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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2009  |  Volume : 27  |  Issue : 1  |  Page : 58-61
 

Acute immune thrombocytopenic purpura triggered by insect bite


1 Government Dental College, Rohtak, India
2 D.J College of Dental Sciences and Research, Modinagar, India

Correspondence Address:
R Namdev
16/12 J, Medical Campus Rohtak
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.50821

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   Abstract 

Idiopathic Thrombocytopenic Purpura (ITP) is a blood disorder characterized by an abnormal decrease in the number of platelets in the blood. Acute thrombocytopenic purpura is most commonly seen in young children, with a sudden onset, following a viral illness, vaccination or an insect bite. The report is a rare case of ITP, which was triggered by a honey-bee bite and caused continuous intermittent bleeding from the gingival sulcular region of the maxillary left permanent first molar, and ecchymotic spots on the forehead, scalp, and lower limbs. A complete hemogram revealed severe thrombocytopenia with platelet count as low as 15,000/mm3. The patient was immediately hospitalized and administered platelet replacement and medication. With this report, the authors, as dentists, emphasize the significance of recognition, early diagnosis, and referral of such patients with bleeding disorders to specialized centers, for prompt treatment.


Keywords: Auto-immune, ecchymosis, idiopathic, petechiae, purpura, thrombocytopenic


How to cite this article:
Namdev R, Dutta S R, Singh H. Acute immune thrombocytopenic purpura triggered by insect bite. J Indian Soc Pedod Prev Dent 2009;27:58-61

How to cite this URL:
Namdev R, Dutta S R, Singh H. Acute immune thrombocytopenic purpura triggered by insect bite. J Indian Soc Pedod Prev Dent [serial online] 2009 [cited 2019 Jul 19];27:58-61. Available from: http://www.jisppd.com/text.asp?2009/27/1/58/50821



   Introduction Top


Idiopathic Thrombocytopenia Purpura (ITP) is a hematological disorder characterized by the markedly decreased number of circulating blood platelets. A platelet count of 15,0000 to 40,0000/mm 3 is considered normal. It occurs when the platelet count is below 40,000/mm 3 .

The American Society of Hematology defined ITP as isolated thrombocytopenia (low platelet count, with otherwise normal results on complete blood count and peripheral blood smear) in a patient with clinically no apparent associated conditions or factors that could cause thrombocytopenia (such as, infection with the human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), lymphoproliferative disorders (LPDs), myelodysplasia, agammaglobulinemia, therapy with certain drugs, alloimmune thrombocytopenia, and congenital or hereditary thrombocytopenia). An abnormal blood count or peripheral blood smear due to a coexisting nonimmune condition (such as, iron deficiency or thalassemia minor), does not, in itself, exclude the diagnosis of ITP. [1] There are two forms of ITP [Table 1]. Acute thrombocytopenic purpura is most commonly seen in young children (two to six years old). The symptoms may follow a viral illness, [2],[3] vaccination or insect bite. [4] The disease is classified as chronic if the platelet count does not stabilize within a period of six months. The report is a rare case of ITP that was triggered by an insect bite.


   Case Report Top


A nine-year-old female patient [Figure 1] reported to the Department of Pedodontics, Government Dental College, Rohtak, with a chief complaint of continuous intermittent bleeding from the gums of the upper left back teeth region since five days, which occurred after a honey bee bit inside her mouth. The patient was trying to eat a "laddu" and as she opened her mouth wide, a honey bee entered her mouth and bit her. History of pain and bleeding from the bite site during eating was present. There was no history of any bleeding problem till then and the medical, surgical, and family histories were noncontributory. Her height and weight were appropriate for her age. A general physical examination revealed that the patient was moderately built and nourished for her age. Her vital signs were normal and there was no hepatosplenomegaly. On lymph node examination, the bilateral submandibular lymph nodes were enlarged and palpable. Furthermore, the lymph nodes were firm, solitary in number, mobile, tender, and measuring about 1 x 1.5 cm in dimension. An intraoral examination revealed bleeding from the sulcular region [Figure 2] of the palatal aspect of maxillary left permanent first molar and bluish discoloration of the gingiva. A pressure pack with topical hemostat application (Tranexamic acid) and stat vitamin-K 5 mg injection was given and patient was referred for blood investigations. A complete hemogram revealed severe thrombocytopenia with the platelet count as low as 15000/mm 3 . Bleeding time was found to be raised (12 minutes). The blood picture showed hypochromic microcytic anemia. PT (Prothrombin Time) and PTT (Partial Thromboplastin Time) were normal.

