#146: ITP – You’ll be cruising when you see bruising!

July 16, 2025 | By Jennifer Chisolm

Audio

Summary:

Join us in this episode with our expert guest the “platelet doctor” Dr. Beau Mitchell (The Children’s Hospital at Montefiore) to learn all about the complexities of diagnosing and managing ITP!  From learning how to evaluate bleeding symptoms to the latest therapies for chronic refractory ITP, Dr. Mitchell provides insight on how to tackle this relatively common hematologic condition. After this episode you will be cruising when you see bruising – because you will know exactly what to do!

ITP Clinical Pearls

1. Presentation matters even more than platelet count! Children with ITP are typically well appearing, if a child is clinically ill appearing you should be suspicious of a different diagnosis
2. Patients who are asymptomatic or have mild bleeding symptoms can be managed with watchful waiting. Mucosal bleeding such as epistaxis or oral cavity bleeding typically warrants treatment. The modified Buchanan and Adix bleeding score is used to stratify bleeding symptoms in ITP. 
3. ITP is classified by duration:

• Newly diagnosed: < 3 months
• Persistent: 3-12 months
• Chronic: >12 months

Immune Thrombocytopenia Notes 

Immune Thrombocytopenia (ITP), which was formally known as “Idiopathic Thrombocytopenic Purpura” is a relatively common hematologic condition in children, often presenting as isolated thrombocytopenia following a recent viral illness. Despite sometimes alarmingly low platelet counts, most children appear well and have a benign clinical course. 

Pathophysiology

  Immune-mediated destruction of platelets; autoantibodies target platelets, leading to their clearance via the reticuloendothelial system, primarily the spleen and liver.

  Heterogeneous disease—some forms are treatment-resistant and per Dr Mitchell’s expert opinion may represent distinct immune subtypes.

Presentation

• Acute ITP typically presents as a well-appearing child with bruising/petechiae and isolated thrombocytopenia
• It is also common for ITP to present as an incidental finding of low platelets on a CBC
• Patients will often have a history of preceding viral illness
• ITP can present in all age groups however is most common in preschool and school aged children 3-7 year old
• ITP in adolescents is more likely to have a more insidious onset with milder thrombocytopenia. They have a higher risk of developing chronic ITP

Work up

ITP is primarily a clinical diagnosis

Initial lab evaluation

• CBC, peripheral smear, ANA, immunoglobulins (IgA, IgG, IgM), TSH, DAT

Other work up to consider

• Further work up if needed is guided by clinical suspicion, for example consideration of infectious work up, testing for drug induced thrombocytopenia, further evaluation for malignancy or autoimmune disease

Management

• Treatment is based on symptoms not platelet count, the modified Buchanan and Adix bleeding score is used to stratify bleeding symptoms in ITP.
• Most children with acute ITP do not require treatment
• Platelet transfusions are generally avoided unless there’s life-threatening bleeding, as the transfused platelets are often rapidly destroyed

First line treatment options

• steroids vs immunoglobulins (IVIG or anti-D)
• In more severe cases combination therapy with steroids + IVIG

Second line treatment options

• Thrombopoietin Receptor Agonists (TPO-RAs): two agents FDA-approved in pediatrics are Eltrombopag and Romiplostim
• Rituximab

Other treatment options

• Treatment options beyond second line agents are based on expert opinion and include immunosuppressants such as sirolimus and mycophenolate and chemotherapy agents such as vincristine
• Splenectomy is reserved for severe, chronic, treatment-refractory cases 

Tips for counseling patients

• Well appearing children with isolated thrombocytopenia are unlikely to have leukemia, Dr Mitchell advises being careful about causing unnecessary distress to families by discussing leukemia prematurely 
• MMR and Covid vaccination can be a trigger for ITP however there is no evidence for risk of recurrence with future doses

Goal

Listeners will explain the basic pathophysiology, diagnosis, and management of ITP to improve both inpatient emergent care and outpatient counseling. 

Learning Objectives

After listening to this episode listeners will…  

1. Recognise the common clinical presentations of ITP in children
2. Learn about differential diagnoses for thrombocytopenia
3. Be familiar with treatment approaches for acute and chronic or refractory ITP

Disclosures

Dr Mitchell reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Chisholm J, Mitchell W, Chiu C, Masur S. “#146 ITP – You’ll be cruising when you see bruising!”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ July 16, 2025.