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.