Considering the findings, the patient was referred to the Pediatrics Department and was admitted there. Dengue serology was also done, which reported negative for anti-dengue antibodies. These tests predominantly differentiated this particular diathesis from other blood disorders. As an emergency treatment, platelet rich plasma and packed cell volume were administered, followed by an injection of Lasix 20 mg IV stat. The bleeding stopped after 20 minutes of this treatment. Injections of Avil 6 mg I.V stat and Dexamethasone 6 mg I.V stat were also administered. The bone marrow examination revealed megakaryocytic thrombocytopenia (megakaryocytes increased in number with some of them immature in morphology). An antinuclear antibody test (Enzyme Liked Immunosorbent Assay - ELISA) tested positive for antibodies. Meanwhile, the patient also developed ecchymotic and petechial spots on the forehead, scalp, and lower limbs [Figure 3],[Figure 4],[Figure 5]. Considering the complete clinical examination and investigations, a final diagnosis of ITP was made.

There was again active bleeding from the same site the next day, which continued for two days, and the patient needed blood transfusion again on both days. A complete hemogram with absolute platelet count was done daily. The platelet count kept between 20,000 and 40,000/mm 3 and the patient remained in the Pediatric Department for a total of eight days. The patient was discharged when there was no report of active bleeding for the last four consecutive days [Figure 6]. The patient was instructed to report every week for follow-up, as the platelet count was still low when she was discharged and so she was at a risk of bleeding. After 20 days of discharge, the patient reported back with bleeding from gums in the lower anterior teeth region. Again, the patient remained admitted for nine days. Platelet concentrate was administered and the bleeding was controlled. Daily an absolute platelet count was done and the platelet count kept between 30,000 and 45,000/mm 3 , and rose to 1.5 lakhs/mm 3 when the patient was finally discharged.


   Discussion Top


Idiopathic Thrombocytopenia Purpura has also been called immune or autoimmune thrombocytopenic purpura. The mechanism of pathology of ITP involves the generation of autoimmune antiplatelet antibodies (typically immunoglobulin G [IgG], produced from B cells, usually within the spleen). The condition is initially often detected because of the presence of oral lesions. Minor traumatic events are continuously inflicted on the oral mucosa during chewing and swallowing of food. The small capillaries that are damaged during the process are normally sealed off with microthrombi. In a patient with thrombocytopenia, however, the thrombi do not form properly. This results in a leakage of blood from the small vessels, causing petechiae. If large quantities of blood are extravasated, an ecchymosis or bruise or hematoma results. Spontaneous gingival hemorrhage often occurs in these patients as does bleeding from the sites of the minor gingival trauma. Other signs and symptoms are, easy or excessive bruising (purpura), prolonged bleeding from cuts, blood in urine or stools, unusually heavy menstrual flows, profuse bleeding during surgery, and so on. [5],[6],[7] The diagnosis of ITP is based principally on the history, physical examination, complete blood count, and examination of the peripheral smear, which should exclude other causes of thrombocytopenia. [8] Although generally healthy at the time of presentation, parents often report a preceding illness or other immune stimulants, such as, allergic reaction, insect bite or immunizations. [4] White and red blood cell counts are usually normal even though the platelet count is low. Bleeding time is prolonged and the capillary fragility test is positive. Tests for coagulation factors are normal. Bone marrow examination shows an increase in the number of megakaryocytes, which show diminished budding and have an intense blue cytoplasm. The myeloid and erythroid series of cells in the marrow are normal. It is appropriate to withhold specific treatment for asymptomatic children with platelet counts of 20,000 to 30,000 and more strongly for children with platelet counts of >30,000, who are asymptomatic or who have only minor purpura. [3],[8] Sixty percent of the children recover spontaneously, within four to six weeks, and over 90 % within three to six months. [5] Hospitalization is appropriate for a child with severe, life-threatening bleeding, regardless of the platelet count, and for a child with a platelet count of <20,000 and mucous membrane bleeding that may require clinical intervention. [8] Certain drugs that can inhibit the already reduced platelet function, are contraindicated, such as aspirin, ibuprofen (Advil, Motrin, others), and blood-thinning medication warfarin (Coumadin). Corticosteroids are regarded as the first line of treatment for first line therapy in adults, utilizing their immunosuppressive role in an autoimmune condition. [5] If a rapid elevation in platelet count is needed, such as, in the case of critical bleeding or in the preparation for surgery, medications such as immunoglobulin or anti-(Rh) D immunoglobulin (intravenously) are used. Intravenous immunoglobulin (IVIG) decreases the platelet count by decreasing autoantibody synthesis and blocking the Fc receptor in Rh positive individuals. Additional therapies for chronic refractory ITP include rituximab, cyclophosphamide, azathioprine, and vinca alkaloids. Research is ongoing with regard to the use of thrombopoietin for refractory ITP. Splenectomy is reserved for unresponsive acute severe ITP or chronic purpura. Selected indications for splenectomy are persistence of disease 12 months after diagnosis, with bleeding symptoms and a platelet count of <10,000 (for ages 3 to 12 years) or with bleeding symptoms and a platelet count of 10,000 to 30,000 (for ages 8 and 12). [8]


