CLINICAL BRIEF

Immune Thrombocytopenic Purpura due to MixedViral Infections

Suresh Kumar & Alka Khadwal & Sanjay Verma &

Sunit C. Singhi

Received: 3 October 2011 /Accepted: 4 April 2012 /Published online: 29 April 2012# Dr. K C Chaudhuri Foundation 2012

Abstract An 11-year-old boy presented with epistaxis,petechial hemorrhages, easy bruising, and purpuric rash.He was diagnosed to have immune thrombocytopenic pur-pura and evidence of concomitant parvovirus B19 anddengue viral infection.

Keywords Dengue virus . Parvovirus B19 . Immunethrombocytopenic purpura (ITP)

Introduction

Immune thrombocytopenic purpura (ITP) is the most com-mon variety of thrombocytopenic purpura in children. It ischaracterized by mucocutaneous bleeding and low plateletcount [1]. ITP is an autoimmune condition in which patho-genic antibodies bind platelets, resulting in acceleratedplatelet clearance. The acute form of ITP is more commonamong children, generally following viral infection, andtend to have a self-limited nature in up to 80 % ofthe cases [2]. A variety of viruses have been implicatedin the etiopathogenesis of ITP. In this article the authorsreport a case of ITP due to concomitant dengue virusand parvovirus B19 infection.

Case Report

An 11-y-old boy was admitted with the complaints of epistaxis,petechial hemorrhages, easy bruising, and purpuric rash since10 days. Three weeks back he had history of intermittent, lowgrade fever which lasted for 7 days. On examination, hewas afebrile, had mild pallor but no lymphadenopathy.Purpuric, non-blanchable rash was noted over face andlower extremities. Systemic examination was normal. Atadmission, investigations revealed hemoglobin 8.2 g/dl,total leukocyte count 6.4×103per mm³ and platelet countof 3×103 per mm³. His renal functions, liver functions,prothrombin time and aPTT were normal. Bone marrowexamination revealed normocellular marrow with adequaterepresentation of granulocytic and erythroid series butincreased megakaryocytic series (megakaryocytic throm-bocytopenia). HIV ELISA, Epstein-Barr virus (EBV)-IgMantibodies, Widal test, antinuclear antibodies (ANA), andsmears for malaria parasites were negative. Further investiga-tions revealed positive IgM antibodies to dengue virus andparvovirus B19 (by capture ELISA). He was diagnosed as acase of ITP due to concomitant dengue and parvovirus B19infection. During the hospital stay (3 weeks), his platelet countgradually increased to 40×103 per mm³ without any specifictreatment. Two weeks after discharge, he was doing well andhis platelet count was 160×103 per mm³.

Discussion

Acute immune thrombocytopenia (ITP) is one of the mostcommon hematological disease among children. ITP is clas-sified as primary (idiopathic) or secondary to underlyingdisorders like connective tissue disease (such as lupus),lymphoproliferative disease (such as lymphoma), immune-

S. Kumar :A. Khadwal : S. Verma (*) : S. C. SinghiDepartment of Pediatrics, Advanced Pediatric Center, PostgraduateInstitute of Medical Education and Research (PGIMER),Chandigarh 160012, Indiae-mail: sanjay06verma@yahoo.com

Indian J Pediatr (May 2013) 80(5):421–422DOI 10.1007/s12098-012-0755-3

deficient states, medication (quinidine, sulfa drugs andheparin) and viral infections [1]. Symptoms of primary viraldisease are usually well established (1–4 weeks) before theonset of the thrombocytopenia and they typically present withsudden onset of petechiae or purpura and mucosal bleeds [3].

The diagnosis of acute ITP in the index case was madebased on muco-cutaneous bleeding, megakaryocytic throm-bocytopenia on bone marrow examination and ruling outother possibilities. Adequate megakaryopoeisis on bonemarrow examinations pointed towards peripheral destruc-tion of platelets. Positive IgM antibodies to dengue virusand parvovirus B19, and subsequently spontaneous im-provement in platelet counts supports the diagnosis of acuteITP due to dengue virus and parvovirus B19.

Thrombocytopenia associated with viral infection seemsto result both from reduction in the production of plateletsand from decrease in the half-life of the platelets. The latteris the principal mechanism [4]. Platelets that are sensitizedby auto antibodies are destroyed by cells of the reticuloen-dothelial system, particularly in spleen. These auto antibod-ies against glycoprotein of the platelet membrane can beidentified in 80 % of the patients [5]. A variety of viruseshave been implicated individually in the etiopathogenesis ofITP, especially in children: HIV-1, hepatitis C virus,varicella-zoster virus, rubella, influenza, Epstein-Barr virus,parvovirus B19, and dengue virus [1, 6, 7]. This indexpatient had unusual combination of parvovirus B19 aswell as dengue virus infection both of which are indi-vidually known to cause thrombocytopenia.

Conclusion

Acute ITP, which is a leading cause of thrombocytopenia inchildren, can occur following mixed parvovirus B19 anddengue viral infection.

Conflict of Interest None.

Role of Funding Source None.

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