Sam Zhao MD, Children’s National Medical Center

The Case
A 12do M with a history of neonatal thrombocytopenia presented with shaking movements, raising concern for an intracranial bleed.

Here’s How You Answered Our Questions:

Discussion:
Nearly all respondents in our online poll wanted a CBC to evaluate for thrombocytopenia. Several respondents also requested a BMP in this infant with possible seizure activity, even though it wasn’t listed an one of the answer choices. During our group discussion, it was argued that even a normal platelet count wouldn’t eliminate the possibility of an old bleed creating a focus for epileptic activity. After learning of the patient’s thrombocytopenia, most respondents also asked for head imaging of some kind to evaluate for a bleed.

Everyone agreed that more history and ideally observation of a shaking episode in the ED would have been extremely helpful in determining the need for further workup. Movements more consistent with a Moro reflex or myoclonic jerks would have been reassuring.

Denouement:
Hematology was consulted to work up the thrombocytopenia. They recommended a head ultrasound, which was performed prior to the patient’s admission to the NICU for further workup. The head ultrasound showed normal ventricular sizes, no abnormal foci of echogenicity, and normal Doppler flow.

The patient underwent a partial SBI workup in the NICU. Due to low platelets, urine and CSF studies were deferred, but a blood culture was sent. He underwent a 7-day course of ampicillin and gentamicin for presumed bacteremia, although the blood culture revealed no growth.

He also received IVIG for his thrombocytopenia, with a total of four doses given during his admission. The repeat doses were administered due to unexpected downtrends in his platelet count: 78k -> 30k -> 23k -> 56k -> 78k. Platelets continued to rise to 434k on the day of discharge. He is currently being followed as an outpatient in hematology clinic.

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