A 3-year-old girl presented with petechial hemorrhages and repeated nosebleeds.

Case #10

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A 3-year-old girl presented with petechial hemorrhages and repeated nosebleeds. Two weeks earlier she had been admitted to a local hospital with nosebleeds accompanied by 2 episodes of vomiting dark red blood. Results of the laboratory evaluation included: white blood cell count, 8.2 × 109 /L [reference interval (RI), 4 × 109 /L to 10 × 109 /L]; hemoglobin, 10.7 g/dL (RI, 11–15 g/dL); platelet count, 142 × 109 /L (RI, 100 × 109 /L to 300 × 109 /L), prothrombin time, 11.5 s (RI, 9–13 s); activated partial thromboplastin time, 31.2 s (RI, 26–39 s); and fibrinogen, 2.5 g/L (RI, 2.0–4.0 g/L). The patient was discharged in good condition after insertion of nasal packs. One day before the current admission, the patient had nose bleeds once again, this time accompanied by 4 episodes of hematemesis and tarry stool. At presentation, she had no fever and no diarrhea. She was not on any medications. The patient had a history of easy bruising, repeated gum bleeding, but not hemarthrosis. There was no family history of abnormal bleeding. On examination, she appeared pale, with normal vital signs. Her skin had scattered petechiae. The physical examination was otherwise unremarkable. At presentation, laboratory findings included the following: hemoglobin, 6.2 g/dL (RI, 11–15 g/dL); reticulocyte count, 6.8% (RI, 0.5%–1.5%). Other laboratory results are shown in Table 1. In vitro testing showed that the patient’s platelets did not aggregate in response to ADP, epinephrine, arachidonic acid, or collagen, but platelets had relatively normal ristocetininduced aggregation. These findings were confirmed on repeat testing. A smear of peripheral blood showed no clusters of normal platelets. A flow cytometry evaluation revealed marked reduction in glycoprotein IIb/IIIa (GPIIb/IIIa).