   Conclusions Top


Signs such as generalized spontaneous gingival bleeding or the presence of petechiae and hematomas on the body should lead to a suspicion of altered coagulation or bleeding disorder. [9] As dentists we should be aware of such cases and consequences so that timely recognition and referral of these patients for precise diagnosis and treatment can be made.

 
   References Top

1.George JN, Woolf SH, Raskob GE, Wasser JS, Aledort LM, Ballem PJ, et al. Diagnosis and treatment of idiopathic thrombocytopenic purpura: Recommendations of the American Society of Hematology. Ann Intern Med 1997;126:319-26.  Back to cited text no. 1    
2.Kooter AJ, Vanderlinden PW, De Klerk G. Acute idiopathic thrombocytopenic purpura in adults following viral infection: Report of two cases. Net J Medicine 2002;60:174-6.  Back to cited text no. 2    
3.Themistocleous E, Ariyaratnam S, Dexbury AJ. Acute idiopathic thrombocytopenic purpura: A case report. Dent Update 2004;31:92-6.  Back to cited text no. 3    
4.Nugent DJ. Immune thrombocytopenic purpura of childhood. Hematology Am Soc Hematol Educ Program 2006;97-103.  Back to cited text no. 4    
5.Vaisman B, Medina AC, Ramirez G. Dental treatment for children with chronic idiopathic thrombocytopenic purpura: A report of two cases. Int J Paediatr Dent 2004;14:355-62.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Hunter ML, Hunter B, Lesser S. Acute idiopathic thrombocytopenic purpura in childhood: Report of a case presenting in general dental practice. Br Dent J 1997;183:27-9.  Back to cited text no. 6  [PUBMED]  
7.James WD, Guiry CC, Grote WR. Acute idiopathic thrombocytopenic purpura. Oral Surg Oral Med Oral Pathol 1984;57:149-51.  Back to cited text no. 7  [PUBMED]  
8.George JN, Woolf SH, Raskob GE, Wasser JS, Aledort LM, Ballem PJ, et al. Idiopathic thrombocytopenic purpura: A practice guideline developed by explicit methods for the American Society of Hematology. Blood 1996;88:3-40.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Marcelo ZM, Jesus SL, Jose LP, Eduardo VF, Haraldo AS, Serglo AF. Idiopathic thrombocytopenic purpura presenting as post-extraction haemorrhage. J Contemp Dent Pract 2007;8:1-7.  Back to cited text no. 9    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]


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    Abstract
    Introduction
    Case Report
    Discussion
    Conclusions
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