Case Report

Conservative Management of Internal Bleeding Following Trauma in an

Immune Thrombocytopenic Purpura Child with COVID‑19 Infection
Mita Erna Wati1 , Alvin Fajri Yudistio1 , Hidayati Utami Dewi2 , Damian Dwi Rahadi3

1
General Practitioner, Ngudi Immune thrombocytopenic purpura (ITP) usually presents with minor bleeding

Abstract
Waluyo Hospital, Blitar,
Indonesia, 2Department of
such as petechiae and purpura. Rarely, life‑threatening events such as intracranial
Child Health, Ngudi Waluyo and intra‑abdominal bleeding can be occurred. Here, we present a case of a
Hospital, Blitar, Indonesia, 9‑year‑old patient who presented to the emergency department after being hit by a
3
Departement of Surgery, motorcycle with a decrease of consciousness and symptoms of shock. On physical
Ngudi Waluyo Wlingi examination, a large abdominal bruise was seen, and it was proved by FAST to
Hospital, Blitar, Indonesia confirm abdominal bleeding. Sign of shock, decrease of hemoglobin, and a free
fluid in Morison’s pouch were found by the FAST examination and led to establish
abdominal bleeding diagnosis. The presence of bleeding in ITP patient, especially
children, can be safely managed with observation alone. This case highlights
the life‑threatening condition, abdominal bleeding in severe thrombocytopenia,
successfully treated with a conservative treatment strategy.
Submitted: 30‑Jun‑2022
Revised: 18‑Oct‑2022 Keywords: COVID‑19, conservative management, internal bleeding, immune
Accepted: 31‑Oct‑2022
Published: 09-Dec-2022 thrombocytopenic purpura

Introduction Immune thrombocytopenic purpura (ITP) is an

autoimmune disease characterized by low platelet count
I nternal bleeding is a collection of blood inside the
abdominal cavity.1,2 Hemorrhage caused by traumatic
injury accounts for over 35% of prehospital deaths and
that occurs most frequently in children and young
adult. ITP usually presents with minor bleeding such
40% of death within the 1st 24 h.2 Blunt abdominal as petechiae and purpura. Sometimes, life‑threatening
trauma can cause contusions or injuries to the bowel, conditions such as intracranial and intra‑abdominal
spleen, liver, and intestines and damage to the internal bleeding can occur.5 The risk of central nervous system
organs, resulting in internal bleeding.1 Solid organ injuries bleeding has been estimated at <1% and severe bleeding
caused by abdominal trauma in children are often related elsewhere is probably still less common. More than
to blunt trauma and mostly severe injuries. Computed 90% of solid organ injuries in children can be treated
tomography (CT) scan is an important radiographic successfully with conservative treatment.3
examination for detecting solid organ injuries, Here, we report a rare case of an abdominal internal
classification of the injury, and treatment determination.3 bleeding in the setting of trauma in a child with ITP. In the
Internal bleeding is diagnosed by abdominal wall COVID‑19 pandemic era, there was a limitation to perform
bruising, and symptoms of shock include tachycardia advance examination (e.g., CT scan). However, even with
and hypotension and are proved by radiographic that limitation, the patient’s condition gradually improved
finding.1,2 Focused assessment with sonography for and was able to be discharged in a fairly good condition.
trauma (FAST) or CT scanners are often used to find the
source of bleeding. Surgery is indicated for patient with Address for correspondence: Dr. Mita Erna Wati,
hemodynamic instability, coagulopathy, hypothermia, Ngudi Waluyo Hospital, Blitar, Indonesia.
E‑mail: mithaua@gmail.com
severe metabolic acidosis, and suboptimal response to
resuscitation. 4 However, underlying disease should be This is an open access journal, and articles are distributed under the terms of the
considered, like hematology disorder. Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
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Website: https://journals.lww.com/bhsj For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

How to cite this article: Wati ME, Yudistio AF, Dewi HU, Rahadi DD.
Conservative management of internal bleeding following trauma in an
DOI: 10.4103/bhsj.bhsj_9_22 immune thrombocytopenic purpura child with COVID‑19 infection. Biomol
Health Sci J 2022;5:137‑41.

© 2022 Biomolecular and Health Science Journal | Published by Wolters Kluwer - Medknow 137
 Wati, et al.: Internal bleeding in immune thrombocytopenic purpura

