Intracranial bleeds secondary to immune thrombocytopenic purpura in children are very rare, occurring in only 0.1–0.5% of children diagnosed with ITP.1
This is the first report in the literature of intracranial bleeding into a solid tumour in a child with ITP. Astrocytomas account for 50% of paediatric primary central nervous system tumours, and of these pilocytic astrocytomas are the most common type.2
Juvenile pilocytic astrocytomas are usually benign, with transformation to a high grade malignant tumour being rare. In this case the tumour was probably beginning to become symptomatic, causing hydrocephalus and papilloedema, but the bleed was the final precipitating event that caused her to come to medical attention.
There are reports in the literature of solid tumours in adults precipitating the development of ITP,3
or of ITP improving after tumour resection.4
In this case there is no evidence that the two conditions are related in causal terms, although as is seen in the case report they impact strongly on each other’s management. It would not be possible to determine which of the two conditions arose first, but the platelet count was not affected in the long run by the removal of the tumour.
When a child with ITP presents with features suggestive of an intracranial bleed it may be assumed to be a spontaneous bleed due only to the thrombocytopenia. This case illustrates the importance of arranging detailed intracranial imaging in such a case to look for other underlying causes, which may require separate management. We recommend MRI with contrast administration, if necessary repeated when the blood products have cleared, as the cost of missing an expanding intracranial mass lesion could be very high.
- When a patient known to have a chronic condition presents with new symptoms, consider the possibility of a new illness and dual pathology, rather than just assuming a deterioration in their original condition.
- While intracranial bleeds in idiopathic thrombocytopenic purpura (ITP) are rare, this diagnosis must not be missed in a child with ITP who presents with a neurological deterioration—urgent imaging is essential.
- In patients with a bleeding tendency who present with features suggestive of an intracranial bleed, particularly in the absence of any history of trauma, it is important to look for underlying lesions such as benign or malignant tumours. These may not be evident on initial imaging due to the acute bleed, so if an abnormality is suspected then repeat imaging, preferably with an MRI, should be carried out when the blood products have cleared.