer-reviewed journals were searched on electronic different databases. The methodological quality of the included studies was appraised using the quality assessment of diagnostic accuracy studies 2 (QADAS-2) tool. The pooled weight mean difference (WMD) of MPV between the ITP group and hypo-productive group was analyzed using a random-effects model meta-analysis. Relevant data were extracted using a Microsoft Excel spreadsheet and analyzed using STATA 11.0 and Meta-disc 1.4 software. Publication bias was evaluated using Deek's funnel plot asymmetry test. A total of 14 articles were included in this systematic review and meta-analysis. The comparison of MPV between groups revealed that the pooled mean value of MPV increased significantly in ITP patients compared to patients with hypo-productive thrombocytopenia (WMD = 2.03; 95% CI, 1.38-2.69). The pooled sensitivity and specificity of MPV in differentiating ITP from hypo-productive thrombocytopenia were 76.0% (95% CI: 71.0%, 80.0%) and 79.0% (95% CI: 75.0%, 83.0%), respectively. The summary positive likelihood ratio (PLR) and negative likelihood ratio (NLR)using the random effects model were 3.89 (95% CI: 2.49, 6.10) and 0.29 (95% CI: 0.18, 0.46), respectively. MPV can be used to discriminate ITP from hypo-productive thrombocytopenia. It can possess large advantages as it is noninvasive, simple, quick, inexpensive, easy to perform, reliable, and routinely generated by automated cell counters.

The Frequency of Immune Thrombocytopenic Purpura in Collagen Vascular Disorders

Background: Many rheumatologic conditions are associated with thrombocytopenia due to antibody-mediated platelet destruction. Knowing the rate of ITP patients who develop vascular collagen diseases and the developed type can help predict future treatments and even take preventive measures. Objectives: This study aimed to know the frequency of immune thrombocytopenic purpura (ITP) in collagen vascular disorders. Methods: The present retrospective cross-sectional study was conducted in 2020 on the health records of 447 eligible patients. First, the patient’s details, such as age, gender, marital status, age at diagnosis, time from the diagnosis of ITP to the development of lupus, and the patients’ ANA and anti-dsDNA test results, were extracted from their records and entered into the preparation checklist. Finally, the data were entered into SPSS-23 and analyzed at a statistically significant level of 0.05. Results: The mean interval between the initial diagnosis of ITP and vascular collagen disease diagnosis was 2.1 ± 0.9 years. The records of 336 patients with systemic lupus erythematosus (SLE) were also assessed, of whom 15 (4.5%) had first developed ITP and then lupus. Hence, of the 447 patients included in the study, 17 (3.8%) with a history of ITP then developed lupus. Conclusions: Comparing the present findings with the results of other studies shows that Iranian patients with ITP develop vascular collagen disease at a lower rate.

Concurrence of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura: a case report and review of the literature

BackgroundImmune thrombocytopenic purpura and thrombotic thrombocytopenic purpura are both causes of thrombocytopenia. Recognizing thrombotic thrombocytopenic purpura is crucial for subsequent treatment and prognosis. In clinical practice, corticosteroids and rituximab can be used to treat both immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura; plasma exchange therapy is the first-line treatment in thrombotic thrombocytopenic purpura, while corticosteroids are strongly recommended as first-line treatment in immune thrombocytopenic purpura. The differential diagnosis of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura is essential in clinical practice. However, case reports have suggested that immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura can occur concurrently.Case presentationWe report the case of a 32-year-old Asian female without previous disease who presented with pancytopenia, concurrent with immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura. The morphology of the megakaryocytes in the bone marrow indicated immune-mediated thrombocytopenia. The patient received glucocorticoid treatment, and her platelet count increased; however, schistocytes remained high during the course of the therapy. Further investigations revealed ADAMTS13 activity deficiency and positive ADAMTS13 antibodies. The high titer of antinuclear antibody and positive anti-U1-ribonucleoprotein/Smith antibody indicated a potential autoimmune disease. However, the patient did not fulfill the current criteria for systemic lupus erythematosus or mixed connective tissue disease. The patient responded well to plasma exchange therapy, and her platelet count remained normal on further follow-up.ConclusionsConcurrence of immune thrombocytopenic purpura and thrombotic thrombocytopenic purpura is rare, but clinicians should be aware of this entity to ensure prompt medical intervention. Most of the reported cases involve young women. Human immunodeficiency virus infection, pregnancy, and autoimmune disease are the most common underlying conditions.

