Outcomes in Mild to Moderate Isolated Thrombocytopenia
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Charles Schlappi, MD, Varsha Kulkarni, MBBS, Prasannalaxmi Palabindela, MBBS, OutcomesChristina Bemrich-Stolz, MD, MSPH, in Thomas Mild Howard, MD, to Lee Hilliard, Moderate MD, IsolatedJeffrey Lebensburger, DO, ThrombocytopeniaMSPH OBJECTIVES: abstract Incidental isolated mild to moderate thrombocytopenia is a frequent laboratory finding prompting a referral to pediatric hematology-oncology. We tested the hypothesis – that patients with isolated asymptomatic mild thrombocytopenia would not progress to METHODS: require an intervention from a pediatric hematologist oncologist. – This is a 5-year retrospective review of 113 patients referred to pediatric hematology oncology for isolated thrombocytopenia. Initial, lowest, and current – × μ platelet counts along with clinical course and need for interventions were recorded. – × μ – × μ 3 Thrombocytopenia was categorized as mild (platelet count: 101 140 10 / L), moderate ≤ × μ3 3 (platelet count: 51 100 10 / L), severe (platelet count: 21 50 10 / L), and very severe RESULTS: 3 (platelet count: 20 10 / L). Eight of 48 patients (17%) referred for initial mild isolated thrombocytopenia progressed to moderate thrombocytopenia at 1 visit. At present, 2 of these patients have moderate thrombocytopenia, 17 remain with mild thrombocytopenia, and 29 patients have resolved thrombocytopenia. Nine of 65 patients (14%) referred for moderate thrombocytopenia progressed to severe or very severe thrombocytopenia on 1 occasion. At present, no patients have severe thrombocytopenia, 18 remain with moderate thrombocytopenia, 14 improved to mild thrombocytopenia, and 33 have resolved thrombocytopenia. Only 3 patients required interventions from a hematologist, whereas CONCLUSIONS: 10 patients required therapy from other subspecialties. We only identified 3 patients (3%) with mild to moderate thrombocytopenia who required an intervention from a hematologist to improve platelet counts. Patients with isolated mild thrombocytopenia with a normal bleeding history and physical examination NIH findings frequently have normalized their platelet counts within 1 month. Division of Pediatric Hematology Oncology. University of Alabama at Birmingham, Birmingham, Alabama WHAT’S KNOWN ON THIS SUBJECT: Isolated thrombocytopenia is a common pediatric laboratory Dr Lebensburger conceptualized and designed the study and drafted the initial manuscript; finding among patients with a bleeding or bruising Drs Schlappi, Kulkarni, and Palabindela designed and coordinated data collection, conducted history as well as being an incidental laboratory the initial analyses, and reviewed and revised the manuscript; Drs Bemrich-Stolz, Howard, and finding. The outcomes and need for referral to pediatric Hilliard participated in the design of the study, reviewed the analyses, and critically reviewed hematology oncology have not been established. the manuscript; and all authors approved the final manuscript as submitted. – DOI: https:// doi. org/ 10. 1542/ peds. 2017- 3804 WHAT THIS STUDY ADDS: The majority of patients with mild or moderate thrombocytopenia normalized Accepted for publication Apr 19, 2018 platelet counts within 3 months. Mild isolated Address correspondence to Jeffrey Lebensburger, DO, MSPH, University of Alabama at thrombocytopenia without a bleeding history Birmingham, 1600 7th Ave South, Lowder 512, Birmingham, AL 35223. E-mail: jlebensburger@peds. or abnormal physical findings did not require uab.edu interventions from pediatric hematology–oncology; PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). moderate isolated thrombocytopenia cases rarely required interventions. Copyright © 2018 by the American Academy of Pediatrics To cite: Schlappi C, Kulkarni V, Palabindela P, et al. Outcomes in Mild to Moderate Isolated Thrombocytopenia. Pediatrics. 2018;142(1):e20173804 Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 142, number 1, July 2018:e20173804 ARTICLE – × µ A broad differential diagnosis exists outcomes for patients with mild categorized patients as having mild –3 × for pediatric patients diagnosed with or moderate thrombocytopenia (platelet count: 101 140 10 / L), – × μ µ isolated thrombocytopenia, defined as and identified only 1 adult study moderate (platelet count: 51 100 3 – 1,× 2 –3 × µ a platelet count <140 150 10 / L. of patients with mild persistent 10 / L), severe (platelet count: μ 3 ≤ × µ When3 platelet counts drop to <30 50 thrombocytopenia. Among the 191 21 50 10 / L), and very3 severe 10 / L, patients may develop adult patients with mild persistent (platelet count: 20 10 / L) petechiae, bruising, and epistaxis, thrombocytopenia, 60% remained thrombocytopenia at the time of prompting