Discussion:
This case report presents the clinical course and management of a
15-year-old girl who was diagnosed with chicken pox and simultaneous
immune thrombocytopenic purpura (ITP). Chicken pox is a highly
contagious, self-limiting, exanthematous infection caused by
varicella-zoster virus [1,4,5]. While chickenpox is typically a mild
and self-limiting disease in healthy children, severity of complication
is higher among adults and those who are immunocompromised. One of the
hematological complications reported is immune thrombocytopenia [6].
Several studies have shown the association between chickenpox and immune
thrombocytopenia (ITP) in both children and adults [1,5]. In this
case, we presented a rare occurrence of simultaneous chickenpox and
immune thrombocytopenic purpura (ITP). In review of literature, we found
a single case reported with a similar case scenario where a 11-year-old
boy presented with hemorrhagic vesicular rashes, petechiae, ecchymosis,
epistaxis, hematuria and melena, dated back in 1947 [4]. In our
case, limited availability of similar studies has imposed significant
limitations in terms of evidence-based decision-making, diagnostic
accuracy and patient management.
ITP is defined as the isolated platelet count below 100,000/microliter
without other hematological abnormalities [7]. Although, ITP occur
both in acute and chronic form, around 80% of childhood disease are of
acute manifestation [8]. It usually presents with ecchymosis,
petechiae, mucosal bleeding, nasal bleeding and excessive menstrual
bleeding in case of female. However, sometimes it may be an incidental
finding without any bleeding manifestation [2]. The pathogenesis of
ITP is not fully understood, and the exact cause remains unclear.
However, the known etiopathogenesis include production of autoantibodies
that target platelet surface glycoproteins resulting in accelerated
platelet clearance by macrophages, impaired platelet production in bone
marrow and increased reactivity of T cells against platelets [9]. In
this case, presence of anemia alongside ITP also raised the possibility
of immune mediated mechanism causing anemia. To further investigate such
case, Coombs test to evaluate the presence of immune mediated hemolysis
could have been done.
According to the recommendation from American Society of Hematology
(ASH) corticosteroids are considered as the first line therapy for ITP.
However, in cases where corticosteroids are contraindicated ASH
guideline suggest considering intravenous immunoglobulin or anti D
immunoglobulin as alternative treatment options [10]. Comparing the
two modalities, systematic review and meta-analysis conducted by Beck CE
et.al, concluded that children treated with corticosteroids are 26%
less likely to rise platelet level than those who are treated with
intravenous IVIG [11]. Despite this, corticosteroids are usually the
first choice due to ease of administration and low cost [12].
11Thrombopoietin receptor agonist such as eltrombopag and romiplostim,
anti CD20 antibody rituximab and surgical splenectomy are considered as
second line therapies for the cases lasting more than three months and
not responding to first line therapies [10]. While bone marrow
transplantation has shown promise as a potential treatment option in
cases where other modalities have failed, its complexity and possible
complications currently prevent it from being considered a standard
treatment approach [13,14].
Simultaneous occurrence of chicken pox demands comprehensive evaluation.
In order to rule out any potential neurological complications, CT scan
was performed, although it is worth noting that such complications are
rare but have been reported in association with chickenpox [15]. CDC
recommends anti-viral therapy for the unvaccinated children older than
12 years old and therefore acyclovir was initiated along with supportive
measures. Intravenous acyclovir given withing 72 hours of disease onset
is considered very effective especially for those who are at risk of
severe disease [4].
This case report highlights the importance of timely diagnosis,
appropriate management strategies such as supportive care, antiviral
treatment and blood transfusions and regular follow up in achieving
successful outcomes. Health care providers should be vigilant about the
co-occurrence of these diseases so that timely intervention can be done
to prevent possible complications. Further reporting of similar cases
and research are warranted to better understand the underlying
mechanisms and optimize the management of these dual diagnoses.