Immune thrombocytopenic purpura: A case report

We report a case of immune thrombocytopenic purpura (ITP) in a 5-year-old female presenting with a maxillofacial injury. The patient attended through the emergency department with marked right periorbital ecchymosis and swelling following a head first collision. This case highlights the importance of early diagnosis of ITP, as well as consideration of a haematological cause in the presence of unexplained or excessive bruising.

Interleukin-37, vascular endothelial growth factor A, and transforming growth factor-β1: promising biomarkers in primary immune thrombocytopenia

ABSTRACT Background Immune thrombocytopenic purpura (ITP) is an acquired autoimmune hematologic disorder with heterogeneous bleeding manifestations. Many biomarkers such as interleukin-37 (IL-37), vascular endothelial growth factor A (VEGFA), and transforming growth factor-β1 (TGFß1) have a role in immunity, inflammation, and megakaryopoiesis. Methods In the present study, immunoassay of interleukin-37 as well as the gene expression of vascular endothelial growth factor A and transforming growth factor-β1 were done in 60 primary ITP patients, 60 thrombocytopenia patients, and 60 healthy volunteers. Results Increased IL-37 level and down regulation of VEGFA and TGFß1gene expression were detected in primary ITP patients when compared with other groups. A negative correlation was observed between IL-37 and platelet count. However, a positive correlation was observed between VEGFA and TGFß1 levels and platelet count. Conclusion Current results suggested that interleukin-37, vascular endothelial growth factor A, and transforming growth factor-β may be promising indicators in the diagnosis of ITP and detection of disease severity with inexpensive and cost-effectiveness compared to the benefits.

Pre- and postpregnancy platelet counts: evaluating accuracy of gestational thrombocytopenia and immune thrombocytopenia purpura diagnoses

Given the overlapping clinical indicators and lack of diagnostic testing, misdiagnosis of immune thrombocytopenic purpura and gestational thrombocytopenia in pregnancy may be common. Current recommendations suggest utilizing platelet nadir during pregnancy to guide diagnosis. This study aimed to assess the accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses using pre- and postpregnancy platelet counts. This was a retrospective cohort study of patients diagnosed with gestational thrombocytopenia and immune thrombocytopenic purpura from January 2017 to December 2019. Platelet counts were extracted from charts and evaluated at several time periods, namely prepregnancy (within 5 years), during pregnancy, and postpartum (>6 weeks to 5 years). A diagnosis of gestational thrombocytopenia was considered inaccurate if platelet counts were <150,000/µL pre- or postpregnancy with no other apparent causes or if the platelet nadir dropped below 100,000/µL during pregnancy. A diagnosis of immune thrombocytopenic purpura was deemed inaccurate if pre- or postpregnancy platelet counts were >150,000/µL. The primary outcome was accuracy of gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses in patients. Secondary outcomes included mean platelet counts during pregnancy and difference in mean platelet counts for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia. Outcomes were summarized with descriptive statistics and compared using Student t tests. A total of 116 patients met the inclusion criteria of which 111 (96%) and 5 (4%) had gestational thrombocytopenia and immune thrombocytopenic purpura diagnoses, respectively. Platelet counts outside of pregnancy were available for 91 (82%) of the patients, and 66 (57%) had prepregnancy platelet counts available. Of the 91 patients, the diagnosis was considered accurate in 61 (67%) and 5 (100%) patients with gestational thrombocytopenia and immune thrombocytopenic purpura, respectively. Conversely, 30 of 35 (86%) patients with immune thrombocytopenic purpura were found to be inaccurately diagnosed with gestational thrombocytopenia after application of platelet thresholds. Among these 30 patients, 10 had a prepregnancy platelet count <150,000/µL, 12 had a postpartum platelet count <150,000/µL, 3 had a platelet count nadir <100,000/µL during pregnancy, and 7 met more than 1 criterion. Pre- and postpregnancy platelet counts and platelet count nadir differed significantly for patients with an accurate vs inaccurate diagnosis of gestational thrombocytopenia (P<.001). When pre- and postpregnancy platelet counts were checked, one-third of cases of gestational thrombocytopenia met the criteria for immune thrombocytopenic purpura and were thus incorrectly diagnosed during pregnancy. Prepregnancy platelet counts, available for most patients, should be considered when diagnosing gestational thrombocytopenia vs immune thrombocytopenic purpura.

