Easy Bruising, Petechiae, and Frequent Nosebleeds in Children

Q: Easy Bruising, Petechiae, and Frequent Nosebleeds in Children

Hello, thank you for your message. <br>Here are my thoughts：<br>1. <br>The pediatric immunologist mentioned the possibility of thalassemia or iron deficiency anemia. <br>Since many family members on my mother's side have thalassemia trait, does that mean my daughter is likely to

Easy bruising, petechiae, and nosebleeds?

Dear Director Gao,
My daughter is currently 7 years old.
Over a year ago, we noticed that she easily develops bruises on her body, although we are unsure if she has bumped into something.
These bruises mostly occur around her knees and the front of her shins, and occasionally on her body.
They generally fade within a week.
We also observe some petechiae, some of which appear to be caused by scratching, while others are of uncertain origin.
However, most of them are localized and tend to fade the next day.
Her skin is prone to itching, and after consulting a doctor, it was suggested that she has very mild atopic dermatitis.
She frequently experiences nosebleeds, occurring 2 to 3 times a month.
Last month, we visited a pediatric allergy and immunology specialist, and the blood test results were as follows:
CBC and differential:
- Hemoglobin: 9.9 (Reference range: 11.5-14.5)
- Hematocrit: 31.5 (Reference range: 33-43)
- MCV: 61.1 (Reference range: 76-90)
- RBC: 5.15 (Reference range: 3.90-5.00)
- Platelets: 332 (Reference range: 140-450) - normal
- WBC: 5.2 (Reference range: 4.0-12.0) - normal
White blood cell differential:
- Lymphocytes: 42.2% (Reference range: 20-40)
- Segmented neutrophils: 50.7% (Reference range: 55-75)
- Other white blood cell classifications: normal
Coagulation profile:
- INR, PT control, PT patient, APTT control, APTT patient: all normal
Immunological tests:
- ANA: 1:80 (Reference range: <1:80)
- Lupus Anticoagulant, C3, C4, Anti-dDNA, Anti-Cardiolipin IgG, Anti-Cardiolipin IgM, Anti-B2 glycoprotein 1 IgG, Anti-B2 glycoprotein 1 IgM: all normal
I would like to ask the doctor a few questions:
1.
The pediatric immunologist mentioned the possibility of thalassemia or iron deficiency anemia, as many family members on my mother's side have thalassemia traits.
Does this mean my daughter is likely to have this type of anemia? If it is thalassemia, could it cause her symptoms?
2.
Are the two white blood cell differential values that fall outside the reference range significant?
3.
The ANA level of 1:80 is elevated, but the pediatrician believes it is acceptable since other immunological markers are normal.
The doctor mentioned that the child has an autoimmune constitution.
What is your opinion on this?
4.
Regarding my child's tendency to bruise, develop petechiae, and experience nosebleeds, are there any further tests needed? What other potential causes could lead to these symptoms? The doctor mentioned that all necessary blood tests have been conducted, and we should observe her condition.
I apologize for the interruption and appreciate your response.
Given the severe pandemic situation, I wish you safety and health during your consultations.
Thank you.

Mei Le, 40~49 year old female. Ask Date: 2021/05/31

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your message.
Here are my thoughts:
1.
The pediatric immunologist mentioned the possibility of thalassemia or iron deficiency anemia.
Since many family members on my mother's side have thalassemia trait, does that mean my daughter is likely to have this type of anemia? If it is thalassemia, could it cause her symptoms? --> Thalassemia is indeed genetically correlated, but whether it leads to anemia depends on the extent of genetic influence.
If there are concerns, a more detailed hemoglobin analysis can provide answers.
However, symptoms like petechiae, bruising, and nosebleeds are less related to thalassemia and require further examination, as your physician has arranged.
2.
The two values in the white blood cell differential are outside the reference range; does this have significance? --> The proportions of various white blood cells can fluctuate.
I believe as long as the appearance of the white blood cells is normal, this result is acceptable.
3.
The ANA titer is 1:80, which is elevated, but the pediatrician thinks it's acceptable because other immune markers are normal.
The doctor believes there is currently no autoimmune disease, but mentioned that the child has an autoimmune constitution.
What is your opinion on this? --> According to rheumatology consensus, we typically investigate when the ANA titer exceeds (or equals) 1:160.
Otherwise, we decide based on whether the child has other symptoms.
While the presence of ANA indicates some immune issues, it currently does not appear severe, and regular monitoring is sufficient.
4.
Regarding the child's tendency to bruise easily, have petechiae, and experience nosebleeds, what further tests are needed? What other causes could lead to these symptoms? The doctor mentioned that all necessary blood tests have been done, and we should observe for now.
--> Easy bruising and nosebleeds could also indicate a hematological issue.
If necessary, you can consult a hematologist, mentioning that a series of tests have been conducted in rheumatology, most of which were normal.
Additionally, it is common for young children to have odd small bleeding spots that usually resolve quickly and are generally not concerning.
However, if they occur frequently, it is advisable to return to rheumatology or even consult a hematologist, as some tests may need to be followed up for changes rather than being assessed just once.
Changhua Hospital, Department of Allergy, Immunology, and Rheumatology, cares for you.

