Treatment of acute immune thrombocytopenic purpura.

Medical history, physical examination, and laboratory testing are essential to arriving at the diagnosis of acute immune thrombocytopenic purpura (ITP). A history of recent viral illness occurs in about half of the pediatric patients who present with acute symptoms of ITP. The physical examination is normal except for purpura; a complete blood cell count with a differential white blood cell count can be used to confirm the diagnosis of acute ITP. Treatment decisions for acute ITP remain controversial. Treatment generally is designed to prevent life-threatening complications, such as intracranial hemorrhage, and may include single or combination therapy with corticosteroids, intravenous immunoglobulin (IVIg), anti-D, and splenectomy. Corticosteroids are inexpensive and offer an alluring option, especially in the recent era of cost-containment. The often slow platelet response and the potentially severe adverse effects of corticosteroid therapy are frequently a deterrent. IVIg usually leads to a rapid rise in platelet count; however, IVIg is very expensive and adverse effects associated with its infusion are common and sometimes troublesome. The role of anti-D in acute ITP is still evolving. It is similar to IVIg in platelet response and is considerably less expensive. Some degree of hemolysis, the main adverse reaction with anti-D, is inevitable due to the binding of anti-D antibody to Rh-positive erythrocytes. However, most cases of hemolysis do not require medical intervention. Splenectomy is reserved for refractory thrombocytopenia with life-threatening hemorrhage in acute ITP or after recurrent severe thrombocytopenia in chronic ITP. Other immunomodulatory therapies are also discussed.