Oral Manifestations of Immune Thrombocytopenic Purpura

Introduction: Hemorrhagic lesions of the oral mucosa are the most common clinical manifestations of Immune thrombocytopenic purpura (ITP). Case Report: A 41-year-old female patient consulted the oral surgery department of the dental consultation and treatment center in Rabat for spontaneous gingivorrhagia. Clinical examination and further examination showed severe thrombocytopenia associated with an anemic syndrome. The diagnosis of ITP was made. Treatment was based on oral corticosteroids and immunoglobulin in the hospital. Conclusion: These manifestations sometimes lead the patient to consult his dental surgeon in the first intention, hence the need to make the diagnosis based on a thorough global examination and to refer the patient to an adapted structure.

Myelodysplastic Syndromes (MDS) Presenting with Isolated Thrombocytopenia: Characteristics, Outcomes, and Clinical Presentation Differences from Immune Thrombocytopenic Purpura (ITP)

Myelodysplastic Syndromes (MDS) Presenting with Isolated Thrombocytopenia: Characteristics, Outcomes, and Clinical Presentation Differences from Immune Thrombocytopenic Purpura (ITP)

Simultaneous Occurrence of Cerebral Venous Sinus Thrombosis and Immune Thrombocytopenic Purpura in a Patient with a History of COVID-19 Infection.

Since the emergence of the coronavirus disease 2019 (COVID-19) pandemic, multiple but rare complications of this infection have been described, comprising cerebral venous sinus thrombosis (CVST) and immune thrombocytopenic purpura (ITP). Although these two complications have been reported as separate entities, to the best of our knowledge, their concurrent presentation has not been reported. In this case report, we present a middle-aged man with a history of COVID-19 infection who developed a sudden-onset severe occipital headache followed by right-sided blindness (right homonymous hemianopia). Upon his diagnostic workup, brain computed tomography scan with and without contrast was indicative of thrombosis of the left transverse venous sinus and hemorrhagic venous infarction. In addition, laboratory data revealed thrombocytopenia, which upon investigation confirmed a diagnosis of ITP. We postulate three pathophysiological mechanisms for this circumstance: either COVID-19 infection caused ITP and then ITP gave rise to CVST, or COVID-19 complications themselves resulted in ITP and CVST independently and simultaneously, or another plausible mechanism is immune-mediated thrombocytopenia caused by the anti-platelet 4-factor antibody, which is the proposed mechanism for CVST after the COVID-19 vaccine.

Oral Manifestations of Immune Thrombocytopenic Purpura

Introduction: Hemorrhagic lesions of the oral mucosa are the most common clinical manifestations of Immune thrombocytopenic purpura (ITP). Case Report: A 41-year-old female patient consulted the oral surgery department of the dental consultation and treatment center in Rabat for spontaneous gingivorrhagia. Clinical examination and further examination showed severe thrombocytopenia associated with an anemic syndrome. The diagnosis of ITP was made. Treatment was based on oral corticosteroids and immunoglobulin in the hospital. Conclusion: These manifestations sometimes lead the patient to consult his dental surgeon in the first intention, hence the need to make the diagnosis based on a thorough global examination and to refer the patient to an adapted structure.

SAT-678 New Onset Type 1 Diabetes and Immune Thrombocytopenic Purpura in an Adolescent Male: A Case Report

