Age: 3.0
Sex: M
Vaccine: HEPA, HEPA
Symptoms: Blood urine, Epistaxis, Haematemesis, Haematocrit decreased, Haematuria
Clinical narrative: Information has been received from a physician concerning a 36 month old male with no past medical history who on 11/14/03 at 14:20 was vaccinated with a second dose of hepatitis A virus vaccine inactivated (Lot # 646570/0739N), SC in the left arm.  There was no illness at the time of vaccination.  On 11/23/03 the pt developed thrombocytopenia ("Likely ITP") with fever, epistaxis and hematuria.  The pt was hospitalized.  Relevant diagnostic laboratory test results were reported as: WBC: 5.6; HgB: 12.0; HCT: 34.4; 65N band; Lymphs: 16*2.  At the time of the report the pt was still in the hospital. The recovery status was reported to be unknown.  Additional information has been requested. Follow up info was received from the physician which indicted that on 11/17/03 the pt developed idiopathic thrombocytopenic purpura with fever, bleeding from the nose, and inot urine. on 11/23/03, diagnostic lab results were reported as platelets 3,000/mm^3. Subsequently the pt recovered. Additional information including an emergency department report and a hospital discharge summary was received from the physician. The patient was hospitalized on 23-NOV-2003 with a chief complaint of hematuria. The history of the present illness indicated that the patient presented with gross hematuria. He was in his usual state of good health until 22-NOV-2003 when he was noted to have a nosebleed. In additon, he had a few spots noted on his back, as well as some bruising of his legs. oN 23NOV 2003, he presented with three episodes of hematamesis. His mother described a couple of episodes where there was some dark brownish blood that he threw up. Additonally, he has hadmore spots on his trunk and extremities and on his mouth. The mother seemed to think he was a little sleepier than usual on 23NOV-2003. Prior to this, he has had a fever for a couple of days that started once he had a hepatitis A shot. A review of systems was negative. A physical exam on 23NOV2003 revealed a tired but nontoxic appearing child in no acute distress. Vital signs revealed a blood pressure of 127/67, heart rate of 86, respiratory rate of 22, and a temperature of 36.3. A head, eyes, ears, nose and troat exam revealed that the pupils were equal, round and reactive to light. Extraocular movements were intact. The left tyapanic membrance was occluded with cerumen. The right trympanic membrance was clear. The oropharynx was notable for a few petehiae on his mouth. The neck was supple with full range of motion. Lungs were clear to auscultation. A cardiac exam revealed a regular rate and rhythm. The abdomen was soft, nontender, nondistended and with normoactive bowel sounds. A rectal exam revealed dark red stool that was heme positive. However, this heme positivity ws only on the muscous sample that was obtained on dignital examination. He also had a few petechia on his legs and he had a few bruises on his shins. The impression and plan was that this was a child who had petechiae and some contusions with a history of epistaxis and vomiting of blood. The concern was that he had a hematologic disorder and because of this some laboratory tests were sent. Results revealed a white count of 5.6, hemoglobin 12; hematocrit 34, platelet cound 3, and a urinalysis revealed grossly bloody urine. See laboratory seciton for all other releveant laboratory results. After consluting with hematology, a uric acid lactic dehydrogenase and plasma CMB were sent. An HIV test was sent as per protocol. The hematologist felt that htis was most likely idiopathic thrombocytopenic purpura. Because of the patient's initial sleepiness, a head computed axial tomography scan was obtained because of the history of thrombocytopenia, however this was negative and actually during the course of his emergency department stay, his mental status improved markedly. Additoanlly, the patient has had some reporte hematemesis and osme blood on rectal examination. It was unclear whether this was swallowed blood from his epistaxis, or whether he had primary gastrointestial bleeding. At that point, it was difficult to differentiate, but the concern was that he had some thrombocytopenia in his blood. Given his marked thrombocytopenia, he was not a candidate for nasal gastric tube placement. Because the patient remained hemodynamically stable and with a normal hemoglobin, the patient could be transferred to a floor to be watched vry closely. The patient was admitted in fair condition to the hematolgoy/oncology unit for close monitoring with an admitting dianosis of thrombocytopenia, likely idopathic thrombocytopenia purpura and gastrointestinal bleeding. According to the hospital course, the patient was allowed to take a regular diet and was tolerating regular food at the time of discharge. The patient was given intravenous immunglobulin 800mg/kg over 8 hours, with platelets the following morning, on 24NOV2003, that had increased to 6. He was given another dose of intravenous immunoglobulin 600mg/kg and platelets increased to 13 on 24NOV2003. The patient had no further active bleeding throught the stay, with no evidenceof hematuria, epistaxis, or hematamesis. The patient, with improvement in platelet count, was deemed safe for discharge home and to follow up in the hematology/oncology clinic. The patient with discharged on 26NOV2003 with a discharge diagnosis of idiopathic thrombocytopenic purpura. Discharge instructions included to return to any hematuria, hematemesis, epistaxis or any other concerns. The patient was to follow up with the heamatologist and to call for an appointment in two to four days. He was to follow up in the hematology/oncologoy clinic on 01DEC2003. Also, the patient was not to use aspirin or ibuprofen (MOTRIN) following discharge untill okayed by the physician. No further information is expected.