What is the most appropriate management for a 12-year-old girl with immune thrombocytopenic purpura (ITP) presenting with thrombocytopenia, petechiae, and a recent history of viral upper respiratory tract infection?

Management of Pediatric ITP Following Viral Infection

The most appropriate first-line management for this 12-year-old girl with newly diagnosed ITP is prednisolone (Option B), as corticosteroids are the recommended first-line treatment for children requiring therapy according to the American Society of Hematology guidelines. 1

Clinical Presentation Analysis

This patient presents with classic post-viral ITP:

• Isolated thrombocytopenia (platelets 20 × 10⁹/L) with normal hemoglobin, hematocrit, MCV, and WBC 1
• Mucocutaneous bleeding (bleeding gums, petechiae) indicating need for treatment 1
• Recent viral URI trigger - a well-established precipitant of pediatric ITP 2, 3, 4
• Increased megakaryocytes on bone marrow - confirming peripheral platelet destruction rather than production failure 1

The platelet count of 20 × 10⁹/L with active bleeding (gingival hemorrhage) clearly meets treatment thresholds. 1

First-Line Treatment Recommendation

Corticosteroids (prednisolone) should be used as first-line treatment for the following reasons:

• The American Society of Hematology 2011 guidelines explicitly recommend corticosteroids as first-line therapy for pediatric ITP requiring treatment (Grade 1B recommendation) 1
• Prednisolone at 4 mg/kg/day for 3-4 days is the preferred short-course regimen for children 5
• This provides effective platelet recovery while minimizing steroid toxicity in the pediatric population 5

Alternative First-Line Options

If more rapid platelet increase is needed:

• IVIg 0.8-1 g/kg as single dose can be used with corticosteroids when faster response is required (Grade 1B) 1, 5
• Anti-D immunoglobulin may be considered in Rh-positive, non-splenectomized children (Grade 2B), though it should be avoided if hemoglobin is decreased from bleeding 1

Why Other Options Are Inappropriate

Azathioprine (Option A) is not indicated:

• No role as first-line therapy in pediatric ITP 1
• Used in combination regimens for persistent disease, not newly diagnosed cases 6

Splenectomy (Option C) is contraindicated at this stage:

• Reserved for chronic or persistent ITP with significant bleeding unresponsive to other therapies (Grade 1B) 1
• Should be delayed for at least 12 months unless severe unresponsive disease (Grade 2C) 1
• This patient has newly diagnosed ITP and has not yet received any treatment 1

Cyclophosphamide (Option D) has no role:

• Not mentioned in standard ITP treatment algorithms 1
• Excessive toxicity for a condition that often responds to corticosteroids 1

Treatment Algorithm for Pediatric ITP

For newly diagnosed pediatric ITP with bleeding:

1. Mild bleeding or platelet count 10,000-30,000/μL: Start prednisolone 4 mg/kg/day for 3-4 days 5

2. Moderate bleeding or need for rapid response: Add IVIg 0.8-1 g/kg single dose to corticosteroids 1, 5

3. Severe bleeding or platelets <10,000/μL with active bleeding:

   • Platelet transfusion immediately 5
   • High-dose methylprednisolone 30 mg/kg/day 5
   • IVIg 0.8-1 g/kg 5

4. Second-line options (if inadequate response after 2-4 weeks):

   • Rituximab for significant ongoing bleeding despite first-line therapy (Grade 2C) 1
   • High-dose dexamethasone as alternative (Grade 2C) 1

5. Splenectomy consideration only after:

   • At least 12 months duration 1
   • Failure of corticosteroids, IVIg, and anti-D 1
   • Persistent significant bleeding affecting quality of life 1

Critical Management Pitfalls

• Avoid prolonged corticosteroid courses in children due to significant growth and developmental toxicities 5
• Do not delay treatment in patients with active bleeding while awaiting additional workup 5, 7
• Avoid NSAIDs and aspirin as they impair platelet function and increase bleeding risk 7, 2
• Restrict contact sports due to intracranial hemorrhage risk with head trauma 2
• Monitor for spontaneous remission - many pediatric post-viral ITP cases resolve within weeks to months 1