A 4-year-old boy, previously well, develops petechiae on the legs 2 weeks after recovery from a viral upper respiratory infection. He has no hepatosplenomegaly and no lymphadenopathy. CBC shows platelets 14 x 10^9/L, Hb 12.5 g/dL, WBC 8,000/mm3 with normal differential. Peripheral smear confirms isolated thrombocytopenia with large platelets. What is the most appropriate initial management?

• A Bone marrow examination before starting any therapy
• B Platelet transfusion to raise the count above 50 x 10^9/L
• C Observation alone if there is no significant mucosal bleeding ✓
• D Splenectomy as first-line definitive therapy

Explanation

This is typical immune thrombocytopenic purpura of childhood: abrupt onset after a viral illness, isolated thrombocytopenia, otherwise normal counts and physical examination. Most children remit spontaneously within weeks to months, so observation is standard when bleeding is limited to skin. Platelet transfusion is reserved for life-threatening hemorrhage because transfused platelets are rapidly destroyed. Splenectomy is a later option for chronic refractory disease, not first-line. Bone marrow study is needed only if atypical features such as blasts or organomegaly are present.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.