Trombositopeni ön tanısı ile tetkik edilen çocukların klinik ve laboratuvar bulgularının retrospektif incelenmesi
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Date
2017
Authors
Öngen, Yasemin Denkboy
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Publisher
Uludağ Üniversitesi
Abstract
Çalışmamız Ocak 2010-Aralık 2015 tarih aralığında Uludağ Üniversitesi Tıp Fakültesi Sağlık Uygulama ve Araştırma Merkezi Hastanesi'ne başvuran ve trombositopeni saptanan çocuklarda; nedenleri araştırmak, tedavi ve takip stratejilerini değerlendirmek, tanıdaki ve tedavideki gecikmeleri azaltmak amacıyla yapıldı. Çalışmada 2005-2015 yılları arasında trombositopeni ile ilişkili İCD kodu olan 1500 hastanın klinik ve laboratuvar bulguları elektronik dosya sisteminden geriye dönük olarak incelendi. Altı yüz yetmiş dört hastanın hemogramında trombositopeni saptanmadığı için (yanlış İCD kodu girilmiş), 73 hastanın dosyasına ulaşılamadığı için, 232 hasta aktif kemoterapi tedavisine devam ettiği için ve 81 hasta bilinen malign olmayan hematolojik hastalık ile takipli olduğundan çalışmadan çıkarıldı. Toplam 440 hasta ile trombositopeni formu dolduruldu. Hastaların %59'u (n:259) erkek, %41'i (n:181) kız cinsiyete sahipti ve ortalama yaşı 6,6±2,1 yıl (1 gün-18 yaş) olarak hesaplandı. En sık trombositopeni nedeni %62 ile immun trombositopeni (İTP) olarak bulundu. İTP hastalarının % 49,2'sinde geçirilmiş üst solunum yolu enfeksiyonu öyküsü mevcuttu. İTP hastalarının %7'sinde viral seroloji pozitifliği saptandı. Otoimmun tetkikler %18 hastada pozitif olarak bulundu. Aşı öyküsü sorgulandığında; 40 hastada son 6 hafta içinde aşı yaptırma öyküsü mevcuttu. İmmun trombositopeni olarak değerlendirilen 258 hastanın 27'sinde (%10,5) ilaç kullanımına bağlı trombositopeni saptandı. Tüm hastaların %6,1'inin (n:27) yenidoğan döneminde olduğu görüldü. İTP hastalarının 137'sine (%53,1) tedavi verildi. Tüm İTP hastalarının 208'inde (%80,6) trombosit normale dönme süresi 0-3 ay arasındaydı. Kronikleşme görülen 36 hastanın 25'inin (%28,1) birincil İTP ve sadece 11'inin (%6,5) ikincil İTP olduğu görüldü. ITP ile izlenen 23 hastada kanama atağı saptandı. Bu kanama atakları yaşamı tehdit edecek ciddiyette değildi ve yalnızca tedavi planında belirleyici oldu. iii Çeşitli çalışmalarda kızlarda İTP sıklığının daha fazla olduğu belirtilmekte olup; otoimmunitenin daha sık görülmesi kız çocuklarda İTP'nin daha sık görülmesini açıklayıcı olabilir. Çalışmamızda yılda başvuran trombositopeni insidansı 100 000 hastada 8,4 ve İTP insidansı 5,1 olarak bulunmuştur bu sonuçlar literatür ile uyumludur. Bir çok çalışmada İTP'nin en sık görülme yaş aralığı 6-10 yaş civarı olarak belirtilmiştir. Çalışmamızda da benzer şekildedir. Çalışmamızda literatürle uyumlu olarak mevsimsel farklılık saptanmamış olup geçirilmiş üst solunum yolu enfeksiyonu predispozan olarak bulunmuştur. Otoantikor pozitifliği saptanan hastalar değerlendirildiğinde kronikleşme açısından ilişki bulunamadı. Aşı sonrası gelişen İTP hastalarında aşıların tekrar dozunda tekrar İTP gelişimi izlenmedi. Özellikle antiepileptik olarak kullanılan ilaçların yan etkisi olarak trombositopeni gelişebileceği gözlendi. Yenidoğan döneminde trombositopeni saptanan hastaların altta yatan sebebe yönelik tedavisi sonucu trombosit sayılarının normale geldiği görüldü. İntravenöz immunglobulin tedavisine yanıt süresi 36,8±1,2 saat ve steroid tedavisine yanıt süresi 63,2±1,2 saat olarak bulundu. Birincil ITP olan olgularda kronikleşme oranı İkincil ITP olgularına göre anlamlı oranda daha fazla olduğu görüldü (p<0,001). Tedavisiz izlenen 121 (%46,9) hastanın trombosit düzeyinin komplikasyon geliştirmeden ilk 3 ayda kendiliğinden normale dönmesi ve verilen farmakolojik tedavilerin de yan etkilerinin olabilmesi nedeniyle "izle ve bekle" stratejisi tarafımızca öncelikle uygulanmaktadır.