primary care providers3, 4 to with mild thrombocytopenia, 7% referral on the basis of the lowest obtain a complete blood count. normalized their platelet counts, platelet count and current platelet Isolated thrombocytopenia may 7% developed an autoimmune count. We included 1 patient as mild also be incidentally identified by a disorder, and 6% were diagnosed at the time of referral despite being × µ primary care provider who performs with immune thrombocytopenia referred for thrombocytopenia3 with a complete blood count for other (ITP); 6 patients developed adult- a platelet count of 143 10 / L; indications, including concerns specific malignancies (including this patient had a previous clinic for anemia, leukopenia and/or breast, lung, and colorectal cancers history of mild thrombocytopenia 7 × µ leukocytosis, or as part of a routine and myelodysplasia). To better and an initial3 in-clinic platelet count health screening with5 hemoglobin understand the outcomes for of 123 10 / L. History of bruising and/or hematocrit. Once isolated pediatric patients with isolated mild at the time of referral, age, sex, and thrombocytopenia is identified, a to moderate thrombocytopenia, referring provider were recorded primary care provider may further we conducted a retrospective chart from clinic and referral notes. – evaluate or refer that patient to a review to assess the incidence, Therapeutic interventions and reason – pediatric hematologist oncologist outcomes, and need for intervention for intervention were recorded from ’ on the basis of either the primary from a pediatric hematologist pediatric hematology clinic notes. care provider6 s concern or parental oncologist among all patients Finally, antineutrophil antibody, desire. Parents and patients referred referred for thrombocytopenia antinuclear antibody, platelet for isolated mild to moderate over a 5-year period. We tested the antibody, and immunoglobulin G thrombocytopenia may experience hypothesis that patients with isolated levels were recorded. Descriptive emotional distress either during mild thrombocytopenia without statistics and univariate analysis the wait for their referral visit and/ bruising and/or bleeding symptoms were conducted by using JMP Pro 12 – or the time spent in a waiting room would not progress to require (SAS Institute, Inc, Cary, NC). – at a pediatric hematology oncology an intervention from a pediatric RESULTS clinic. Often, this distress is due hematologist oncologist. to concern by the patient and/or METHODS parent that the child has cancer. In addition, current health economics Among 2820 patients referred to the necessitates improved use of health outpatient UAB Pediatric Hematology – care specialists. Therefore, having We conducted an institutional review Oncology Clinic over a 5-year period, a clear understanding of which board approved retrospective study 2256 patients were referred for patients with mild to moderate of all outpatient referrals to the evaluation of a hematologic disease. thrombocytopenia require evaluation – University of Alabama at Birmingham The most commonn hematologic or intervention from a pediatric (UAB) Pediatric Hematology referral to our clinic was for sickle hematologist oncologist would help Oncology Clinic from June 2012 to cell disease ( = 296; 13%) and nthe primary care providers make the June 2017. We excluded patients second most common referral was ’ most beneficial referrals. initially admitted to the hematology to evaluate thrombocytopenia ( = oncology service at Children s of 204; 9%). Among the 204 patients Although we hypothesize that Alabama for thrombocytopenia who with an outpatient referral for pediatric patients with mild to required additional follow-up in our thrombocytopenia, 113 of these moderate thrombocytopenia, no outpatient clinic. The diagnosis and referrals were for isolated moderate or clinical symptoms, or any abnormal demographics were recorded for mild thrombocytopenia. The incidence physical findings may not warrant every patient. We recorded the date of referrals for mild to moderate – an immediate referral to a pediatric and platelet count at the time of the isolated thrombocytopenia was 23 hematologist oncologist, there is first episode of thrombocytopenia patients per year. The mean age at minimal literature that can support and the referral visit, lowest platelet referral was 10.6 years, and younger this hypothesis. We could not count, and the most recent platelet age was associated with a lower identify any pediatric reports of count (as of January 2018). We platelet count at the time of referral Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 SCHLAPPI et al TABLE 1 Referral Platelet Counts Variables n Mean Platelet Count at Range Referral thrombocytopenia, 23 resolved within 1