INTRODUCTION:Type 1 diabetes mellitus (T1D) is an autoimmune condition caused by anti-pancreatic antibodies which attack and destroy the insulin-producing beta cells. Similarly, in immune thrombocytopenic purpura (ITP), anti-platelet antibodies destroy platelets, causing low platelet counts which can lead to petechiae and bleeding. Common autoimmune conditions seen in children with T1D include thyroid and celiac disease. Previous case reports discussed ITP in children with known T1D. Our patient presented with new onset T1D and diabetic ketoacidosis (DKA) in addition to new onset ITP.CLINICAL CASE:The patient is a 12 year old previously healthy male with a several week history of polyuria, polydipsia and nocturia, in addition to fatigue and lack of weight gain in the previous two years. Initial labs confirmed diagnosis of T1D with hemoglobin A1c of 12.9% and serum glucose of 460 mg/dL, in addition to DKA, with bicarbonate of 13 mmol/L, pH of 7.30, elevated anion gap and beta-hydroxybutyrate. Due to the presence of DKA, the patient was started on an insulin drip. Thyroid labs showed hyperthyroidism, with TSH- <0.02 (0.5-4.5 mIU/L) and free T4- 2.84 (0.7-1.68 ng/dL), so he was started on methimazole 20 mg daily. Confirmatory pancreatic antibodies and thyroid antibodies were sent. CBC showed thrombocytopenia with initial platelet count of 41,000, hemoglobin of 16.9 g/dL, and white blood cells of 5.05. Follow up platelets continued low at 37,000, so he was seen by a hematologist, which confirmed the Diagnosisx of ITP. Patient had a history of easy bruising in arms and legs, one episode of epistaxis and minimal bleeding after brushing teeth, with negative history of hematuria. Follow up labs resulted in negative thyroid antibodies (TPO Ab, TSI and thyroglobulin Ab) with normalization of labsthyroid function tests, so the methimazole was discontinued. Patient is being followed by Hematologya hematologist, and pancreatic antibodies were done, which were negative. Hematology concurred with diagnosis of ITP despite negative antibodies due to diagnosis of T1D. First line therapy for ITP is IVIG and steroids, however due to national shortage of IVIG and risk for worsening hyperglycemia with steroids, these were avoided. Instead, patient was started on Eltrombopag daily for treatment of his ITP. Platelet count has improved on eltrombopag, with latest range of 126-146,000. Latest hemoglobin A1c is of 6.2%.CONCLUSION:In the case of new onset type 1 diabetes mellitusT1D, it is’s important to keep in mind that ITP is another autoimmune condition that can present in these patientspresent. In addition to IVIG and steroids, Eltrombopag is a good ttreatment option that does not interfere with glycemic control. More research is needed to measure the frequency of ITP among patients with type 1 diabetes.

Minimally invasive surgical treatment in patients with immunological thrombocytopenic purpura

Two female patients, one 28 years-old, and the other 61 years-old, with a history of asthenia, purpura and thrombocytopenia (both &lt;15,000 platelets / mm3). Once other etiologies were excluded, and the diagnosis of immune thrombocytopenic purpura (ITP) was established, corticoid therapy was started in both cases. However, the patients remained with a platelet count &lt;20,000 / mm3, characterizing refractory ITP, and the splenectomy was indicated. The surgical team opted for a hybrid minimally invasive surgical procedure. Providing a better visualization of the surgical field, less abdominal trauma, greater technical dexterity, and early hospital discharge, the use of minilaparoscopic instruments proved to be a safe and effective approach for these patients.

Hormonal contraceptive induced immune thrombocytopenic purpura

Immune thrombocytopenic purpura (ITP) is an acquired disorder of platelets that clinically manifests with mucocutaneous bleeding. There areseveral causes of ITP, but its association with hormonal contraceptive implants has not been widely reported. A 39‑year‑old Para 10+0 7 alivepresented to the Yobe State University Teaching Hospital with complaints of nasal bleeding, gum bleeding, purpura, and menorrhagia, whichwere noticed a month after insertion of a Levonorgestrel – containing hormonal contraceptive implant, at a Primary Healthcare facility. Completeblood count, peripheral blood film, and bone marrow aspiration cytology led to the diagnosis of ITP. Epistaxis was managed conservatively.The patient was placed on prednisolone with a noticeable increase in platelet count and remarkable improvement in the clinical state. ITP is acomplication of the hormonal contraceptive implant. Clinicians should be aware of the possible association of contraceptive implants and ITP. Keywords: Hormonal contraceptive implants, immune thrombocytopenic purpura, mucocutaneous bleeding, prednisolone

Platelets level response after three days therapy in children with acute Immune Thrombocytopenic Purpura (ITP): a 10 years’ experience at the tertiary hospital

