Baby with Petechiae and Bruises

Lori Luchtman-Jones

A well-appearing, term infant was born by vaginal delivery to a healthy 27-year-old mother with a benign prenatal and postpartum course. Within an hour of birth he developed generalized petechiae and bruising over his trunk and left arm. His CBC was normal for a term newborn: WBC 10 x 103/mL, hemoglobin 18.4 g/dL, and platelets 173 x 103/mL. An extensive evaluation for sepsis was begun, and he was treated empirically with antibiotics and an antiviral agent until cultures of spinal fluid, urine, and blood were negative at 72 hours. A herpes simplex virus PCR was negative on blood and spinal fluid as well. The CSF was described as "bloody," and he bled from the puncture site for over an hour. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were normal for age. At 6 days of life, he had a generalized seizure. MRI of his head showed a hemorrhagic infarction of the left centrum ovale region. The baby was begun on an anticonvulsant. After discharge to home, his mother noticed intermittent bruising of his arms, leg, and ear. After intramuscular injection of childhood immunizations at 2 months of age, the site bled intermittently for several hours. The baby also had occasional epistaxis. Serial evaluations of platelet count, prothrombin time (PT), and activated partial prothrombin time (aPTT) were normal.

At 6 months of age he was referred for a pediatric hematology evaluation. He was taking no medications except phenobarbital. There was no family history of bleeding problems, and his parents and older brother (full sibling) were in good health. Physical exam revealed a well-developed, well-nourished, developmentally appropriate 6-month-old infant with a band of petechiae around the lower third of the left upper arm, where the phlebotomist's tourniquet had been placed.

Laboratory results at age 6 months were as follows:

Analyte

Hemoglobin

Value, Conventional Units

Reference Interval, Conventional Units

Value, SI Units

Reference Interval, SI Units

Reference

Value,

Interval,

Reference

Conventional

Conventional

Value,

Interval,

Analyte

Units

Units

SI Units

SI Units

Hematocrit

26%

29-41

0.26 volume

0.29-0.41

MCV

68 fL

74-108

Same

Reticulocyte count

2%

0.5-1.5

0.02 fraction

0.005-0.015

Platelet count

390 x 103/mL

140-400

390 x 109/L

140-400

PT

13.8 s

12.2-14

Same

aPTT

36.2 s

30.5-37

Same

Fibrinogen

283 mg/dL

218-306

2.83 g/L

2.18-3.06

Factor VIII activity

92%

60-160

0.92 IU

0.6-1.6

Factor IX activity

72%

60-160

0.72 IU

0.6-1.6

Platelet function

>300 s

70-170

Same

screen: col/epi

Platelet function

>250 s

50-150

Same

screen: col/ADP

Given the evidence of a significant bleeding disorder from infancy onward with normal platelet count and coagulation tests, and abnormal platelet function screening results, a congenital qualitative platelet disorder was suspected. Platelet aggregometry was performed on the patient (see Fig. 64.1).

To confirm that the patient's platelets lacked Gpllb/IIIa receptors for fibrinogen binding, peripheral blood was incubated with fluorescent antibodies to CD41 (Gpllb) and 61 (Gpllla) and analyzed by flow cytometry. Compared to control platelets, the patient's platelets were CD41/CD61-negative, while the parents' platelets stained with approximately 50% of the intensity of control platelets. On the basis of these test results, the infant was diagnosed with Glanzmann thrombasthenia.

After the seizure, he was begun on phenobarbital, which will probably be discontinued in early childhood if no other seizures occur. Iron drops were prescribed for his micro-cytic, hypochromic anemia, presumed to be iron deficiency anemia secondary to chronic blood loss. Because of his bleeding problems shortly after delivery, he was not circumcised at that time. Given the risk of alloimmunization (see definition of alloimmunization later, under Treatment section) and the potential need for a platelet transfusion with elective circumcision, this patient's mother decided against the procedure. She and his physicians will consider circumcision in the future should he require a platelet transfusion for another reason.

This baby received his subsequent childhood immunizations subcutaneously, rather than intramuscularly, in order to prevent intramuscular hematoma. His parents made sure that he had soft toys to play with and padded sharp corners and ledges at home. When his mobility increases over the next few months, he will be fitted with a soft helmet. Soft helmets may prevent or lessen head trauma in toddlers and children, but many families and older patients dislike the stigmatization. Dental hygiene practices are especially important in patients with bleeding tendencies, both because gingivitis is associated with bleeding, and also because tooth extraction is associated with risk of hematoma and bleeding.

How To Deal With Rosacea and Eczema

How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

Get My Free Ebook


Responses

  • jonas
    Which labs are drawn on a baby with petechiae?
    2 years ago

Post a comment