Reply Date: 2021/05/31

More Info

Understanding the symptoms of easy bruising, petechiae, and frequent nosebleeds in children can be quite concerning for parents. Your daughter’s situation, as described, raises several important points that warrant careful consideration and further investigation.

1. Anemia Types and Symptoms: The pediatric immunologist's suggestion of possible thalassemia (often referred to as "海洋型貧血" or "oceanic anemia") or iron deficiency anemia is significant. Thalassemia is a genetic blood disorder that affects hemoglobin production, leading to anemia. Symptoms of thalassemia can include fatigue, weakness, and in some cases, easy bruising due to the lower red blood cell count and associated complications. However, just because there is a family history of thalassemia does not guarantee that your daughter has it. Genetic testing can confirm whether she carries the trait or has the disease. Iron deficiency anemia can also lead to symptoms such as fatigue and pallor, and it can sometimes cause easy bruising due to the impact on platelet function and blood clotting.

2. White Blood Cell Count: The slight deviations in the white blood cell differential count (lymphocytes and segmented neutrophils) may not be clinically significant, especially if the overall white blood cell count is within normal limits. These variations can occur due to a variety of benign reasons, including recent infections or stress. However, it is essential to monitor these values over time to ensure they remain stable.

3. ANA Test Results: The presence of a positive ANA (antinuclear antibody) test at a titer of 1:80 can be concerning, but it is important to interpret this result in the context of other clinical findings and tests. A positive ANA can be seen in various conditions, including autoimmune diseases, but it can also be present in healthy individuals, particularly children. Since other autoimmune markers are normal, it is reasonable to conclude that there is no active autoimmune disease at this time. The term "autoimmune constitution" may refer to a predisposition to autoimmune conditions, but it does not imply that your daughter currently has an autoimmune disease.

4. Further Investigations: Given your daughter's symptoms of easy bruising, petechiae, and frequent nosebleeds, it may be prudent to conduct further evaluations. These could include:
- Coagulation Studies: While basic coagulation tests (PT, APTT) are normal, specific tests for von Willebrand disease or platelet function tests may be warranted if bleeding symptoms persist.

- Complete Blood Count (CBC): Regular monitoring of her hemoglobin, hematocrit, and platelet counts can help track any changes over time.

- Bone Marrow Evaluation: In rare cases, if there are persistent unexplained symptoms, a bone marrow biopsy may be considered to rule out any hematological disorders.

5. Potential Causes: Other potential causes for easy bruising and bleeding in children can include:
- Platelet Disorders: Conditions affecting platelet function or number can lead to increased bleeding.

- Vascular Disorders: Conditions that affect the blood vessels can also cause easy bruising.

- Nutritional Deficiencies: Deficiencies in vitamins such as Vitamin C (scurvy) or Vitamin K can lead to bleeding issues.

In conclusion, while your daughter's symptoms are concerning, they can arise from a variety of causes, some of which may be benign. It is crucial to maintain open communication with your healthcare providers, follow up on any recommended tests, and keep a close watch on her symptoms. If her symptoms worsen or new symptoms arise, do not hesitate to seek further medical advice. Regular follow-ups with a pediatric hematologist or immunologist may also provide additional insights and management strategies tailored to her specific needs.

Similar Q&A

Understanding Frequent Nosebleeds in Young Children: Causes and Concerns

Dr. Hsiao, I would like to consult about a 5-year-old child who experiences nosebleeds every 2-3 months. What could be the possible issues? Thank you.

Dr. Xiao Kaiwen reply Pediatrics
First, rule out any coagulation issues, such as unexplained bruising or petechiae on the body, and hepatosplenomegaly. If these are not present, it is likely that the nasal mucosa is relatively fragile, and minor stressors (such as blowing the nose or picking the nose) can lead t...

Understanding Frequent Nosebleeds in Children: Causes and Solutions

Hello: My son is eight years old, with a height of less than 110 cm and a weight of about 20 kg. In the past three months, he has frequently experienced nosebleeds with bright red blood, sometimes occurring before waking up at 4 to 5 AM, or at other times as well. I would like to...

Dr. Huang Junxiong reply Surgery
Hello: I apologize, but this question may require you to consult an otolaryngologist.

Managing Frequent Nosebleeds in Children: Causes and Solutions

My daughter is 7 years old, and for the past two days, she has been experiencing nosebleeds after sneezing, which seem to be continuous and can last for about five minutes, accompanied by blood clots. An ENT specialist and two pediatricians have stated that her nasal membranes ar...

Dr. Zhang Wenwang reply Pediatrics
1. In addition to considering structural issues of the nose, it is important to check whether platelet levels in the blood are normal. 2. A balanced diet is the most important factor.

Understanding Nosebleeds in Children: Causes and Concerns for Parents

My child is four years old and suddenly had a nosebleed around 3 AM on November 14th, with blood all over their face, which was truly alarming. I would like to ask the doctor why they would have a nosebleed without any trauma. Does this situation indicate anything concerning? A w...

Dr. Ye Dawei reply Otolaryngology
There should be no issues. If it's an adult, then the possibility of nasopharyngeal carcinoma should be considered. In children, it is usually just nasal mucosa bleeding.