Background: Immune thrombocytopenic purpura (ITP) is the most common cause of thrombocytopenia in children that characterized by isolated thrombocytopenia that vary in bleeding manifestations. The onset of disease is sudden and a self-limiting condition that requires treatment when clinically significant bleed occurs. A treatment goal is to increase platelet level above safety level and reduce the risk of severe bleeding. This study aims to evaluate the platelets level increment after three days treatment among children with acute ITP.Methods: An analytic retrospective cross-sectional study was conducted in Haematology-Oncology Paediatric Division Sanglah General Hospital, Bali, Indonesia from October 2008 to October 2018 in ITP patients. Diagnosis of ITP was evaluated based on the clinical manifestation and laboratory finding. Oral corticosteroid medication with dosage 2 mg/kg/day or 4 mg/kg/day with or without platelets transfusion were enrolled in this study from medical records. Data were analyzed using SPSS version 20 for Windows.Results: There were 93 children met the inclusion criteria and included in this study. A median platelets level at admission was 6.81(1-86.8) x 109/L. Majority symptoms of children with ITP in our tertiary care centre presented with mild to moderate clinical bleeding symptoms. Only 5.6% children with platelets level below 10x109/L had intracranial bleeding. Median platelets level was 31(2.47-382) x 109/l and there was a significant platelets level increment after three days of therapy (P&lt;0.05).Conclusion: The platelets level increment significantly in children with acute ITP after three days of therapy.

Immune thrombocytopenic purpura increased risk of subsequent pancreatitis: A Nationwide population cohort study

Immune thrombocytopenic purpura (ITP) is characterized by thrombocytopenia and bleeding diathesis. Pancreatitis is a very rare complication but may be fatal. We analyzed data of newly diagnosed ITP patients, excluding those with a history of splenectomy, unknown sex or date of birth, or preexisting pancreatitis at the time of ITP diagnosis, and compared these with selected age-, gender-, and index-year-matched controls, using the Taiwan National Health Insurance Research Database from 1996 to 2013. The study enrolled 100,177 ITP patients and 100,177 controls. We found that pancreatitis risk was higher in secondary ITP patients, regardless of age group, gender, baseline Charlson comorbidity index (CCI) score, history of biliary stone, hyperlipidemia, or alcoholism, than in the control population. Primary ITP patients with CCI score 1 and without biliary tract stone history also showed a higher pancreatitis risk than the controls. The incidence rate and cumulative incidence of pancreatitis were increased in primary, secondary, and unspecified ITP cases. These phenomena may be related to the presence of autoantibodies against glycoprotein IIb/IIIa, or to IgG4, microparticle obstruction, or sclerosis. We noted a direct association between ITP and the development of pancreatitis in Taiwan population.

Teetering on a liver\u2019s edge: a case report highlighting clinical decision-making in thrombocytopenia

BackgroundThis report illustrates the importance of a detailed history and physical exam and careful analysis of hematologic parameters when diagnosing ITP. This case demonstrates that even with subtle deviations from typical ITP findings one must promptly reevaluate the diagnosis. This case also highlights the importance of peripheral smear review by an expert in pediatric hematopathology.Case presentationA previously healthy 10 year-old Asian boy presented with 2 months of easy bruising. Review of systems was negative for any constitutional symptoms. On examination, he appeared well but had numerous large ecchymoses. He had no appreciable lymphadenopathy or splenomegaly. The liver was palpable 1.5 cm below the costal margin. A complete blood count (CBC) showed: platelets = 17 × 109/L, hemoglobin = 128 g/L, white blood cell count = 5.43 × 109/L, and neutrophils = 1.63 × 109/L. A blood smear was reported as normal. Urate was 370 umol/L and lactate dehydrogenase (LDH) was 803 U/L. The child was admitted with a presumptive diagnosis of immune thrombocytopenic purpura (ITP) and treated with intravenous immunoglobulin. The following day, the blood smear was reviewed by a hematopathologist who identified blasts. A bone marrow aspiration (BMA) confirmed the diagnosis of precursor B-cell acute lymphoblastic leukemia.ConclusionIn children presenting with suspected ITP, leukemia should always be considered. A BMA was historically performed on all patients with presumed ITP to rule out leukemia. In 2011, the American Society of Hematology (ASH) stopped recommending routine BMA in patients suspected of having ITP. ASH advises in cases with unusual findings on history, physical examination or CBC, it is reasonable to perform a BMA. Our patient had mild hepatomegaly, which may have qualified him for a BMA. He also had an elevated LDH and urate, which are not listed as criteria for BMA by ASH but were considered atypical for ITP by the clinical team. A literature search did not reveal any primary data assessing these markers.While corticosteroids are a first line treatment in ITP, they must be reserved for when clinicians are confident that the patient does not have leukemia. Steroid administration prior to diagnosing leukemia results in delayed diagnosis and may increase the risk of complications and decrease survival.