Pediatric Immune Thrombocytopenia in Lebanon: Treatment and Predictors of Outcome

To the Editor: A retrospective analysis was conducted on 105 pediatric patients (60% males; median age at presentation 5 years) with immune thrombocytopenia (ITP) attending Rafic Hariri University and Nini Hospitals, Lebanon, between 1985 and 2012. The presenting symptom in 89% of cases was mucocutaneous bleeding; none had gastrointestinal or intracranial bleeding; 22.9% were taking medications, 24.8% had preceding infections, and 2.85% recent vaccination. Mean platelet count at presentation was 16 10/L. Bone marrow aspirates (BMAs) at diagnosis (60%) and after treatment failure (20%) confirmed ITP diagnosis. Main treatment modalities were steroids (61.9%), intravenous immunoglobulin (IVIG) (43.8%), and close observation (29.5%) (Supplemental Figure 1). Median time to splenectomy was 6.75 months after presentation. Patients who received platelet transfusions had platelet counts<10 10/L and wet purpura; none had life-threatening bleeding. Newly diagnosed, persisting, chronic, relapsing, and refractory forms were present in 40%, 16.2%, 27.7%, 1.9%, and 0.9% of patients, respectively; 13.3%were lost to followup. Urgent hospitalization was necessary in 27.6%. Life-threatening complications occurred in two patients: rituximab associated anaphylactic shock and gastrointestinal bleeding-associated hypotension. One patient developed mild systemic lupus erythematosis. Significant correlations are summarized in Table I. Positive correlations included chronicity with older age at presentation or treatment with steroids, rituximab, or splenectomy; urgent hospitalization with severe ITP and platelet transfusion; BMA at diagnosis with steroid use and platelet transfusion; BMA after treatment failure correlated with chronicity, IVIG use, and splenectomy; platelet transfusion with persistent, relapsing, and severe ITP; IVIG treatment with severe ITP, urgent hospitalization, and chronicity; both life-threatening and non-life-threatening complications with chronic ITP, treatment with rituximab, and splenectomy. We observed negative correlations of both urgent hospitalization and IVIG treatment with increased age. Time to platelet recovery and life-threatening complications were not significantly decreased by corticosteroids (P1⁄4 0.1, P1⁄4 0.2) or IVIG (P1⁄4 0.7, P1⁄4 0.1). Neither disease severity nor chronicity differed according to gender. This study represents the largest ITP survey from Lebanon and its results echo those of international studies in underscoring the benign disease outcome and failure of treatment to shorten recovery time or prevent life-threatening complications. [1,2] It demonstrates that ITPmanagement in Lebanon is heterogeneous even in the same center. The high number of patients undergoing BMA, the low number of patients managed with observation only, underutilization of tranexamic acid, early splenectomy, and platelet transfusion for patients without life-threatening bleeds are therapeutic measures not consistent with the 2011 guidelines,[3] but common in private clinic settings. These practices may be attributed to the fact that most patients were treated before 2011 and that treatment decisions in Lebanon are influenced by socioeconomic, cultural, and educational family characteristics including suboptimal compliance; concerns about bleeding, phlebotomies, and drug toxicities; and residence in remote locations without specialized care. Even in