Age: 1.31
Sex: F
Vaccine: MMR
Symptoms: Skin irritation, Swelling, Vomiting
Clinical narrative: Patient woke up with several large and swollen bruises as well as smaller bruises on parts of her body: her right foot, left and right shins, right flank, clavicular area, torso, above the left eye, right forehead. She also had petechiae at her neck, diaper area, feet, and gums.  In addition, she had blood blisters on her tongue. We had noticed some red/purple spots in her diaper area the day before, but thought it was probably skin irritation due to a sandy beach.  We had also noticed bruises on her shins, but thought they might have been a response to falling the day before on some rocks (at a beach).  We did think the bruises were rather extreme, since her fall had not been bad, but we did not think too much about it until patient awoke the next day with all the new bruises and petechiae.  After consulting with a doctor, we went to the ER. Patient's blood was tested, revealing a low platelet count of 3,000.  Patient was diagonosed with ITP and admitted to the hospital.  She was pretreated with Tylenol and Benadryl and then given Winrho (sp?) the first night. The next morning's CBC showed that patient's platelets had fallen to 1,000.  Patient started bleeding from her mouth during the day, and she developed many more small bruises on her body: arms, head, etc.  The second night in the hospital patient was pretreated with Tylenol and Benadryl and given IVIg.  She had a mild reaction to IVIg (body chills) that stopped once the infusion rate was decreased.  The third day's CBC showed improvement in her platelet count.  It had increased to 23,000, so the doctor decided to discharge patient in the afternoon, with the understanding that she would follow up with an appt at the Hematology Clinic at the hospital the next morning.  Before leaving patient vomited but was afebrile.  When we got home that night, she vomited again and developed a fever of 101.6.  We called the on-call doctor and gave patient some Tylenol and Benadryl.  The on-call doctor thought that patient was probably reacting to the IVIg.  The next morning patient's results at the Hematology Clinic were good: her platelet count was up to 91,000.  She did not vomit again or have a fever that fourth day.  The next day we flew back home, since we were out of state on vacation.  We are going to follow up with our pediatrician and a hematologist.  We don't yet know if the ITP will be temporary or chronic, and we don't yet know if patient will have additional low platelet counts in the following weeks (once the IVIg wears off).   1/5/10 & 1/7/09:  ED Records and vaccine records received for dates of service 7/21/09 to 10/8/09. Dx: Idiopathic Thrombocytopenia purpura.  Received MMR, 8 days later developed fever and nasal congestion.  2 weeks later noted multiple bruises and petechiae over most of body and spontaneous bleeding from the mouth.  Platelet count was 1,000 upon presentation to ED.  Admitted.  Administered IVIG.  Platelet levels recovered.  Seen for cough, rhinorrhea tx. with Augmentin.  1/07/10 DC Summary and hospital records received for DOS  07/21/09-/7/23/09. Pt. presented with bruising at left eye, right flank, clavicular area and petechial rash on neck, feet and groin. Admitted and treated wih IVIG. Platelet  levels recovered Discharged to f/u with Hematologist. DX: Idiopathic thrombocytopenia purpura 01/07/10 PCP and Pediatric Urgent Care records received for DOS 06/2909-12/07/09. On 10/20/09 Hemotolgy consult confirmed diagnosis of ITP and recommended serial CBCs. On 11/12/09  PT presented with h/o red stool x 1 attributed to red food dye in stool.