This study was accomplished in Uludag University Faculty of Medicine between January 2010 and December 2015 to investigate etiologies, evaluate treatment and follow-up strategies and prevent delays of diagnosis and treatment in patients with thrombocytopenia. Clinical and laboratory data of 1500 patients having ICD codes related with thrombocytopenia between 2005 and 2015 were evaluated retrospectively from the electronic file system database. A number of patients were excluded because of wrong ICD code entry with normal platelet count (n=674), inaccessible files (n=73), continuing chemotherapy (n=232) and having formerly known benign hematologic diseases (n=81). Total of 440 patients filled thrombocytopenia forms. Fifty-nine percent of patients were male (n=529), 41% were female (n=181) and the mean age was 6.6±2.1 years (age range 1 day to 18 years). The most common etiology was immune thrombocytopenia (ITP) (62%). There was history of upper respiratory tract infection (URTI) in 49.2% and positive viral serology in 7% of ITP patients. There was history of vaccination on the last 6 weeks in 40 patients. Drug induced thrombocytopenia was detected in 27 of 258 patients having ITP (10.5%). Newborns constituted 6.1% of all patients (n=27). Treatment was given to 137 patients having ITP (53.1%). Normalization time of the platelet count was between 0 to 3 months in 208 of ITP patients (80.6%). Primary ITP was diagnosed in 25 (28.1%) and secondary ITP in 11 (6.5%) of 36 patients having chronic disease. Attack of hemorrhage was observed in 23 patients having ITP. These attacks were not life-threatening and were only decisive in the treatment plan. Some studies report that ITP is more frequent in girls. This can be explained with more autoimmunity seen in these patients. Incidence of v annually referring thrombocytopenia and ITP were 8.4 and 5.1/100000, respectively in our study and these results were concomitant with the literature data. Age range which ITP is most commonly seen is reported as 6- 10 years in most studies and our results are quite similar. Seasonal difference was not observed and former URTI was found as the predisposing factor in our study, concomitant with the literature. There was no correlation between chronicity and autoantibody positivity. Post-vaccination ITP did not relapse after maintenance dose of the vaccine. Thrombocytopenia was seen to generate after anti-epileptic drug usage. Thrombocytopenia recurred after treating the underlying cause in neonates. Response times to intravenous immunoglobulin and steroid treatments were 36.8±1.2 hours and 63.2±1.2, respectively. Chronicity ratio was seen to be statistically higher in patients with primary ITP than with secondary ITP (p<0.001). "Watch-and-wait" strategy is principally preferred in our clinic; because platelet counts of 121 (46.9%) untreated patients normalized spontaneously in 3 months without any complication and of potential side effects of pharmacologic treatments.
This study was accomplished in Uludag University Faculty of Medicine between January 2010 and December 2015 to investigate etiologies, evaluate treatment and follow-up strategies and prevent delays of diagnosis and treatment in patients with thrombocytopenia. Clinical and laboratory data of 1500 patients having ICD codes related with thrombocytopenia between 2005 and 2015 were evaluated retrospectively from the electronic file system database. A number of patients were excluded because of wrong ICD code entry with normal platelet count (n=674), inaccessible files (n=73), continuing chemotherapy (n=232) and having formerly known benign hematologic diseases (n=81). Total of 440 patients filled thrombocytopenia forms. Fifty-nine percent of patients were male (n=529), 41% were female (n=181) and the mean age was 6.6±2.1 years (age range 1 day to 18 years). The most common etiology was immune thrombocytopenia (ITP) (62%). There was history of upper respiratory tract infection (URTI) in 49.2% and positive viral serology in 7% of ITP patients. There was history of vaccination on the last 6 weeks in 40 patients. Drug induced thrombocytopenia was detected in 27 of 258 patients having ITP (10.5%). Newborns constituted 6.1% of all patients (n=27). Treatment was given to 137 patients having ITP (53.1%). Normalization time of the platelet count was between 0 to 3 months in 208 of ITP patients (80.6%). Primary ITP was diagnosed in 25 (28.1%) and secondary ITP in 11 (6.5%) of 36 patients having chronic disease. Attack of hemorrhage was observed in 23 patients having ITP. These attacks were not life-threatening and were only decisive in the treatment plan. Some studies report that ITP is more frequent in girls. This can be explained with more autoimmunity seen in these patients. Incidence of v annually referring thrombocytopenia and ITP were 8.4 and 5.1/100000, respectively in our study and these results were concomitant with the literature data. Age range which ITP is most commonly seen is reported as 6- 10 years in most studies and our results are quite similar. Seasonal difference was not observed and former URTI was found as the predisposing factor in our study, concomitant with the literature. There was no correlation between chronicity and autoantibody positivity. Post-vaccination ITP did not relapse after maintenance dose of the vaccine. Thrombocytopenia was seen to generate after anti-epileptic drug usage. Thrombocytopenia recurred after treating the underlying cause in neonates. Response times to intravenous immunoglobulin and steroid treatments were 36.8±1.2 hours and 63.2±1.2, respectively. Chronicity ratio was seen to be statistically higher in patients with primary ITP than with secondary ITP (p<0.001). "Watch-and-wait" strategy is principally preferred in our clinic; because platelet counts of 121 (46.9%) untreated patients normalized spontaneously in 3 months without any complication and of potential side effects of pharmacologic treatments.
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Keywords
Çocukluk çağı trombositopenisi, İmmun trombositopeni, Yenidoğan trombositopenisi, Childhood thrombocytopenia, Immune thrombocytopenia, Newborn thrombocytopenia
Citation
Öngen, Y. D. (2017). Trombositopeni ön tanısı ile tetkik edilen çocukların klinik ve laboratuvar bulgularının retrospektif incelenmesi. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.