Case Report management. The patient was on complete bed rest and
A 9‑year‑old child presented to our emergency received fluid and oxygen therapy, blood transfusion,
department with a decrease of consciousness, nausea, hemostatic agent (carbazochrome), Vitamin K,
vomiting, and abdominal pain. The patient was hit by tranexamic acid, and supportive treatment for COVID‑19
a motorcycle while walking. Previously, the patient had infection. As a symptomatic therapy, paracetamol was
been diagnosed with ITP since 2 years old. There was given to relieve pain, and ranitidine was given if there
no history of fever, cold, cough, itchy throat, or close was epigastric pain [Table 2].
contact to a COVID‑19 patient. The patient was given a total of two units of packed red
The vital signs were unstable with blood pressure of blood cells each with a volume of 250 ml, six units of
86/42 mmHg, heart rate of 135 bpm, respiratory rate platelet component, and 250 ml of fresh frozen plasma
of 30 breaths/min, and peripheral oxygen saturation of to correct anemia, thrombocytopenia, and prolonged
85% room air. On examination, the patient looked to PPT and APTT. Antibiotic was given to the patient
have pallor with some bruising, mostly on the chest and as infection prophylaxis. The patient’s condition was
abdomen [Figure 1], and the peripheral acral was cold. improved without oxygen supplementation on the
6th day of admission. Hemoglobin and hemostatic factor
As a part of a routine examination, a complete blood
(APTT and partial thromboplastin time) were gradually
count revealed anemia (hemoglobin 4.6 gr/dL),
improved to the normal level on the 4th day of admission,
leukocytosis (white blood cell 21000/mm3), severe
and the patient was discharged after 8 days of admission
thrombocytopenia (platelet count 9000/mm3), prolonged
with a negative result for PCR swab test.
plasma prothrombin time (PPT) of >180s, and activated
partial thromboplastin time (APTT) of >90s. His liver Discussion
function test, renal function test, and electrolyte serum
were normal [Table 1]. The abdominal FAST showed Internal bleeding is a life‑threatening condition that needs
a free fluid in Morison’s pouch, which is a sign of a comprehensive examination and prompt treatment
internal bleeding. The thorax X‑ray showed right lung because it can lead to a shock condition. Traumatic
contusion [Figure 2]. Polymerase chain reaction (PCR)
test was positive; hence, we had to admit this patient Table 1: Laboratory result and normal range for tested
to the isolation ward. Based on history, clinical parameters
manifestation, and laboratory test, the patient was Parameter Result Normal range
diagnosed with unstable internal bleeding, anemia, Hemoglobin (g/dL) 4, 6 12‑16
thrombocytopenia, ITP, and COVID‑19 infection Leukocyte (/uL) 21×103 4‑12
Thrombocyte (/uL) 9.000 100‑300
The patient was planned to be referred to a tertiary APTT (s) >90 10‑14
hospital for optimal treatment. However, it could not be PTT (s) >180 25‑35
done, because at that time, Indonesia was in the second SGOT (U/L) 21 <37
wave COVID‑19 outbreak, so the referral hospital was SGPT (U/L) 17 <41
full. We decided to treat the patient with a conservative Urea (mg/dL) 42 20‑45
Creatinine (mg/dL) 1.02 0.5‑1.5
PCR swab test Positive Negative
PTT: Partial thromboplastin time, APTT: Activated PTT,
SGOT: Serum glutamic‑oxaloacetic transaminase, SGPT: Serum
glutamic pyruvic transaminase, PCR: Polymerase chain reaction

Figure 2:  (1) USG showed a free fluid  (yellow arrow) in Morison’s

Figure 1: Bruise (yellow arrows) on the patient’s left abdomen and left pouch (2) Thorax X‑ray showed right lung contusion (white arrow).
hip after injury USG: Ultrasonography

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 Wati, et al.: Internal bleeding in immune thrombocytopenic purpura

patient management with hemorrhagic shock is complex Although the patient was stable after resuscitation, CT
and challenging. In a shock condition, early recognition scan could not be performed at that time, because the
and initial resuscitation are essential to maintain oxygen patient had tested positive for COVID‑19. There was a
delivery to prevent tissue hypoxia, inflammation, and limitation to do an advanced examination and surgery in
organ dysfunction. It is indicated with decreased blood a COVID‑19 patient. We planned to refer the patient to
pressure, increased heart rate, and respiratory rate, then a tertiary hospital, but this could not be done because
prolonged capillary refill time.6 the referral hospital was full. Hence, we decided to treat
The primary and secondary surveys suggested by the the patient conservatively with all maximal medications
advanced trauma life support should be performed for that we could perform.
every traumatic case. The physical examinations and The successful nonoperative management of trauma
radiological evaluations can help localize the sources patients depends on accurate diagnosis and injury
of bleeding.7 A FAST is a rapid examination performed management as well as the identification of ongoing
by emergency physicians as a screening test for bleeding. In a hemodynamically stable patient, contrast
intra‑abdominal bleeding after trauma. The FAST has CT scan is currently the best choice of diagnostic
been reported sensitivities between 85% and 99% and tool that is highly accurate in imaging blunt abdomen
specificities 98%, but a negative ultrasound result does and chest trauma, especially for solid organ injury
not rule out intra‑abdominal abnormality.7,8 and arterial injury.9 The CT‑based grading system has
Our patient came with the sign of shock and abdominal been made to assess a splenic injury, with the goals of
bruise and then confirmed abdominal bleeding with planning appropriate management. CT scan can also
the FAST examination. However, a history of ITP and reveal the presence of lesion requiring surgery, such
severe thrombocytopenia (patient’s platelet count was as pancreatic or bowel injuries. Hence, CT scan plays
9000/mm3) was a consideration for doing surgery because an important role in helping the doctors in making a
it can lead to more bleeding and worsen the condition. decision to use a surgical or conservative management in

Table 2: Patient clinical progress and treatment

Treatment and vital sign Day of admission
1 2 3 4 5 6 7 8
Blood pressure (mmHg) 86/54 92/64 96/57 100/75 109/87 95/61 90/60 103/72
Heart rate (bpm) 135 107 83 82 79 82 96 97
Respiratory rate (breath/min) 30 28 28 28 24 20 20 20
Oxygen saturation (%) 85 95 96 96 95 96 97 99
Hemoglobin (g/dL) 4.6 12.5 13.5
APTT >90 14.5
PTT >180 30.7
PCR swab test + −
O2 NRBM + + +
O2 simple mask +
O2 nasal cannula +
O2 room air + + +
Fluid resuscitation +
Infection NaCl 0, 9% 1000 mL/24 h + + + + + + + +
Ranitidine 30 mg infection/24 h + + + + +
Paracetamol 300 mg infection/8 h + + + + +
Ceftriaxone 1 g infection/12 h + + + + +
Carbazochrome drip/24 h + + + + +
Vitamin K 10 mg infection/24 h + + +
Tranexamic acid 250 mg infection/8 h + + + + +
Zink 20 mg bid + + + + + + + +
LBio bid + + + + + + + +
200 mL of PRC transfusion + +
6 units of TC transfusion +
250 mL of FFP transfusion +
NRBM: Nonrebreathing mask, PRC: Packed red cell, TC: Thrombocyte concentrates, FFP: Fresh frozen plasma, PTT: Partial thromboplastin
time, APTT: Activated PTT, PCR: Polymerase chain reaction. +: Positive, −: Negative

Biomolecular and Health Science Journal  ¦  Volume 5  ¦  Issue 2  ¦  July-December 2022 139
 Wati, et al.: Internal bleeding in immune thrombocytopenic purpura

internal bleeding. Nowadays, nonsurgical management patients, especially children, can be safely managed
of abdominal bleeding has been made possible in a with observation alone.11 In a hemodynamically stable
hemodynamically stable patient with the widespread pediatric patient, it has increasingly become the standard
use of CT‑Scan.10 If we do not perform CT scan, we of care for the last few decades.1 It is proved by our
may not know if there is ongoing bleeding or there is patient who successfully recovered with a conservative
a surgically important finding. Hence, the treatment of treatment with strict monitoring and observation.
internal bleeding patient cannot be optimal.
Conclusion
ITP is an autoimmune disease characterized by low
platelet count and high risk of bleeding tendency. Internal bleeding is a life‑threatening condition that
Dangerous internal bleeding can occur when the platelet needs a comprehensive examination and prompt
count falls below 10.000/μL.. Platelets are critical for treatment because it can lead to a shock condition.
maintaining vascular integrity that provides the surface Surgery is indicated for patient with hemodynamic
of coagulation protein and adhere to the vessel wall at instability, coagulopathy, hypothermia, severe metabolic
the sites of endothelial injury. Platelet‑type bleeding acidosis, and suboptimal response to resuscitation. The
in ITP manifests as a spontaneous bleeding located in presence of ITP is one of not doing surgeries because
the skin, mucosal, gastrointestinal, or intracranial. ITP severe thrombocytopenia can lead to bleeding and
treatment principles consider disease severity and risk of worsen the condition. The present case indicates that
bleeding. It is important to decide when the treatment acute abdominal bleeding does not always require
is needed and when it can be safely delayed. Just like surgical intervention in patients with a high risk of
our patient, when we cannot perform a surgery caused bleeding such as ITP.
by severe thrombocytopenia, conservative treatment is a Declaration of patient consent
safer procedure. 11 The authors certify that they have obtained all
COVID‑19 infection induces immune‑thrombotic appropriate patient consent forms. In the form, the legal
coagulation coagulopathy through platelet activation, guardian has given his consent for images and other
aggregation, and immunomodulatory activity. There clinical information to be reported in the journal. The
is evidence that platelets can contain SARS‑2 virus guardian understands that names and initials will not
despite the absence of angiotensin‑converting enzyme be published and due efforts will be made to conceal
2 receptor, which is the entry of virus into the cell. identity, but anonymity cannot be guaranteed.
Direct viral‑mediated injury leading to damaged platelet Acknowledgment
releases cytokine and antimicrobial peptides which lead We would like to thank the patient’s mother for her
to hyperinflammatory reaction. In addition to this, the consent to this case report publication.
platelet consumption would lead to thrombocytopenia.
As with other viral infections, COVID‑19 may trigger a Financial support and sponsorship
relapse in an existing ITP patient.12 Nil.
The role of thrombocyte transfusion in the management Conflicts of interest
of ITP remains controversial due to it is believed to There are no conflicts of interest.
be limited due to the shortened survival of transfused
platelets. Published guidelines recommend that References
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